Strengthening medical specialisation policy in low-income and middle-income countries

Bridging the knowledge gap! Health outcomes in informal e-waste workers

BACKGROUND

Although several studies analyzed the impact of e-waste recycling on human health, most publications did not differ between e-waste workers and bystanders, such as residents. This could lead to an underestimation of health effects in workers. In addition, frequently reported surrogate findings do not properly reflect clinical significant health outcomes. The aim of this review was to analyze the direct health effects of informal e-waste recycling in informal e-waste workers.

METHODS

According to PRISMA guidelines, we systematically searched 3 databases (Embase®, PubMed®, Web of Science) for studies from low- and middle-income countries published in German or English between 1980 and 1 November 2021. Of the 2613 hits, 26 studies (cross-sectional, longitudinal and case-control studies) met the specified criteria and were included. We categorized the results into hormonal, respiratory, renal, cardiovascular, musculoskeletal health and general symptoms in informal e-waste workers.

RESULTS

Exposure to e-waste was associated with altered lipid metabolism, thyroid hormonal imbalances, impaired fertility, renal dysfunction, increased prevalence of respiratory symptoms, asthma, cardiac arrhythmias, hypertension, musculoskeletal pain, injuries in up to 89% and skin disorders in up to 87.5-100% of e-waste workers.

CONCLUSION

Due to inconsistent findings, weak associations or poor study quality, it has rarely been possible to establish a causal relationship between informal e-waste work and health effects, except for injuries or skin conditions. Besides high-quality studies, a collective national and international political focus on e-waste disposal is needed.

Building Consensus on the Point-of-Care Ultrasound Skills Required for Effective Healthcare Service Delivery at District Hospitals in South Africa: A Delphi Study

BACKGROUND

Despite the widespread availability of ultrasound machines in South African district hospitals, there are no guidelines on the competency in point-of-care ultrasound (POCUS) use required by generalist doctors in this setting. This study aimed to define the required POCUS competencies by means of consensus via the Delphi method.

METHODS

An online Delphi process was initiated in June 2022, using the existing American Academy of Family Physicians' ultrasound curriculum (84 skillsets) as the starting questionnaire. Panelists were selected across the country, including two from district hospitals in each province and two from each academic family medicine department in South Africa (N = 36). In each iterative round, the participants were asked to identify which POCUS skillsets were essential, optional (region-specific), or non-essential for South African district hospitals. This process continued until consensus (>70% agreement) was achieved on all of the skillsets.

RESULTS

Consensus was achieved on 81 of the 84 skillsets after 5 iterative rounds (96.4%), with 3 skillsets that could not achieve consensus (defined as <5% change over more than 2 consecutive rounds). The final consensus identified 38 essential, 28 optional, and 15 non-essential POCUS skillsets for the South African district hospital context.

CONCLUSIONS

The list of essential POCUS skillsets provided by this study highlights the predominance of obstetric- and trauma-based skillsets required for generalist healthcare workers in South African district hospitals. The findings will require priority setting and revalidation prior to their implementation across the country.

Pain management in cancer surgery: Global inequities and strategies to address them

Among patients undergoing surgical oncologic operations, patients in low- and middle-income countries are at particularly high risk for inadequate perioperative analgesia. This article reviews some of the guiding pillars of pain management for cancer surgery, including use of regional analgesia and acute pain service consultation, multimodal adjunctive analgesia, and judicious opioid use while presenting data on international disparities for each pillar and proposing strategies to address these inequities.

Going Back Home: Understanding Physician Migration to the United States

In 2021, US foreign-born population reached a high of 14.2% of the total US population. Up to 28% of US working immigrants are physicians. The decision to leave one's home country, though, is rarely an easy one to make and is often riddled with cultural and emotional challenges.

Specialty preferences of studying-abroad medical students from low- and middle-income countries

BACKGROUND

This study explored the specialty preferences of China-educated international medical students (IMSs), who are mainly from low- and middle-income countries (LMICs) and constitute a potential medical workforce both for their home countries and foreign countries, and the influence of migration intentions on their specialty preferences.

METHODS

A cross-sectional, questionnaire-based survey was conducted at 5 universities in China. The questionnaire link was distributed electronically among the IMSs at the 5 universities via emails. The questionnaire enquired IMSs' demographic information, migration intentions and their specialty preferences. The Chi-square test was applied to determine the influence of the respondent's gender, intention to practise in the home country and intention to practise in a high-income country on their specialty choices. The Chi-square test was also applied to determine the influence of the respondent's gender, year of study and country of origin on their preferences for generalist-orientated or non-generalist orientated specialties.

RESULTS

Altogether, 452 IMSs returned their responses, yielding a response rate of 64.1%. Approximately half of the IMSs planned to not return to their home country. The most selected specialty was general surgery and the least selected specialty was physical medicine and rehabilitation. No significant differences were evident in most specialty preferences between those who intended to return home and those who intended to stay abroad. Among the IMSs having intentions of returning to their home country, male students tended to choose a generalist-orientated specialty, while female students tended to choose a non-generalist-orientated specialty.

CONCLUSION

China-educated IMSs could play important roles in the primary care services as well as other shortage specialties both for their home countries or foreign countries. Therefore, it is recommended that governments in these countries plan migration and recruitment policies that cater for these studying-abroad medical students from LMICs, especially in this challenging time during the COVID-19 pandemic.

Performance and Agreement When Annotating Chest X-ray Text Reports—A Preliminary Step in the Development of a Deep Learning-Based Prioritization and Detection System

A chest X-ray report is a communicative tool and can be used as data for developing artificial intelligence-based decision support systems. For both, consistent understanding and labeling is important. Our aim was to investigate how readers would comprehend and annotate 200 chest X-ray reports. Reports written between 1 January 2015 and 11 March 2022 were selected based on search words. Annotators included three board-certified radiologists, two trained radiologists (physicians), two radiographers (radiological technicians), a non-radiological physician, and a medical student. Consensus labels by two or more of the experienced radiologists were considered “gold standard”. Matthew’s correlation coefficient (MCC) was calculated to assess annotation performance, and descriptive statistics were used to assess agreement between individual annotators and labels. The intermediate radiologist had the best correlation to “gold standard” (MCC 0.77). This was followed by the novice radiologist and medical student (MCC 0.71 for both), the novice radiographer (MCC 0.65), non-radiological physician (MCC 0.64), and experienced radiographer (MCC 0.57). Our findings showed that for developing an artificial intelligence-based support system, if trained radiologists are not available, annotations from non-radiological annotators with basic and general knowledge may be more aligned with radiologists compared to annotations from sub-specialized medical staff, if their sub-specialization is outside of diagnostic radiology.

Quality of maternal healthcare and travel time influence birthing service utilisation in Ghanaian health facilities: a geographical analysis of routine health data

OBJECTIVES

To investigate how the quality of maternal health services and travel times to health facilities affect birthing service utilisation in Eastern Region, Ghana.

DESIGN

The study is a cross-sectional spatial interaction analysis of birth service utilisation patterns. Routine birth data were spatially linked to quality care, service demand and travel time data.

SETTING

131 Health facilities (public, private and faith-based) in 33 districts in Eastern Region, Ghana.

PARTICIPANTS

Women who gave birth in health facilities in the Eastern Region, Ghana in 2017.

OUTCOME MEASURES

The count of women giving birth, the quality of birthing care services and the geographic coverage of birthing care services.

RESULTS

As travel time from women's place of residence to the health facility increased up to two2 hours, the utilisation rate markedly decreased. Higher quality of maternal health services haves a larger, positive effect on utilisation rates than service proximity. The quality of maternal health services was higher in hospitals than in primary care facilities. Most women (88.6%) travelling via mechanised transport were within two2 hours of any birthing service. The majority (56.2%) of women were beyond the two2 -hour threshold of critical comprehensive emergency obstetric and newborn care (CEmONC) services. Few CEmONC services were in urban centres, disadvantaging rural populations.

CONCLUSIONS

To increase birthing service utilisation in Ghana, higher quality health facilities should be located closer to women, particularly in rural areas. Beyond Ghana, routinely collected birth records could be used to understand the interaction of service proximity and quality.

Comparison between the world health organization (WHO) and international society of hypertension (ISH) guidelines for hypertension

The global burden of hypertension remains an unsolved problem, especially in low- and middle-income countries (LMICs). For this reason, clinical practice guidelines containing the latest evidence-based recommendations are crucial in the management of hypertension. It is noteworthy that guidelines simply translated from those of high-income countries (HICs) are not the solution to the problem of hypertension in LMICs. Among the numerous guidelines available, those of the World Health Organisation and the International Society of Hypertension are the latest to be published as of the writing of this article. In this review, we conducted both general and specific comparisons between the recommendations supplied by both guidelines. Differences in aspects of hypertension management such as the timing of antihypertensive initiation, assessment of comorbidities and cardiovascular risk factors, pharmacological therapy selection, and blood pressure target and reassessment are explored. Lastly, the implications of the differences found between the two guidelines in both LMICs and HICs are discussed.Key messagesCurrently, with low treatment and control rates, hypertension remains a burden in low- and middle-income countries (LMICs).The lack of customised guidelines for LMICs cannot be solved simply by adopting guidelines from high-income countries.The World Health Organisation (WHO) recently published a clinical guideline for the pharmacological management of hypertension in LMICs. We compare select recommendations from the guidelines to those published by the International Society of Hypertension.

Applicability of European Society of Cardiology guidelines according to gross national income

AIMS

To assess the feasibility to comply with the recommended actions of ESC guidelines on general cardiology areas in 102 countries and assess how compliance relates to the country's income level.

METHODS AND RESULTS

All recommendations from seven ESC guidelines on general cardiology areas were extracted and labelled on recommended actions. A survey was sent to all 102 ESC national and affiliated cardiac societies (NCSs). Respondents were asked to score recommended actions on their availability in clinical practice on a four-point Likert scale (fully available, mostly/often available, mostly/often unavailable, fully unavailable), and select the top three barriers perceived as being responsible for limiting their national availability. Applicability was assessed overall, per World Bank gross national income (GNI) level, and per guideline.A total of 875 guideline recommendations on general cardiology was extracted. Responses were received from 64 of 102 (62.7%) NCSs. On average, 71·6% [95% confidence interval (CI): 68.6-74.6] of the actions were fully available, 9.9% (95% CI: 8.7-11.1) mostly/often available, 6.7% (95% CI: 5.4-8.0) mostly/often unavailable, and 11·8% (95% CI: 9.5-14.1) fully unavailable. In low-income countries (LICs), substantially more actions were fully unavailable [29·4% (95% CI: 22.6-36.3)] compared with high-income countries [HICs, countries 2.4% (95% CI: 1.2-3.7); P < 0.05]. Nevertheless, a proportion of actions with the lowest availability scores were often fully or mostly unavailable independent of GNIs. Actions were most often not available due to lack of reimbursement and other financial barriers.

CONCLUSION

Local implementation of ESC guidelines on general cardiology is high in HICs and low in LICs , being inversely correlated with country gross national incomes.

House officers' specialist career choices and motivators for their choice- a sequential mixed-methods study from Malaysia

PURPOSE

Shortage and maldistribution of medical specialists hamper healthcare quality. The specialist career choices of house officers determines the future composition of healthcare systems. We studied house officers'' specialist career choices and motivators for their choice.

PARTICIPANTS AND METHODS

We conducted online in-depth interviews among seven house officers using an interview guide developed based on a literature review. The transcripts were analyzed. Major themes were identified. A 33-item questionnaire was developed, and the main and sub-themes were identified as motivators for specialist career choice. An online survey was done among 185 house officers. Content validation of motivators for specialist choice was done using exploratory factor analysis. First, second and third choices for a specialist career were identified. Multinomial logistic regression analyses were done to determine the socio-demographic factors and motivators associated with the first choice.

RESULTS

HOs perceived that specialist training opportunities provide a wide range of clinical competencies through well-structured, comprehensive training programs under existing specialist training pathways. Main challenges were limited local specialist training opportunities and hurdles for 'on-contract' HO to pursue specialist training. Motivators for first-choice specialty were related to 'work schedule', 'patient care characteristics', 'specialty characteristics', 'personal factors', 'past work experience', 'training factors', and 'career prospects.' House officers' first choices were specialties related to medicine (40.5%), surgery (31.5%), primary care (14.6%), and acute care (13.5%). On multivariate analysis, "younger age", "health professional in the family", "work schedule and personal factors", "career prospects" and "specialty characteristics" were associated with the first choice.

CONCLUSIONS

Medical and surgical disciplines were the most preferred disciplines and their motivators varied by individual discipline. Overall work experiences and career prospects were the most important motivators for the first-choice specialty. The information about motivational factors is helpful to develop policies to encourage more doctors to choose specialties with a shortage of doctors and to provide career specialty guidance.

Building PRM in sub-Saharan Africa

It is estimated that about 50% of people in low- and middle- income countries who require rehabilitation do not get it. Multidisciplinary rehabilitation services led by Physical and Rehabilitation Medicine (PRM) physicians have been shown to improve functioning, independence and the quality of life of persons with reduced functioning or disability. However, there is a dearth of PRM physicians in low to middle income countries (LMICs), particularly in sub-Saharan Africa. One potential solution to this lack of specialists is the establishment of PRM training programs, which are currently lacking. The International Rehabilitation Forum (IRF) developed and implemented a fellowship program to train physicians in rehabilitation medicine and has been successful in Ghana, Ethiopia and Cameroon, all LMICs in sub-Saharan Africa. However, ongoing challenges include inadequate PRM trainers, availability of logistics and services for hands on experience, and funding. The fellowship program has a promising future and an ultimate goal of having locally trained fellows leading the program and expanding it to other LMICs. There has however been no publication of the process followed to achieve this or of a similar process undertaken anywhere in Africa. The process followed in this publication highlights the journey from engaging stakeholders to the admission of new and current fellows in training.

Development and validation of motivators for medical specialist career choice questionnaire (MMSCCQ) - a methodological study

INTRODUCTION

A validated instrument to assess the motivating factors influencing junior doctors' medical specialist career choices is not available. The Motivators for Medical Specialist Career Choice Questionnaire (MMSCCQ) was developed and validated in the present study.

METHODS

An exploratory sequential mixed-methods study was conducted among house officers (HO) of a tertiary care hospital. A literature review was used to construct an interview guide. Seven HOs participated in an online, one-on-one audio-recorded in-depth interview (IDI). Seven sub-themes and 33 codes identified by thematic analyses were used to develop the MMSCCQ. The importance of each motivator was rated on a five-point Likert scale. The MMSCCQ was pretested, and a random sample of 262 house officers was invited to participate in an online survey. Psychometric evaluation was done using reliability statistics, and exploratory and confirmatory factor analyses.

RESULTS

The seven main themes identified by thematic analyses were labeled as factors related to 'work schedule and personal life,' 'training opportunities', 'past work experiences', 'specialty characteristics', 'career prospects', 'patient care characteristics', and 'social factors.' The highest ratings were given to "previous job experience" and "patient care traits. "The response rate was 71%, the mean age of the 185 HOs was 26.7 years (SD = 1.6). Females made up 63.8% of the population. The internal consistency for the overall questionnaire measured by Cronbach's alpha was 0.85. Each construct demonstrated an acceptable internal consistency. Twenty-six of 33 items were maintained after an exploratory factor analysis was conducted, yielding 7 constructs with a 64.9% variance. Confirmatory factor analyses established the construct validity.

CONCLUSION

The MMSCCQ has acceptable reliability and construct validity. Further studies are needed to test psychometric properties in different settings.

Lessons learned from the history of postgraduate medical training in Japan: from disease-centred care to patient-centred care in an aging society

BACKGROUND

Health workers, the core of health service delivery and a key driver of progress towards universal health coverage, must be available in sufficient numbers and distributed fairly to serve the entire population. In addition, the planning and management of the health workforce must be responsive to the changing needs of society, including changes in age structure and epidemiology. Considering these issues, this paper examines in historical perspective the evolution of postgraduate medical training and practice in Japan, from the late nineteenth century to the present.

MAIN TEXT

When the first medical schools were established in the country towards the end of the nineteenth century, Japan was a largely agrarian society, with a population of about 30 million and an average life expectancy of 30-40 years. During the twentieth century, life expectancy and the national population continued to increase in a context of rapid economic growth. Since the 1980s, another demographic transition has occurred: low fertility rates and an aging society. As a result, the inputs and skills required from health professionals have changed considerably over time, posing new challenges to the national health sector and the management of human resources for health.

CONCLUSIONS

The case of Japan offers valuable lessons for other countries experiencing a rapid epidemiological and demographic transition. To provide medical care that meets health priorities in the communities, we must consider not only the training of specialists, but also ensure the availability of a large cadre of physicians who possess basic skills and can provide patient-centred care. Furthermore, the Japanese experience shows that a highly hierarchical system and organisational culture are ill-suited to respond quickly to the changing demands of society.

Disparities in obstetric hemorrhage outcomes

Both the maternal and fetal outcomes of pregnancy vary greatly according to a pregnant woman’s community and her condition. The most devastating outcome is the death of a mother. In 2017, there were ≈295,000 maternal deaths globally with dramatic differences in maternal mortality based on geographic region, country, and women’s underlying conditions. Worldwide, the leading cause of maternal death is hemorrhage, comprising 94% of maternal deaths, with most cases occurring in low‐ or middle‐income countries. Whether a hemorrhage originates from inside the uterus (80%‐90%), from lacerations or incisions (10%‐20%), or from an underlying coagulopathy (<1%), an acute acquired coagulopathy will evolve unless the hemorrhage is controlled. In low‐ or middle‐income countries, the full range of resources to control hemorrhage is not available, but besides the usual obstetric measures, blood availability, hemostatic medication, and hematologic expertise are necessary to save mothers’ lives. Hemostasis and thrombosis experts can address the disparities in obstetric hemorrhage outcomes not only as providers but as consultants, researchers, and advocates.

The paediatrician workforce and its role in addressing neonatal, child and adolescent healthcare in Kenya

OBJECTIVE

To examine the availability of paediatricians in Kenya and plans for their development.

DESIGN

Review of policies and data from multiple sources combined with local expert insight.

SETTING

Kenya with a focus on the public, non-tertiary care sector as an example of a low-income and middle-income country aiming to improve the survival and long-term health of newborns, children and adolescents.

RESULTS

There are 305 practising paediatricians, 1.33 per 100 000 individuals of the population aged <19 years which in total numbers approximately 25 million. Only 94 are in public sector, non-tertiary county hospitals. There is either no paediatrician at all or only one paediatrician in 21/47 Kenyan counties that are home to over a quarter of a million under 19 years of age. Government policy is to achieve employment of 1416 paediatricians in the public sector by 2030, however this remains aspirational as there is no comprehensive training or financing plan to reach this target and health workforce recruitment, financing and management is now devolved to 47 counties. The vast majority of paediatric care is therefore provided by non-specialist healthcare workers.

DISCUSSION

The scale of the paediatric workforce challenge seriously undermines the ability of the Kenyan health system to deliver on the emerging survive, thrive and transform agenda that encompasses more complex health needs. Addressing this challenge may require innovative workforce solutions such as task-sharing, these may in turn require the role of paediatricians to be redefined. Professional paediatric communities in countries like Kenya could play a leadership role in developing such solutions.