Geren S. Stone

The Ethics of Medical Volunteerism

Responding to disparities in health, thousands of health care providers volunteer annually for short-term medical service trips (MSTs) to serve communities in need as a result of environmental, geographic, historical, or sociopolitical factors. Although well intentioned, short-term MSTs have the potential to benefit and harm those involved, including participants and communities being served. The contexts, resource and time limitations, and language and cultural barriers present ethical challenges. There have been increasing requests for standardized global guidelines, transparency, and open review of MSTs and their outcomes. Principles of mission, partnership, preparation, reflection, support, sustainability, and evaluation inform and equip those engaging in medical volunteerism.

Monitoring iCCM referral systems: Bugoye Integrated Community Case Management Initiative (BIMI) in Uganda

Background In Uganda, over half of under-five child mortality is attributed to three infectious diseases: malaria, pneumonia and diarrhoea. Integrated community case management (iCCM) trains village health workers (VHWs) to provide in-home diagnosis and treatment of these common childhood illnesses. For severely ill children, iCCM relies on a functioning referral system to ensure timely treatment at a health facility. However, referral completion rates vary widely among iCCM programmes and are difficult to monitor. The Bugoye Integrated Community Case Management Initiative (BIMI) is an iCCM programme operating in Bugoye sub-county, Uganda. This case study describes BIMI’s experience with monitoring referral completion at Bugoye Health Centre III (BHC), and outlines improvements to be made within iCCM referral systems. Methods This study triangulated multiple data sources to evaluate the strengths and gaps in the BIMI referral system. Three quantitative data sources were reviewed: (1) VHW report of referred patients, (2) referral forms found at BHC, and (3) BHC patient records. These data sources were collated and triangulated from January–December 2014. The goal was to determine if patients were completing their referrals and if referrals were adequately documented using routine data sources. Results From January–December 2014, there were 268 patients referred to BHC, as documented by VHWs. However, only 52 of these patients had referral forms stored at BHC. Of the 52 referral forms found, 22 of these patients were also found in BHC register books recorded by clinic staff. Thus, the study found a mismatch between VHW reports of patient referrals and the referral visits documented at BHC. This discrepancy may indicate several gaps: (1) referred patients may not be completing their referral, (2) referral forms may be getting lost at BHC, and, (3) referred patients may be going to other health facilities or drug shops, rather than BHC, for their referral. Conclusions This study demonstrates the challenges of effectively monitoring iCCM referral completion, given identified limitations such as discordant data sources, incomplete record keeping and lack of unique identifiers. There is a need to innovate and improve the ways by which referral compliance is monitored using routine data, in order to improve the percentage of referrals completed. Through research and field experience, this study proposes programmatic and technological solutions to rectify these gaps within iCCM programmes facing similar challenges. With improved monitoring, VHWs will be empowered to increase referral completion, allowing critically ill children to access needed health services. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1300-z) contains supplementary material, which is available to authorized users.

Career choices and global health engagement: 24-year follow-up of U.S. participants in the Indiana University-Moi University elective

BACKGROUND Global health experiences evoke a profound awareness of cultural differences, inspire learners to prioritize professional values, and provide a lens for addressing global health care challenges. This study compares the long-term career and practice choices of participants in a 2-month Indiana University-Moi University, Kenya elective from 1989-2013 with those of a control group. METHODS Global health elective (GHE) participants and a random sample of alumni without GHE experience were surveyed on their clinical practice, public health and global health activities. RESULTS Responses from 176 former participants were compared with a control group of 177 alumni. GHE participants were more likely than similar controls to provide care to underserved U.S. populations (p=0.037), spend time in global health, public health, and public policy activities (p=0.005) and be involved in global health advocacy (p=0.001). Using multivariable analysis, GHE participants were more likely to be generalists (p<0.05), report that healthcare costs influenced medical decision-making (p<0.05), and provide healthcare outside the U.S. for ≥1 week/year (p<0.001). CONCLUSIONS Many years out of training, GHE participants were more likely to be generalists working with underserved populations, to be cost-conscious in their healthcare decision-making, and to be involved in global health, public health or public policy. IMPLICATIONS With the primary care provider shortage and need for greater awareness among providers of healthcare costs, our study shows that that global health experiences may yield broader benefits to the U.S. medical system.

The association between insurance status and in-hospital mortality on the public medical wards of a Kenyan referral hospital

Background Observational data in the United States suggests that those without health insurance have a higher mortality and worse health outcomes. A linkage between insurance coverage and outcomes in hospitalized patients has yet to be demonstrated in resource-poor settings. Methods To determine whether uninsured patients admitted to the public medical wards at a Kenyan referral hospital have any difference in in-hospital mortality rates compared to patients with insurance, we performed a retrospective observational study of all inpatients discharged from the public medical wards at Moi Teaching and Referral Hospital in Eldoret, Kenya, over a 3-month study period from October through December 2012. The primary outcome of interest was in-hospital death, and the primary explanatory variable of interest was health insurance status. Results During the study period, 201 (21.3%) of 956 patients discharged had insurance. The National Hospital Insurance Fund was the only insurance scheme noted. Overall, 211 patients (22.1%) died. The proportion who died was greater among the uninsured compared to the insured (24.7% vs. 11.4%, Chi-square=15.6, p<0.001). This equates to an absolute risk reduction of 13.3% (95% CI 7.9-18.7%) and a relative risk reduction of 53.8% (95% CI 30.8-69.2%) of in-hospital mortality with insurance. After adjusting for comorbid illness, employment status, age, HIV status, and gender, the association between insurance status and mortality remained statistically significant (adjusted odds ratio (AOR)=0.40, 95% CI 0.24-0.66) and similar in magnitude to the association between HIV status and mortality (AOR=2.45, 95% CI 1.56-3.86). Conclusions Among adult patients hospitalized in a public referral hospital in Kenya, insurance coverage was associated with decreased in-hospital mortality. This association was comparable to the relationship between HIV and mortality. Extension of insurance coverage may yield substantial benefits for population health.

The relationship of weekend admission and mortality on the public medical wards at a Kenyan referral hospital

BACKGROUND Research has demonstrated disparities in the outcomes of patients admitted to hospital on weekends in high-income countries. No published research has evaluated if any similar discrepancy exists in low-resource settings. METHODS To determine if any difference in mortality exists between weekend and weekday admissions on the public medical wards at a Kenyan referral hospital, we performed a retrospective observational study of inpatients over a 3-month study period. RESULTS During the study period, 261 (27.3%) of the 956 patients were admitted over the weekend. The mortality rates for patients admitted on weekends and weekdays did not differ with 156 (22.4%) of the 695 patients admitted on weekdays dying compared to 55 (21.1%) of the 261 patients admitted on weekends. After adjusting for age, insurance status, co-morbid illness, HIV status, employment, referral status and gender, still no association existed between weekend admission and mortality. CONCLUSIONS Among adult patients on the medical wards, patients admitted on weekends had similar mortality rates to those admitted on weekdays. This similarity may reflect a stable level of care or a generalized shortage of resources and staffing that subsumes any impact of weekly variations. Future research examining optimal staffing and resource levels is needed in such settings.

Kenya's voluntary male medical circumcision program: Translatable lessons for both domestic and international programs.

As a case of translating a healthcare intervention from randomized controlled trial to public health program, Kenyas voluntary male medical circumcision (VMMC) program offers an example of demand generation through active engagement with the population and reducing barriers to uptake. It illustrates various means by which the Kenyan leadership focused on demand generation which have value both domestically and internationally to healthcare leaders. Community and public engagement must start early and continue focused on key stakeholders and spokespersons. Barriers including cost, time, culture, and personal preference must be identified and addressed. This engagement and overall program must constantly be re-evaluated and shaped iteratively based on data.

Assessment of attitudes and targeted educational needs for refugee care providers in a Ugandan hospital

Objectives To evaluate medical trainees’ attitudes toward refugee patients in a refugee host country, and to identify educational needs. Methods A 54-question cross-sectional questionnaire was administered to a convenience sample of 81 post-graduate medical trainees at Mbarara Regional Referral Hospital, Uganda, in 2016. Descriptive statistics on medical trainees’ attitudes and educational needs regarding care for refugees were calculated. One-way ANOVA was used to assess relationships between an attitude scale and respondent characteristics. Reliability and validity of the survey items and attitude scale were assessed using Cronbach’s alpha, item-to-scale correlation, and factor analysis. Results The mean score on the attitude scale of 2.8 (SD=1.7) indicated positive attitudes toward refugees. All respondents had contact with refugees, and 89% (n=72) reported a need for further training. Many specifically indicated the need for training in use of translators, support personnel, and behavioral health. Cronbach’s alpha values of greater than 0.7 indicated good internal consistency. Item-to-scale correlation and factor analysis validate the use of an attitude scale. ANOVA showed no significant difference between mean attitude scores in gender (F(1,77)=0.11, p=0.7367), country of origin (F(1.78) =0.53, p=0.8723), or year of study (F(4,74) =0.31, p=0.8273). Conclusions Medical trainees in Uganda report positive attitudes toward refugees and a need for additional education in refugee care in multiple specific areas. This study piloted the use of an attitude scale for refugee healthcare providers with promising validity and reliability. Use of these questions could inform curriculum development in refugee host countries.

Sauti Za Wananchi “voice of the people”: patient satisfaction on the medical wards at a Kenyan Referral Hospital

Introduction Patient satisfaction is one indicator of healthcare quality. Few studies have examined the inpatient experiences in resource-scarce environments in sub-Saharan Africa. Methods To examine patient satisfaction on the public medical wards at a Kenyan referral hospital, we performed a cross-sectional survey focused on patients’ satisfaction with medical information and their relationship with staffing and hospital routine. Ratings of communication with providers, efforts to protect privacy, information about costs, food, and hospital environment were also elicited. Results Overall, the average patient satisfaction rating was 64.7, nearly midway between “average” and “good” Higher rated satisfaction was associated with higher self-rated general health scores and self-rated health gains during the hospitalization (p = 0.023 and p = 0.001). Women who shared a hospital bed found privacy to be “below average” to “poor” Most men (72.7%) felt information about costs was insufficient. Patients rated food and environmental quality favorably while also frequently suggesting these areas could be improved. Conclusion Overall, patients expressed satisfaction with the care provided. These ratings may reflect modest patients’ expectations as well as acceptable circumstances and performance. Women expressed concern about privacy while men expressed a desire for more information on costs. Inconsistencies were noted between patient ratings and free response answers.