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Shet AS, Rao A, Jebaraj P, Mascarenhas M, Zwarenstein M, Galanti MR, Atkins S. Lay health workers perceptions of an anemia control intervention in Karnataka, India: a qualitative study. BMC Public Health 2017; 17:720. [PMID: 28923041 PMCID: PMC5604152 DOI: 10.1186/s12889-017-4758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background Lay health workers (LHWs) are increasingly used to complement health services internationally. Their perceptions of the interventions they implement and their experiences in delivering community based interventions in India have been infrequently studied. We developed a novel LHW led intervention to improve anemia cure rates in rural community dwelling children attending village day care centers in South India. Since the intervention is delivered by the village day care center LHW, we sought to understand participating LHWs’ acceptance of and perspectives regarding the intervention, particularly in relation to factors affecting daily implementation. Methods We conducted a qualitative study alongside a cluster randomized controlled trial evaluating a complex community intervention for childhood anemia control in Karnataka, South India. Focus group discussions (FGDs) were conducted with trained LHWs assigned to deliver the educational intervention. These were complemented by non-participant observations of LHWs delivering the intervention. Transcripts of the FGDs were translated and analyzed using the framework analysis method. Results Several factors made the intervention acceptable to the LHWs and facilitated its implementation including pre-implementation training modules, intervention simplicity, and ability to incorporate the intervention into the routine work schedule. LHWs felt that the intervention impacted negatively on their preexisting workload. Fluctuating relationships with mothers weakened the LHWs position as providers of the intervention and hampered efficient implementation, despite the LHWs’ highly valued position in the community. Modifiable barriers to the successful implementation of this intervention were seen at two levels. At a broader contextual level, hindering factors included the LHW being overburdened, inadequately reimbursed, and receiving insufficient employer support. At the health system level, lack of streamlining of LHW duties, inability of LHWs to diagnose anemia and temporary shortfalls in the availability of iron supplements constituted potentially modifiable barriers. Conclusion This qualitative study identified some of the practical challenges as experienced by LHWs while delivering a community health intervention in India. Methodologically, it highlights the value of qualitative research in understanding implementation of complex community interventions. On the contextual level, the results indicate that efficient delivery of community interventions will require streamlining of LHW workloads and improved health system infrastructure support. Trial registration This trial was registered with ISRCTN.com (identifier: ISRCTN68413407) on 23 September 2013.
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Affiliation(s)
- Arun S Shet
- Hematology Research Division, St. Johns Research Institute, St. Johns National Academy of Health Sciences, Bangalore, 560034, India. .,Department of Hematology/Medical Oncology, St. Johns Medical College and Hospital, Bangalore, India. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Abha Rao
- Hematology Research Division, St. Johns Research Institute, St. Johns National Academy of Health Sciences, Bangalore, 560034, India
| | - Paul Jebaraj
- Hematology Research Division, St. Johns Research Institute, St. Johns National Academy of Health Sciences, Bangalore, 560034, India
| | | | - Merrick Zwarenstein
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Maria Rosaria Galanti
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Centre for Epidemiology and Community Medicine, Stockholm Health Care District, Stockholm, Sweden
| | - Salla Atkins
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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George A, Tetui M, Pariyo GW, Peterson SS. Maternal and newborn health implementation research: programme outcomes, pathways of change and partnerships for equitable health systems in Uganda. Glob Health Action 2017; 10:1359924. [PMID: 28876193 PMCID: PMC5786315 DOI: 10.1080/16549716.2017.1359924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Asha George
- School of Public Health, University of the Western Cape, Bellville, Republic of South Africa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Moses Tetui
- Makerere University School of Public Health (MakSPH), Makerere University, Kampala, Uganda
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - George W Pariyo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Stefan S Peterson
- Makerere University School of Public Health (MakSPH), Makerere University, Kampala, Uganda
- Health Section, Programme Division, UNICEF NY, New York, NY, USA
- International Maternal and Child Health, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
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Chandler CIR, Burchett H, Boyle L, Achonduh O, Mbonye A, DiLiberto D, Reyburn H, Onwujekwe O, Haaland A, Roca-Feltrer A, Baiden F, Mbacham WF, Ndyomugyenyi R, Nankya F, Mangham-Jefferies L, Clarke S, Mbakilwa H, Reynolds J, Lal S, Leslie T, Maiteki-Sebuguzi C, Webster J, Magnussen P, Ansah E, Hansen KS, Hutchinson E, Cundill B, Yeung S, Schellenberg D, Staedke SG, Wiseman V, Lalloo DG, Whitty CJM. Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies. Health Syst Reform 2016; 2:373-388. [PMID: 31514719 PMCID: PMC6176770 DOI: 10.1080/23288604.2016.1179086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.
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Affiliation(s)
- Clare I R Chandler
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Helen Burchett
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Louise Boyle
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Olivia Achonduh
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | - Anthony Mbonye
- School of Public Health-Makerere University & Commissioner Health Services, Ministry of Health , Kampala , Uganda
| | - Deborah DiLiberto
- Clinical Research Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hugh Reyburn
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics , University of Nigeria Enugu-Campus , Enugu , Nigeria
| | - Ane Haaland
- Institute of Health and Society , Department of Community Medicine , Blindern , Oslo , Norway
| | | | - Frank Baiden
- Malaria Group, Kintampo Health Research Centre , Kintampo , Ghana
| | - Wilfred F Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | | | - Florence Nankya
- Infectious Diseases Research Collaboration , Kampala , Uganda
| | - Lindsay Mangham-Jefferies
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sian Clarke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hilda Mbakilwa
- Joint Malaria Programme, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Joanna Reynolds
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sham Lal
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Toby Leslie
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | | | - Jayne Webster
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen , Denmark
| | - Evelyn Ansah
- Dangme West District Health Directorate, Ghana Health Service , Dodowa , Ghana
| | - Kristian S Hansen
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Eleanor Hutchinson
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Bonnie Cundill
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Shunmay Yeung
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - David Schellenberg
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Sarah G Staedke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Virginia Wiseman
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK.,School of Public Health and Community Medicine , Kensington , New South Wales , Australia
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Shet AS, Zwarenstein M, Mascarenhas M, Risbud A, Atkins S, Klar N, Galanti MR. The Karnataka Anemia Project 2--design and evaluation of a community-based parental intervention to improve childhood anemia cure rates: study protocol for a cluster randomized controlled trial. Trials 2015; 16:599. [PMID: 26718897 PMCID: PMC4697328 DOI: 10.1186/s13063-015-1135-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 12/18/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Childhood anemia is highly prevalent worldwide. Improving the hemoglobin level of preschool age children could yield substantial benefits in cognitive and psychosocial development and overall health. While evidence-based recommendations for reducing childhood anemia in high anemia prevalence countries are available, there is no experimental evidence of community centered education and counseling programs, as a route to improved acceptance of iron supplements, demonstrating beneficial effects on anemia outcomes. We report on the evaluation protocol of a complex educational intervention led by the community lay health worker (LHW) and delivered to mothers of 12-59-month-old anemic children living in and visiting village day care centers in a large district of southern India. METHODS AND DESIGN The study is designed as a cluster randomized controlled trial. The intervention is based on the social cognitive theory and aims to promote among mothers, anemia awareness, dietary modifications to increase iron intake in the child, and recognition of the need for enhanced adherence to supplemental iron in the anemic child. From 270 eligible villages in the study area, a sample of 60 villages will be randomized to intervention [n = 30] or to treatment as usual [n = 30] of the study. LHWs in the intervention arm will be trained to administer the following intervention components to mothers of anemic children: 1] monthly distribution of Iron and folic acid (IFA) supplements to mothers of anemic children, and 2] five monthly counseling sessions of mothers of anemic children covering: a] anemia awareness education b] IFA adherence counseling and assessment, c] dietary modification to improve iron intake, and d] hygiene and sanitation. LHWs in the control arm will distribute IFA to mothers of anemic children as in the intervention arm but will not provide monthly education and counseling support. The primary outcome is the difference between the two experimental groups in anemia cure rates of children found to be anemic at baseline. Secondary outcomes, assessed as differences between all participants in both experimental groups, are: change in mothers' knowledge regarding anemia; 24 hour dietary iron intake; net improvement in individual hemoglobin values; serum ferritin; and the difference in overall cluster level childhood anemia prevalence. All outcomes will be measured 6 months after the start of the intervention. Multilevel linear and logistic regression models will be used to analyze differences between intervention and control groups in outcome variables. DISCUSSION This trial is designed to evaluate the effectiveness of an intervention intended to improve anemia cure rates in anemic children living in villages of Chamarajnagar, Karnataka a large district in south India. The extensive study of secondary endpoints will be used to identify possible weak points in the compliance to intervention delivery and uptake. This evaluation is one of the few large randomized trials evaluating the impact of an education and counseling intervention to reduce childhood anemia prevalence. TRIAL REGISTRATION This trial was registered with ISRCTN.com (identifier: ISRCTN68413407) on 17 September 2013.
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Affiliation(s)
- Arun S Shet
- Hematology Research Division, St. Johns Research Institute, Bangalore, India.
- Department of Medical Oncology, St. Johns Medical College and Hospital, Bangalore, India.
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Merrick Zwarenstein
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | | | | | - Salla Atkins
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Neil Klar
- Department of Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Maria Rosaria Galanti
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
- Centre for Epidemiology and Community Medicine, Stockholm Health Care District, Stockholm, Sweden.
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Nanyonjo A, Nakirunda M, Makumbi F, Tomson G, Källander K. Community acceptability and adoption of integrated community case management in Uganda. Am J Trop Med Hyg 2015; 87:97-104. [PMID: 23136284 PMCID: PMC3748529 DOI: 10.4269/ajtmh.2012.11-0763] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Integrated community case management (iCCM) is a recommended strategy to curb child mortality. Drawing on diffusion of innovations (DOIs), the acceptability and adoption of iCCM were qualitatively explored. Data from focus group discussions and interviews with community members, community health workers (CHWs), and supervisors conducted in seven communities were analyzed using content analysis. Perceived relative advantage and compatibility of the program with sociocultural beliefs and healthcare expectations of the communities positively affected acceptability and adoption of iCCM. The degree of stringency, quality, and cost of access to healthcare were crucial to adoption. Failure of the health system to secure regular drug supplies, monetary support, and safe referrals globally hindered adoption. Individual CHW characteristics like undesired behavior, demotivation, and lack of reciprocated trust deterred adoption in some areas. Optimal functioning of iCCM programs will require community sensitization and targeted health systems strengthening to enhance observable program benefits like reduced child mortality.
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Affiliation(s)
- Agnes Nanyonjo
- *Address correspondence to Agnes Nanyonjo, Malaria Consortium Uganda, PO Box 8045, Kampala, Uganda and Division of Global Health (IHCAR), Karolinska Institutet, 17177 Stockholm, Sweden. E-mail:
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Reynolds J, DiLiberto D, Mangham-Jefferies L, Ansah EK, Lal S, Mbakilwa H, Bruxvoort K, Webster J, Vestergaard LS, Yeung S, Leslie T, Hutchinson E, Reyburn H, Lalloo DG, Schellenberg D, Cundill B, Staedke SG, Wiseman V, Goodman C, Chandler CIR. The practice of 'doing' evaluation: lessons learned from nine complex intervention trials in action. Implement Sci 2014; 9:75. [PMID: 24935096 PMCID: PMC4079170 DOI: 10.1186/1748-5908-9-75] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/13/2014] [Indexed: 01/16/2023] Open
Abstract
Background There is increasing recognition among trialists of the challenges in understanding how particular ‘real-life’ contexts influence the delivery and receipt of complex health interventions. Evaluations of interventions to change health worker and/or patient behaviours in health service settings exemplify these challenges. When interpreting evaluation data, deviation from intended intervention implementation is accounted for through process evaluations of fidelity, reach, and intensity. However, no such systematic approach has been proposed to account for the way evaluation activities may deviate in practice from assumptions made when data are interpreted. Methods A collective case study was conducted to explore experiences of undertaking evaluation activities in the real-life contexts of nine complex intervention trials seeking to improve appropriate diagnosis and treatment of malaria in varied health service settings. Multiple sources of data were used, including in-depth interviews with investigators, participant-observation of studies, and rounds of discussion and reflection. Results and discussion From our experiences of the realities of conducting these evaluations, we identified six key ‘lessons learned’ about ways to become aware of and manage aspects of the fabric of trials involving the interface of researchers, fieldworkers, participants and data collection tools that may affect the intended production of data and interpretation of findings. These lessons included: foster a shared understanding across the study team of how individual practices contribute to the study goals; promote and facilitate within-team communications for ongoing reflection on the progress of the evaluation; establish processes for ongoing collaboration and dialogue between sub-study teams; the importance of a field research coordinator bridging everyday project management with scientific oversight; collect and review reflective field notes on the progress of the evaluation to aid interpretation of outcomes; and these approaches should help the identification of and reflection on possible overlaps between the evaluation and intervention. Conclusion The lessons we have drawn point to the principle of reflexivity that, we argue, needs to become part of standard practice in the conduct of evaluations of complex interventions to promote more meaningful interpretations of the effects of an intervention and to better inform future implementation and decision-making.
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Affiliation(s)
- Joanna Reynolds
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Pollock AM, Price D. Loss of population data sources when health systems are not responsible for geographically defined populations: implications of the Health and Social Care Act of 2012 in England. ACTA ACUST UNITED AC 2013; 19:4-5. [PMID: 23645887 DOI: 10.1136/eb-2013-101287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Biomedical health services and health systems research require timely, complete, accurate and accessible data relating to geographical populations in order to facilitate needs assessment and planning of medical care, new medicines and technology. The international trend towards competition and privatisation has largely proceeded as if data generation were immune to market fragmentation and loss of universal coverage. By examining recent reforms to the English National Health Service, the authors show that this is not the case. Routine and population data are products of administrative systems and the nature, completeness and quality of data available to clinical and public health researchers are substantially impaired by market reforms.
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Affiliation(s)
- Allyson M Pollock
- Centre for Primary Care and Public Health, Queen Mary, University of London, , London, UK
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Ricca J, Kureshy N, LeBan K, Prosnitz D, Ryan L. Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact. Health Policy Plan 2013; 29:204-16. [PMID: 23434515 DOI: 10.1093/heapol/czt005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Evidence exists that community-based intervention packages can have substantial child and newborn mortality impact, and may help more countries meet Millennium Development Goal 4 (MDG 4) targets. A non-governmental organization (NGO) project using such programming in Mozambique documented an annual decline in under-five mortality rate (U5MR) of 9.3% in a province in which Demographic and Health Survey (DHS) data showed a 4.2% U5MR decline during the same period. To test the generalizability of this finding, the same analysis was applied to a group of projects funded by the US Agency for International Development. Projects supported implementation of community-based intervention packages aimed at increasing use of health services while improving preventive and home-care practices for children under five. METHODS All projects collect baseline and endline population coverage data for key child health interventions. Twelve projects fitted the inclusion criteria. U5MR decline was estimated by modelling these coverage changes in the Lives Saved Tool (LiST) and comparing with concurrent measured DHS mortality data. RESULTS Average coverage changes for all interventions exceeded average concurrent trends. When population coverage changes were modelled in LiST, they were estimated to give a child mortality improvement in the project area that exceeded concurrent secular trend in the subnational DHS region in 11 of 12 cases. The average improvement in modelled U5MR (5.8%) was more than twice the concurrent directly measured average decline (2.5%). CONCLUSIONS NGO projects implementing community-based intervention packages appear to be effective in reducing child mortality in diverse settings. There is plausible evidence that they raised coverage for a variety of high-impact interventions and improved U5MR by more than twice the concurrent secular trend. All projects used community-based strategies that achieved frequent interpersonal contact for health behaviour change. Further study of the effectiveness and scalability of similar packages should be part of the effort to accelerate progress towards MDG 4.
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Affiliation(s)
- Jim Ricca
- MCHIP, 1776 Massachusetts Ave NW Suite 300, Washington, DC 20036, USA. E-mail:
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Nelson BD, Kasper J, Hibberd PL, Thea DM, Herlihy JM. Developing a Career in Global Health: Considerations for Physicians-in-Training and Academic Mentors. J Grad Med Educ 2012; 4:301-6. [PMID: 23997872 PMCID: PMC3444181 DOI: 10.4300/jgme-d-11-00299.1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Global health is an expansive field, and global health careers are as diverse as the practice of medicine, with new paths being forged every year. Interest in global health among medical students, residents, and fellows has never been higher. As a result, a greater number of these physicians-in-training are participating in global health electives during their training. However, there is a gap between the level of trainee interest and the breadth and depth of educational opportunities that prepare them for a career in global health. OBJECTIVE Global health experiences can complement and enhance each step of traditional physician training, from medical school through residency and fellowship. Global health experiences can expose trainees to patients with diverse pathologies, improve physical exam skills by decreasing reliance on laboratory tests and imaging, enhance awareness of costs and resource allocation in resource-poor settings, and foster cultural sensitivity. The aim of this article is to describe issues faced by physicians-in-training and the faculty who mentor them as trainees pursue careers in global health. METHODS We conducted a narrative review that addresses opportunities and challenges, competing demands on learners' educational schedules, and the need for professional development for faculty mentors. CONCLUSIONS A widening gap between trainee interest and the available educational opportunities in global health may result in many medical students and residents participating in global health experiences without adequate preparation and mentorship. Without this essential support, global health training experiences may have detrimental consequences on both trainees and the communities hosting them. We discuss considerations at each training level, options for additional training, current career models in global health, and challenges and potential solutions during training and early career development.
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Svoronos T, Mate KS. Evaluating large-scale health programmes at a district level in resource-limited countries. Bull World Health Organ 2011; 89:831-7. [PMID: 22084529 DOI: 10.2471/blt.11.088138] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 06/27/2011] [Accepted: 07/03/2011] [Indexed: 11/27/2022] Open
Abstract
Recent experience in evaluating large-scale global health programmes has highlighted the need to consider contextual differences between sites implementing the same intervention. Traditional randomized controlled trials are ill-suited for this purpose, as they are designed to identify whether an intervention works, not how, when and why it works. In this paper we review several evaluation designs that attempt to account for contextual factors that contribute to intervention effectiveness. Using these designs as a base, we propose a set of principles that may help to capture information on context. Finally, we propose a tool, called a driver diagram, traditionally used in implementation that would allow evaluators to systematically monitor changing dynamics in project implementation and identify contextual variation across sites. We describe an implementation-related example from South Africa to underline the strengths of the tool. If used across multiple sites and multiple projects, the resulting driver diagrams could be pooled together to form a generalized theory for how, when and why a widely-used intervention works. Mechanisms similar to the driver diagram are urgently needed to complement existing evaluations of large-scale implementation efforts.
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Affiliation(s)
- Theodore Svoronos
- Institute for Healthcare Improvement, 20 University Road, Cambridge, MA 02138, United States of America.
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Osrin D, Prost A. Perinatal interventions and survival in resource-poor settings: which work, which don't, which have the jury out? Arch Dis Child 2010; 95:1039-46. [PMID: 20980274 PMCID: PMC3428881 DOI: 10.1136/adc.2009.179366] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
UNLABELLED Perinatal conditions make the largest contribution to the burden of disease in low-income countries. Although postneonatal mortality rates have declined, stillbirth and early neonatal mortality rates remain high in many countries in Africa and Asia, and there is a concentration of mortality around the time of birth. Our article begins by considering differences in the interpretation of 'intervention' to improve perinatal survival. We identify three types of INTERVENTION a single action, a collection of actions delivered in a package and a broader social or system approach. We use this classification to summarise the findings of recent systematic reviews and meta-analyses. After describing the growing evidence base for the effectiveness of community-based perinatal care, we discuss current concerns about integration: of women's and children's health programmes, of community-based and institutional care, and of formal and informal sector human resources. We end with some thoughts on the complexity of choices confronting women and their families in low-income countries, particularly in view of the growth in non-government and private sector healthcare.
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Affiliation(s)
- David Osrin
- Centre for International Health and Development, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Whitworth J, Sewankambo NK, Snewin VA. Improving implementation: building research capacity in maternal, neonatal, and child health in Africa. PLoS Med 2010; 7:e1000299. [PMID: 20625547 PMCID: PMC2897765 DOI: 10.1371/journal.pmed.1000299] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
As part of a series on maternal, neonatal, and child health in sub-Saharan Africa, Valerie Snewin and colleagues discuss the challenges of implementation and research capacity in Africa.
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