Tracy L. Rabin

Towards reframing health service delivery in Uganda: the Uganda Initiative for Integrated Management of Non-Communicable Diseases

Background The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development. Methods Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs. Results In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs. Discussion Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.Background The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development. Methods Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs. Results In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs. Discussion Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.

Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement

The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health.

Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.

Abstract Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program. Methods We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models. Findings The programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered. Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.

Implementation of Patient-Centered Education for Chronic-Disease Management in Uganda: An Effectiveness Study.

Background The majority of non-communicable disease related deaths occur in low- and middle-income countries. Patient-centered care is an essential component of chronic disease management in high income settings. Objective To examine feasibility of implementation of a validated patient-centered education tool among patients with heart failure in Uganda. Design Mixed-methods, prospective cohort. Settings A private and public cardiology clinic in Mulago National Referral and Teaching Hospital, Kampala, Uganda. Participants Adults with a primary diagnosis of heart failure. Interventions PocketDoktor Educational Booklets with patient-centered health education. Main Measures The primary outcomes were the change in Patient Activation Measure (PAM-13), as well as the acceptability of the PocketDoktor intervention, and feasibility of implementing patient-centered education in outpatient clinical settings. Secondary outcomes included the change in satisfaction with overall clinical care and doctor-patient communication. Key Results A total of 105 participants were enrolled at two different clinics: the Mulago Outpatient Department (public) and the Uganda Heart Institute (private). 93 participants completed follow up at 3 months and were included in analysis. The primary analysis showed improved patient activation measure scores regarding disease-specific knowledge, treatment options and prevention of exacerbations among both groups (mean change 0.94 [SD = 1.01], 1.02 [SD = 1.15], and 0.92 [SD = 0.89] among private paying patients and 1.98 [SD = 0.98], 1.93 [SD = 1.02], and 1.45 [SD = 1.02] among public paying patients, p<0.001 for all values) after exposure to the intervention; this effect was significantly larger among indigent patients. Participants reported that materials were easy to read, that they had improved knowledge of disease, and stated improved communication with physicians. Conclusions Patient-centered medical education can improve confidence in self-management as well as satisfaction with doctor-patient communication and overall care in Uganda. Our results show that printed booklets are locally appropriate, highly acceptable and feasible to implement in an LMIC outpatient setting across socioeconomic groups.

Medical Education Capacity-Building Partnerships for Health Care Systems Development.

Health care workforce development is a key pillar of global health systems strengthening that requires investment in health care worker training institutions. This can be achieved by developing partnerships between training institutions in resource-limited and resource-rich areas and leveraging the unique expertise and opportunities both have to offer. To realize their full potential, however, these relationships must be equitable. In this article, we use a previously described global health ethics framework and our ten-year experience with the Makerere University-Yale University (MUYU) Collaboration to provide an example of an equity-focused global health education partnership.

Ethical dilemmas during international clinical rotations in global health settings: Findings from a training and debriefing program

Abstract Purpose: This study describes the impact of an open-access, case-based global health ethics workshop and describes the breadth of dilemmas faced by students to inform future interventions. Methods: Eighty-two medical students who undertook electives at 16 international sites between 2012 and 2015 received web-based surveys at three time points, incorporating quantitative and free-text probes of knowledge, skills, and attitudes related to global health clinical ethics dilemmas. Sixty students (73%) completed the pre-workshop survey, 38 (46%) completed the post-workshop survey, and 43 (52%) completed the post-trip survey. Results: Analysis demonstrated improvement following the workshop in self-rated preparedness to manage ethical dilemmas abroad, identify ways to prepare for dilemmas, engage support persons, and manage related emotions (all comparisons, p < 0.001). Participants described 245 anticipated or actual dilemmas, comprising nine domains. Nearly one-third of the dilemmas that were experienced involved the student as an active participant. Only 21% of respondents experiencing a dilemma discussed the dilemma with a local support person. Conclusions: This analysis describes an ethics curriculum that prepares students to face ethical dilemmas during international clinical rotations. It broadens the representation of the dilemmas that students face, and highlights areas for curricular focus and optimization of on-site and post-trip student support resources.

The global health chief resident: modifying an established role, strengthening a collaboration

What problems were addressed? The growing desire among medical trainees for structured exposure to global health issues has increased the demand for short-term field experiences in health care centres abroad. Establishing collaborations to provide these opportunities involves maintaining a balance between sponsoring and host institution interests. Trainees encounter a number of challenges in the course of these experiences, including personal and medical cultural differences, and ethical concerns relating to professionalism and patient care. The job of chief resident encompasses a host of administrative, educational and clinical activities that are well suited to addressing the needs that emerge as a result of these experiences. What was tried? In the 2010–2011 academic year, the Yale Primary Care Residency Programme created two new leadership positions: global health chief residents. These chiefs split their time between Yale and the established Makerere University–Yale University (MUYU) medical education collaboration based at Mulago National Referral Hospital, in Kampala, Uganda, the country’s national referral and teaching hospital. These two individuals are committed to careers in global health and had previously spent a total of 15 months working at Mulago Hospital in various capacities; thus they were familiar with the institution, faculty staff and leadership. Although they fulfilled typical clinical and educational responsibilities when in the USA, their goals during the time they spent in Uganda included providing educational supervision to visiting and local trainees, participating in direct patient care as members of the local faculty, and providing administrative support to the Kampalaand New Haven-based staff of the collaboration. Clinically, the chief residents served as attending physicians and held both bedside and classroom teaching sessions for Ugandan trainees. Administratively, they facilitated cross-cultural communications regarding finances, procedures and educational content, assisted the local staff and visiting trainees in understanding one another’s needs, standardised the on-site orientation process, and involved staff and faculty members from both universities in completing a summary report of the first 5 years of the collaboration. Importantly, their cumulative experiences with both institutions enabled them to provide emotional support and gave them the insight they needed to assist visiting trainees in processing their clinical and personal experiences. What lessons were learned? A tense political situation, arising from the presidential election that occurred during their stay, intermittent public demonstrations and a terrorist attack in Kampala a few months prior to their arrival, reduced the number of trainees who visited Uganda as part of the MUYU collaboration during the chief residents’ tenure. The chiefs took appropriate safety precautions and followed US State Department recommendations. Instead of negatively impacting the experience, this provided a greater opportunity for involvement in Ugandan medical education and in the administrative structure of the collaboration than had been anticipated. Recently proposed guidelines for global health training experiences emphasise the responsibilities of sponsoring institutions regarding the mentorship of visiting trainees, with a view towards meeting local needs and the priorities of host institutions. We successfully modified a well-established educational role, that of the chief resident, to improve the experience of our trainees while on rotation abroad and also demonstrated a commitment between international collaborators. We believe this role is reproducible and would strongly encourage all international collaborations that involve undergraduate or postgraduate medical education to consider placing a chief resident on site.

Improving inpatient medication adherence using attendant education in a tertiary care hospital in Uganda

Abstract Quality problem Although widely utilized in resource-rich health care systems, the use of quality improvement (QI) techniques is less common in resource-limited environments. Uganda is a resource-limited country in Sub-Saharan Africa that faces many challenges with health care delivery. These challenges include understaffing, inconsistent drug availability and inefficient systems that limit the provision of clinical care. Initial assessment Poor adherence to prescribed inpatient medications was identified as a key shortcoming of clinical care on the internal medicine wards of Mulago National Referral Hospital, Kampala, Uganda. Baseline data collection revealed a pre-intervention median inpatient medication adherence rate of 46.5% on the study ward. Deficiencies were also identified in attendant (lay caretaker) education, and prescriber and pharmacy metrics. Choice of solution A QI team led by a resident doctor and consisting of a QI nurse, a pharmacist and a ward nurse supervisor used standard QI techniques to address this issue. Implementation Plan-Do-Study-Act cycle interventions focused on attendant involvement and education, physician prescription practices and improving pharmacy communication with clinicians and attendants. Evaluation Significant improvements were seen with an increase in overall medication adherence from a pre-intervention baseline median of 46.5% to a post-intervention median of 92%. Attendant education proved to be the most effective intervention, though resource and staffing limitations made institutionalization of these changes difficult. Lessons learned QI methods may be the way forward for optimizing health care delivery in resource-limited settings like Uganda. Institutionalization of these methods remains a challenge due to shortage of staff and other resource limitations.

Integrated Care of Refugees in a Primary Care Residency Clinic

Providing quality health care for refugees requires cross-cultural competence and unique medical knowledge.1,2 While the Society of General Internal Medicine called for the development of longitudinal training for residents in refugee care in 2004,3 most residents do not feel prepared to care for new immigrants.4 We describe the experience of the Yale Combined Internal Medicine-Pediatrics Residency Program in providing integrated care for a population of Burmese refugees. This model presented numerous challenges but we believe it represents a viable, rewarding alternative to one in which refugees are cared for in a distinct clinic. In 2007, our patient-centered medical home practice serving a multiethnic, largely poor and underserved community began caring for 66 newly resettled Burmese refugees, most of whom were members of the Karen ethnic minority. We developed 3 distinct interventions that helped us provide quality care to this group. We first organized an introductory community meeting that brought together faculty, residents, and office staff with representatives of the community. We held home visits during which we led health education discussions, reviewed common health concerns, and held pediatric acute care and catch-up immunization clinics. Connecticut, like many states, lacked comprehensive guidelines for refugee health care. Since our Karen patients were randomly distributed between physicians, we devised a standardized instrument to provide guidance during the initial visit. It prompted the clinician to gather information relevant to refugees and provide recommendations regarding infectious disease screening. The provision of efficient, quality care was limited by a vast cultural divide and by unreliable telephone interpretation. Taking medical histories, eliciting symptoms, and comprehending and following through on management plans were challenging. The extended time taken by visits with our Burmese patients affected patient flow and clinic efficiency. An integrated care model offers several advantages. Serving as a medical home to this population created a sense of trust between patients and providers. We focused on refugee-specific matters and general health issues concurrently and could effectively coordinate care with the resettlement agency and community. However, this model of care also presented distinct challenges. Varying degrees of cultural competence meant different levels of comfort in caring for this population. Our screening protocol was developed in parallel with home visits and ongoing primary care, limiting its effective, widespread implementation. We were faced with the question of when and how to shift the focus from fulfilling the needs of the newly arrived refugee to those of the primary care patient. Finally, though this vulnerable population merited special attention, we struggled with how to balance their needs with those of our other patients. With tens of thousands of refugees being resettled annually in the United States,5 exposure to their medical care needs is a vital component of residency training and one that fosters cultural competency. Our interventions provided structure and built trust as we cared for this population. Though rife with challenges, we believe a residency clinic can provide effective, comprehensive care to refugees.

Taking it Global: Structuring Global Health Education in Residency Training

ABSTRACTTo meet the demand by residents and to provide knowledge and skills important to the developing physician, global health (GH) training opportunities are increasingly being developed by United States (U.S.) residency training programs. However, many residency programs face common challenges of developing GH curricula, offering safe and mentored international rotations, and creating GH experiences that are of service to resource-limiting settings. Academic GH partnerships allow for the opportunity to collaborate on education and research and improve health care and health systems, but must ensure mutual benefit to U.S. and international partners. This article provides guidance for incorporating GH education into U.S. residency programs in an ethically sound and sustainable manner, and gives examples and solutions for common challenges encountered when developing GH education programs.