Jennifer Chipps

The Effectiveness of Cultural-Competence Training for Health Professionals in Community-Based Rehabilitation: A Systematic Review of Literature

AIMS To find and review studies in which investigators evaluated cultural-competence training in community-based rehabilitation settings; critique study methods, describe clinical outcomes, and make recommendations for future research. BACKGROUND A review of the effectiveness of cultural-competence training for health professionals in community-based rehabilitation settings was conducted. DATA SOURCES Research citations from 1991-2006 in CINAHL, Medline, Pubmed, PsycInfo, SABINET, Cochrane, Google, NEXUS, and unpublished abstracts were searched. METHODS Searching, sifting, abstracting, and assessing quality of relevant studies by three reviewers. Studies were evaluated for sample, design, intervention, threats to validity, and outcomes. A meta-analysis was not conducted because the studies did not address the same research question. RESULTS Five studies and one systematic review were evaluated. Positive outcomes were reported for most training programs. Reviewed studies generally had small samples and poor design. CONCLUSIONS/IMPLICATIONS The paucity of studies and lack of empirical precision in evaluating effectiveness necessitate future studies that are methodologically rigorous to allow confident recommendations for practice.

Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

OBJECTIVE To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. METHOD One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. RESULTS The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. CONCLUSION The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

Admission rates as an indicator of the prevalence of severe asthma in the community

Background: A reliable indicator of the prevalence of severe asthma in the community is needed to monitor population‐based asthma control strategies. We examined the potential use of asthma admissions to hospital as such an indicator. Methods: We recruited subjects from the Emergency Department (ED) of a childrens hospital. The attending doctor completed the ‘physician questionnaire’ which included questions on the patients asthma severity and interval severity/chronicity of asthma. The parent/guardian completed the ‘parent questionnaire’. It included questions on demography, asthma knowledge and attitudes, asthma history and social support. We performed univariate and multiple logistic regression to determine predictors for hospital admission. Results: Interval severity of asthma, pre‐treatment severity of wheeze and low post‐treatment pulse oximetry best predicted whether children presenting with asthma were admitted. Demographic variables, factors associated with access to health services and factors related to the asthma history and management were not significant predictors of admission. Discussion: At the population level, it may be possible to utilise routine hospital admission rates as an indicator of the prevalence of severe asthma in the community, especially within the context of monitoring trends in asthma prevalence. Our study was conducted in a metropolitan tertiary paediatric hospital. The reliability of hospital admission rates as indicators of the prevalence of severe asthma in other hospital settings, in different population groups and over time remains to be established.

Effectiveness and feasibility of telepsychiatry in resource constrained environments? A systematic review of the evidence

OBJECTIVE A review of systematic reviews of the effectiveness and feasibility of videoconference-based telepsychiatry services for resource constrained environments was conducted. Specifically with the aim of producing an evidence-based review of the effectiveness and feasibility of videoconference-based telepsychiatry services in resource constrained countries like South Africa. METHODS Eight key questions on telepsychiatry effectiveness and feasibility were identified and inclusion and exclusion criteria were developed. Review of citations from 2000-2011 from CINAHL, Medline, Pubmed, PsycInfo, EBSCOhost, SABINET, Cochrane Database of Systematic Reviews (CCTR), Cochrane Controlled Trial Registry (CCTR), Database of Abstracts of Reviews of Effectiveness (DARE), unpublished abstracts through NEXUS and internet search engines (Google/Google scholar) was conducted. RESULTS Ten systematic reviews were included for review. Despite the methodological limitations and heterogeneity of the systematic reviews, there appears to be good evidence of effectiveness (reliability and improved outcomes) and feasibility (use, satisfaction, acceptability and cost) for videoconference-based telepsychiatry internationally. The application of this evidence in lower middle income countries is dependent on the integration of telepsychiatry into local health system contexts. CONCLUSION Based on the evidence, resource constrained countries such as South Africa should be encouraged to develop telepsychiatry programs along with rigorous evaluation methods.

Systematic review of health data quality management and best practices at community and district levels in LMIC

Research findings have reported lack of reliable health data and poor management for district health information systems in low and middle-income countries (LMIC). This paper aims to review the literature on problems with health data quality management and health information evidences and evidences of best practices and use at community and district levels in LMIC, with a view to making recommendations for future research. Research citations, conference proceedings and diseases surveillance reports from 2000–2011 were accessed in PubMed, Medline, LISTA (EBSCO), CINAHL, Cochrane, and Google. Relevant studies were selected, the methodologies critiqued and synthesized. The researchers accessed 1383, and 38 were reviewed by three reviewers. Poor quality health data, low level of health information use, and poor management of health information systems were found. These findings hinder evidence-based decisions based and planning at community and district levels in LMIC. Though poor practices were found, improved health care services delivery with improved health data efficiency was found to be possible.

Practice guidelines for videoconference-based telepsychiatry in South Africa

Telepsychiatry, the practice of psychiatry over distance using information and communication technologies is, after teleradiology, the most practiced form of telemedicine in the world. As with any new technology, clinical service, or intervention in medicine, it is prudent to have guidelines for the safe and efficacious use of the technology in clinical practice. Guidelines facilitate best practice and provide both clinicians and patients with a set of standards and procedures that serve to protect their interests. Protection is particularly important when dealing with vulnerable groups.

Videoconference-based education for psychiatry registrars at the University of KwaZulu-Natal, South Africa

OBJECTIVE Psychiatry registrars form the backbone of specialized psychiatric service provision in South Africa. Medical schools are centralized while clinical services need to be widespread and accessible. Video-conferencing has the potential to link registrars at satellite hospitals with academic centers. The study thus evaluated of the use of videoconferencing in a Psychiatry Education Program delivered via videoconferencing. METHOD To evaluate the implementation of the videoconference-based psychiatry registrar program, a pre- and post evaluative design was used. This involved all registrars in the 2008 and 2009 academic education program at the University of KwaZulu-Natal, South Africa. Access to education, satisfaction, suitability and costs of the psychiatry registrar education were studied. RESULTS In the evaluation of the Registrar Program, general satisfaction with the videoconferencing program was reported, though concerns were expressed about the level of interaction using this mode, the quality of the transmitted pictures of the anatomy specimens and the quality of the sound. Access to education was improved with potential cost savings identified. CONCLUSION Well supported and planned videoconference-based teaching is a feasible, cost-effective and acceptable method of supporting registrars at sites distant from academic centers.

Screening a heterogeneous elderly South African population for cognitive impairment: the utility and performance of the Mini- Mental State Examination, Six Item Screener, Subjective Memory Rating Scale and Deterioration Cognitive Observee.

OBJECTIVE The aim of this study was to report on the prevalence of cognitive impairment, and to assess the performance and utility of subjective, objective and informant screening tools in a heterogeneous community sample. METHOD A sample of 302 elderly participants (>60 years) living in residential homes in a large city in South Africa were screened for the presence of cognitive impairment using objective (Mini-Mental State Examination [MMSE] and Six Item Screener-[SIS]), subjective (Subjective Memory Complaint [SMC]and Subjective Memory Rating Scale [SMRS]) and informant (Deterioration Cognitive Observee [DECO]) screening tools. All tools were compared to the MMSE and the influence of demographic variables on the performance on these tools was considered. RESULTS Significantly lower MMSE scores were found in participants aged 80-89 years (p=.023) and those who had 8-11 years of education (p=.002). For every one additional year of education, participants were 0.71 times less likely to screen positive on the MMSE. Differential item functioning on various components of the MMSE was demonstrated due to the effects of education, race and gender. There was significant differential performance between the recommended and alternate attention/concentration items (p<.001) with the alternate item favouring better performance. Based on the MMSE cutoff score of < 23, the prevalence of cognitive impairment was 16.9%; the prevalence yielded by the remaining tools ranged from 10.5% using the DECO to 46% as determined by the presence of a SMC. Using the MMSE as the reference standard for the presence of cognitive impairment, the SIS, SMC, SMRS and DECO had sensitivities of 82.3%, 54.6%, 17.0% and 37.5%, and specificities of 71.3%, 57.6%, 87.4% and 96.7% respectively. Age and race influenced performance on the MMSE, SIS and SMRS. CONCLUSION Different types of cognitive screening tools yielded varying sensitivities and specificities for identifying cognitive impairment when compared to the MMSE. The influence of race, age and education on test performance highlights the need for suitable, culture-fair screening tools. Locally, the alternate item for attention/concentration should be preferred.

Readiness of health-care institutions in KwaZulu-Natal to implement telepsychiatry.

We assessed the preparedness of health districts and designated hospitals in the KwaZulu-Natal (KZN) province for proposed telepsychiatry services. An e-health readiness questionnaire for developing countries was administered to managers of health districts and managers of designated psychiatric hospitals by telephone interview. Ten of the 11 district managers and managers/medical officers of 45 of 58 designated hospitals were interviewed. Notwithstanding some concerns regarding the tool, low levels of e-health readiness were found. District managers recorded e-health readiness scores of 137–217 out of 300. This was similar to the hospital managers, who recorded readiness scores of 121–260 out of 300. For telepsychiatry to succeed in KZN, an awareness programme will be required to facilitate the necessary change management.

A survey of University Students' Perceptions of Learning Management Systems in a Low-Resource Setting using a Technology Acceptance Model

Learning management systems have been widely advocated for the support of distance learning. In low-resource settings, the uptake of these systems by students has been mixed. This study aimed to identify, through the use of the Technology Acceptance Model, the individual, organizational, and technological factors that could be influencing the use of learning management systems. A simple quantitative descriptive survey was conducted of nursing and health science students at a university in South Africa as part of their first exposure to a learning management system. A total of 274 respondents (56.7%) completed the survey questionnaire, made up of 213 nursing respondents (87.7%) and 61 health sciences respondents (25%). Overall, the respondents found the learning management system easy to use and useful for learning. There were significant differences between the two groups of respondents, with the respondents from health sciences being both younger and more computer literate. The nursing respondents, who received more support and orientations, reported finding the learning management system more useful. Recommendations are made for training and support to ensure uptake.