Digital tools for direct assessment of autism risk during early childhood: A systematic review

LAY ABSTRACT

The challenge of finding autistic children, and finding them early enough to make a difference for them and their families, becomes all the greater in parts of the world where human and material resources are in short supply. Poverty of resources delays interventions, translating into a poverty of outcomes. Digital tools carry potential to lessen this delay because they can be administered by non-specialists in children's homes, schools or other everyday environments, they can measure a wide range of autistic behaviours objectively and they can automate analysis without requiring an expert in computers or statistics. This literature review aimed to identify and describe digital tools for screening children who may be at risk for autism. These tools are predominantly at the 'proof-of-concept' stage. Both portable (laptops, mobile phones, smart toys) and fixed (desktop computers, virtual-reality platforms) technologies are used to present computerised games, or to record children's behaviours or speech. Computerised analysis of children's interactions with these technologies differentiates children with and without autism, with promising results. Tasks assessing social responses and hand and body movements are the most reliable in distinguishing autistic from typically developing children. Such digital tools hold immense potential for early identification of autism spectrum disorder risk at a large scale. Next steps should be to further validate these tools and to evaluate their applicability in a variety of settings. Crucially, stakeholders from underserved communities globally must be involved in this research, lest it fail to capture the issues that these stakeholders are facing.

Evaluating the prerequisites for adapting a paediatric nighttime telemedicine and medication delivery service to a setting with high malarial burden: A cross-sectional pre-implementation study

OBJECTIVE

We sought to evaluate the prerequisites (demand, interest, feasibility) for adapting a paediatric nighttime telemedicine and medication delivery service (TMDS) to Ghana.

METHODS

A cross-sectional survey of households and associated healthcare providers was conducted in urban and rural Ghana. Households were identified through randomised geospatial sampling; households with at least one child <10 years were enrolled. Household surveys collected information relating to demographics, household resources, standardised case scenarios, recent paediatric health events, satisfaction with healthcare access, and interest in TMDS intervention models. Providers were identified by households and enrolled. Provider surveys collected provider type, hours of operation, services, and opinions of a TMDS model.

RESULTS

A total of 511 (263 urban, 248 rural) households and 18 providers (10 urban, 8 rural) were surveyed. A total of 262 health events involving children <10 years were reported, of which 47% occurred at night. Care was sought for >70% of health events presenting at night; however, care-seeking was delayed until morning or later for >75% of these events; 54% of households expressed dissatisfaction with their current access to paediatric care at night; 99% of households expressed that a nighttime TMDS service for children would be directly useful to their families. Correspondingly, 17 of 18 providers stated that a TMDS was needed in their community; >99% of households had access to a cellular phone. All households expressed willingness to use their phones to call a TMDS and allow a TMDS provider into their homes at night. Willingness to pay and provider-recommended price points varied by setting.

CONCLUSIONS

Prerequisites for adapting a TMDS to Ghana were met. A nighttime paediatric TMDS service was found to be needed, appealing, and feasible in Ghana. These data motivate the adaptation of a TMDS to urban and rural Ghana.

Disadvantaged Students Utilize School Campus and Its Resources More Than Non-disadvantaged Students

Introduction Disadvantaged populations were disproportionately affected by the COVID-19 pandemic, both in the medical and educational settings. Lower-income families often do not have a laptop/desktop computer, adequate internet connection, or a dedicated study space. This unfortunately contributed to poorer academic performance during distance learning. To combat this, the Kirk Kerkorian School of Medicine (KKSOM) did not close down campus during the pandemic. This study analyzes the utilization of campus and live Zoom lectures by KKSOM students and its impact on educational outcomes. Methods We sent an Institutional Review Board (IRB)-approved survey to KKSOM students and asked about study locations, Zoom lecture attendance, and relationship quality during the pandemic. The class of 2024 had a unique experience as they were first-year students during the start of the COVID-19 pandemic and the transition to online learning. However, they always had access to campus and technological resources. We compared the survey scores from a Qualtrics electronic survey and the National Board of Medical Examiners (NBME) scores of students who self-indicated disadvantaged status, first-generation, underrepresented minority, and lower socioeconomic status to those who did not meet these criteria. Data analysis was done using SPSS software version 28.0.1.1 (IBM Corp., Armonk, NY). Results  First-generation students studied on campus more frequently than their counterparts (31% versus 20%, p < 0.05) and less at home in general (55.4% versus 67.5%, p < 0.05). Lower socioeconomic status (SES) students attended live Zoom lectures more often as well (56.6% versus 43.1%, p < 0.05). Lastly, no significant differences were found between disadvantaged and non-disadvantaged groups for the class of 2024 in the NBME exam scores or relationship quality scores. Conclusion Our results suggest that students from disadvantaged backgrounds spend more time studying on campus than at home. Additionally, during the COVID-19 pandemic, they attended live Zoom lectures more often than their non-disadvantaged counterparts. Access to campus was not restricted for KKSOM students during the pandemic. This may be one explanation for the lack of disparity between disadvantaged and non-disadvantaged students with regard to academic performance and relationship quality. This makes a strong argument for the importance of campus accessibility for the success of students, especially those from disadvantaged backgrounds.

"Otherwise … he will be a beggar": a focus group study to understand the Perspectives of physiotherapists about measuring rehabilitation outcomes and impact in low-resource and conflict-affected settings

PURPOSE

Rehabilitation outcomes are important for patients, professionals and policy makers. Most outcome measures (OMs) were developed for "Western" contexts and may be inadequate for low-resource and conflict settings, where the ability to demonstrate impact would be critical to strengthening the sector. This study aims to understand perspectives of physiotherapists from challenging environments regarding current practices, value, barriers, and facilitators of measuring rehabilitation outcomes.

MATERIALS & METHODS

Focus group discussions were held in English with 35 physiotherapists from 18 countries. Audio recordings were transcribed verbatim, anonymised, and analysed using reflexive thematic analysis.

RESULTS

Four themes emerged illustrating the levels at which outcomes and measures were discussed: User (patients, families), provider (physiotherapists, rehabilitation workers), application (OMs), and structure (management, health system). Participants discussed diversity in current practices and patient populations, utility of OMs and a neglected rehabilitation sector lacking investment. Barriers to progressing outcome measurement included lacking patient health literacy, rehabilitation provider training, valid OMs, and leadership. Participants suggested improved patient involvement, routine outcome measurement by using, developing, or adapting simple, context- and stakeholder-relevant OMs, and support from management.

CONCLUSIONS

These insights illustrate the need of and provide robust recommendations for context-adapted development of rehabilitation outcome measurement in various challenging contexts.

Understanding Fertility Attitudes and Outcomes Among Survivors of Adolescent and Young Adult Cancers in a Low-Resource Setting: A Registry-Based Computer-Assisted Telephone Interview Survey

Purpose: To establish the extent of self-reported reproductive failure associated with cancer treatment, and attitudes toward fertility among adolescent and young adult (AYA) cancer survivors in Uganda. Methods: A registry-based computer-assisted telephone interview survey was conducted in Uganda. The survey population were survivors of childhood, adolescent and early adulthood cancers diagnosed between 2007 and 2018. The survey explored fertility outcomes, experiences of oncofertility and fertility attitudes of AYA cancer survivors. Results: Thirty-four (female = 14 and male = 20) interviews were completed. Survivors were 18-35 years of age. The median age at cancer diagnosis was 23.5 for females and 17.5 for males. Kaposi's sarcoma contributed to 44% of primary cancer diagnoses. All the survivors had received chemotherapy alone or in combination with other modalities and 79% of survivors had not received satisfactory information about future fertility before cancer treatment. Twenty one percent of males and 46% females met the criteria for infertility and 60% of these had met this criterion after their cancer diagnosis. Eighty two percent wanted to raise a biologically related child. Forty seven percent would be dissatisfied with their lives if they were unable to have a child or additional children. Conclusion: AYA cancer survivors in this low-resource setting reported reproductive failure, despite a strong fertility desire. Information and counseling provided on therapy-related problems before cancer treatment was insufficient and reinforces the need to build capacity for oncofertility resources within the region.

A narrative review of course evaluation methods for continuing professional development: The case of paediatric and neonatal acute-care in-service courses in low and lower-middle income countries: BEME Guide No. 76

BACKGROUND

Training a skilled healthcare workforce is an essential part in reaching the United Nations Sustainable Development Goal to end preventable deaths in children and neonates. The greatest burden of mortality lies in low and lower-middle income countries (LLMIC). Short term, in-service courses have been implemented in many LLMIC to improve the quality of care delivered, but the evaluation methods of these courses are inconsistent.

METHOD

Studies describing evaluations of course and outcome measures were included if the course lasted seven days or less with postgraduate participants, included paediatric or neonatal acute or emergency training and was based in a LLMIC. This narrative review provides a detailed description of evaluation methods of course content, delivery and outcome measures based on 'Context, Input, Process and Product' (CIPP) and Kirkpatrick models.

RESULTS

5265 titles were screened with 93 articles included after full-text review and quality assessment. Evaluation methods are described: context, input, process, participant satisfaction, change in learning, behaviour, health system infrastructure and patient outcomes.

CONCLUSIONS

Outcomes, including mortality and morbidity, are rightly considered the fundamental aim of acute-care courses in LLMIC. Course evaluation can be difficult, especially with low resources, but this review outlines what can be done to guide future course organisers in providing well-conducted courses with consistent outcome measures for maximum sustainable impact.

Navigating the Tension between Fatherhood Ideals and Realities of a Post-Conflict Setting: A Phenomenological Study of Former Child Soldiers in Sierra Leone

The concept of "fatherhood" in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and responses to recent crises such as the Ebola pandemic and the aftermath of a civil war. Very little is understood about how male former children associated with armed forces and armed groups (CAAFAG) are navigating fatherhood and understanding their roles as fathers, particularly as many have grown up without fathers or parents themselves and experienced violence. Our study builds upon previous ethnographic research in Sierra Leone, and uses a phenomenological approach to understand 1) the meaning and importance of fatherhood to former child soldiers in Sierra Leone, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care as well as violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG fathers in Sierra Leone are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially. CAAFAG fathers experienced the greatest tension between their ideals of fatherhood and their socio-economic circumstances in terms of financial support, such as paying school fees. In other words, fathers felt inhibited in becoming the types of fathers they hoped to be due to their experiences in a post-conflict, resource-constrained environment.

Gross motor function profile of children with cerebral palsy in a low-resource setting: A call for reflection on the model of care

PURPOSE

The current study aimed to explore Gross Motor Function Measure (GMFM) profiles among children with cerebral palsy (CP) at various Gross Motor Function Classification System (GMFCS) levels in a low-resource setting. Seventy-one ambulatory children with CP (61% males), were studied after signed informed consent was obtained from parents and assent from children older than 12 years.

METHODS

Ambulatory capacity of children with CP was classified using GMFCS levels. Functional ability of all participants was measured using GMFM-88.

RESULTS

Children with CP in a low-resource setting had 12-44% lower GMFM scores in dimensions of standing, walking, running, and jumping with reference to children from high-resource settings with similar ambulatory capacity reported previously. The most affected components across various GMFCS levels were 'sitting on a large and small bench from floor,' 'arm-free squatting,' 'half-kneeling,' 'kneel-walking,' and 'single-limb hop'.

CONCLUSION

Knowledge of GMFM profiles can guide clinicians and policymakers in low-resource settings for strategic rehabilitation planning and extend the focus of rehabilitation from restoration of body structure and function to the wider domain of social participation in leisure, sport, work, and the community at large. Additionally, providing tailored rehabilitation based on a profile of motor function can ensure an economically, environmentally, and socially sustainable future.

The Acceptability of Self-Collected Samples for STI Testing: A Qualitative Study Among Adults in Rakai, Uganda

Introduction

Self-collected samples (SCS) for sexually transmitted infection (STI) testing have been shown to be feasible and acceptable in high-resource settings. However, few studies have assessed the acceptability of SCS for STI testing in a general population in low-resource settings. This study explored the acceptability of SCS among adults in south-central Uganda.

Methods

Nested within the Rakai Community Cohort Study, we conducted semi-structured interviews with 36 symptomatic and asymptomatic adults who self-collected samples for STI testing. We analyzed the data using an adapted version of the Framework Method.

Results

Overall, participants did not find SCS physically uncomfortable. Reported acceptability did not meaningfully differ by gender or symptom status. Perceived advantages to SCS included increased privacy and confidentiality, gentleness, and efficiency. Disadvantages included the lack of provider involvement, fear of self-harm and the perception that SCS was unhygienic. Most participants preferred provider-collected samples to SCS. Nevertheless, almost all said they would recommend SCS and would do it again in the future.

Conclusion

Despite a preference for provider-collection, SCS are acceptable among adults in this setting and support expanded access to STI diagnostic services.

Context Matters: Factors Affecting Implementation of Simulation Training in Nursing and Midwifery Schools in North America, Africa and Asia

Background

Robust evidence supports the effectiveness of simulation training in nursing and midwifery education. Simulation allows trainees to apply newly-learned skills in a supportive environment.

Method

This study was conducted using the Consolidated Framework for Implementation Research (CFIR). We conducted in-depth individual interviews with simulation experts around the world.

Results

Findings from this study highlight best-practices in facilitating simulation implementation across resources settings. Universal accelerators included: (1) adaptability of simulation (2) "simulation champions" (3) involving key stakeholders and (4) culturally-informed, pre-implementation planning.

Conclusions

Shared constructs reported in diverse settings provide lessons to implementing evidence-based, flexible simulation trainings in pre-service curriculum.

Assessment of depression in children and adolescents with sickle cell anemia in a low-resource setting: a comparative study

Children with sickle cell anemia (SCA) usually face psychological complications especially depression. Assessment of depression in resource-limited settings may help identify the extent to which the children with SCA in such settings may need its introduction as part of routine care. This study aimed to assess depression in children and adolescents with SCA in a low-resource setting. This cross-sectional observational study involved 84 children and adolescents with SCA aged 7-17 years who were selected using a systematic random sampling technique. Their controls were 84 age- and sex-matched individuals with AA hemoglobin genotype. A structured questionnaire was used to collect socio-demographic data while depression was assessed with the Children's Depression Inventory. The prevalence of depression was non-significantly higher in subjects compared to the controls (8.3% vs. 2.4%) (Fisher's χ² = 1.88, p = 0.171). Though not statistically significant, the subjects had 3.7 times higher odds of having depression compared to the controls (OR = 3.7; 95% CI 0.75-18.50; p = 0.107). Of the 5 depression subscales, the subjects had a significantly higher difference in the negative mood (p = 0.042). Despite the comparable prevalence of depression with their normal controls, children and adolescents with SCA had a higher negative mood and higher odds of having depression than normal individuals. Thus, there is a need for the introduction of depression assessment as a complement to routine care of these children with SCA in resource-poor settings.

Understanding the role of parents' social connectedness in children's behavioral wellbeing in low-income communities: A study protocol

Group-based parent-training (PT) is one of the most common and well-established approaches for strengthening parenting skills and reducing child behavior problems. When offered in school settings, the social connections formed among participants may generate additional benefits for parents, schools, and children. However, to date there has been limited research on the potential benefits or harms associated with social connectedness (SC) in group-based PT. This paper describes the study protocol for an ongoing National Institute of Nursing Research-funded mixed-methods study that aims to examine the extent to which group-based PT, delivered in elementary schools serving families from predominantly low-resource communities, generates SC among parents and if SC is associated with greater (a) reduction in child behavior problems and (b) engagement in their child's education. Using a prospective descriptive design, the study is nested within an ongoing quasi-experimental parent study evaluating the group-based PT intervention, the Chicago Parent Program (CPP) in Baltimore City schools. Challenges for this study include recruitment and retention of parents with constraints caused by the COVID-19 pandemic. The study uses multiple methods and informants to understand the potential mechanisms underlying PT group effects and results have the potential to serve as an important foundation for future studies focused on SC, its impacts on parent-child outcomes in low-resource settings, and strategies for strengthening SC in health promotion interventions. PATIENT OR PUBLIC CONTRIBUTION: Chicago Parent Program was developed with input from an advisory board of parents. Additionally, the parent study protocol was written and is co-led in partnership with a community organization.

Assessment of laboratory capacity in conflict-affected low-resource settings using two World Health Organization laboratory assessment tools

OBJECTIVES

Laboratory diagnostic services are essential to drive evidence-based treatment decisions, manage outbreaks, and provide population-level data. Many low- and middle-income countries (LMICs) lack sufficient diagnostic capacity, often further exacerbated in conflict-affected areas. This project assessed laboratory services in conflict-affected LMICs to understand gaps and opportunities for improving laboratory capacity.

METHODS

The World Health Organization Laboratory Assessment Tool Facility Questionnaire (WHO Laboratory Tool) and Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) checklist were used to assess five laboratories in Eastern Democratic Republic of the Congo (DRC) and five in Gaza, Palestine. Total scores and percentage outcomes by indicator were calculated.

RESULTS

Average WHO Laboratory Tool score across all facilities was 41% (range 32-50%) in DRC and 78% (range 72-84%) in Gaza. Lowest scoring indicators in DRC were Biorisk management (13%, range 8-21%), Documentation (14%, range 6-21%), and in Gaza, were Facilities (59%, range 46-75%) and Documentation (60%, range 44-76%). Highest scoring indicators in DRC were Facilities (70%, range 45-83%) and Data and Information Management (61%, range 38-80%), and in Gaza were Data Information and Management (96%) and Public Health Function (91%, range 88-94%). In DRC, no laboratory achieved a SLIPTA star rating. In Gaza, two laboratories had a 3-star SLIPTA rating, one had a 2-star rating and two had a 1-star rating.

CONCLUSIONS

Laboratory systems in conflict-affected LMICs have significant gaps. Implementating improvement strategies in such settings may be especially challenging.

Improving Hybrid CTC/Attention Architecture for Agglutinative Language Speech Recognition

Unlike the traditional model, the end-to-end (E2E) ASR model does not require speech information such as a pronunciation dictionary, and its system is built through a single neural network and obtains performance comparable to that of traditional methods. However, the model requires massive amounts of training data. Recently, hybrid CTC/attention ASR systems have become more popular and have achieved good performance even under low-resource conditions, but they are rarely used in Central Asian languages such as Turkish and Uzbek. We extend the dataset by adding noise to the original audio and using speed perturbation. To develop the performance of an E2E agglutinative language speech recognition system, we propose a new feature extractor, MSPC, which uses different sizes of convolution kernels to extract and fuse features of different scales. The experimental results show that this structure is superior to VGGnet. In addition to this, the attention module is improved. By using the CTC objective function in training and the BERT model to initialize the language model in the decoding stage, the proposed method accelerates the convergence of the model and improves the accuracy of speech recognition. Compared with the baseline model, the character error rate (CER) and word error rate (WER) on the LibriSpeech test-other dataset increases by 2.42% and 2.96%, respectively. We apply the model structure to the Common Voice-Turkish (35 h) and Uzbek (78 h) datasets, and the WER is reduced by 7.07% and 7.08%, respectively. The results show that our method is close to the advanced E2E systems.

Treatment of COVID-19 Patients with Two Units of Convalescent Plasma in a Resource-Constrained State

IMPORTANCE

Many therapies are used to treat COVID-19, the disease caused by the virus SARS-CoV-2, including convalescent plasma. The clinical utility of using 2 units of convalescent plasma for COVID-19 hospitalized patients is not fully understood.

OBJECTIVE

Many therapies are used to treat COVID-19, the disease caused by the virus SARS-CoV-2, including convalescent plasma. The clinical utility of using 2 units of convalescent plasma for COVID-19 hospitalized patients is not fully understood. Our study aims to determine the safety and efficacy of treating hospitalized COVID-19 patients with 2 units of COVID-19 convalescent plasma (CCP).

METHOD

This was a retrospective study of Arkansas patients treated with CCP using the (US) Food and Drug Administration (FDA) emergency Investigational New Drug (eIND) mechanism from April 9, 2020, through August 9, 2020. It was a multicenter, statewide study in a low-resource setting, which are areas that lack funding for health care cost coverage on various levels including individual, family, or social. Adult patients (n = 165, volunteer sample) in Arkansas who were hospitalized with severe or life-threatening acute COVID-19 disease as defined by the FDA criteria were transfused with 2 units of CCP (250 mL/unit) using the FDA eIND mechanism. The primary outcome was 7- and 30-day mortality after the second unit of CCP.

RESULTS

Unadjusted mortality was 12.1% at 7 days and 23.0% at 30 days. The unadjusted mortality was reduced to 7.7% if the first CCP unit was transfused on the date of diagnosis, 8.7% if transfused within 3 days of diagnosis, and 32.0% if transfused at or after 4 or more days of diagnosis. The risk of death was higher in patients that received low, negative, or missing titer CCP units in comparison to those that received higher titer units.

CONCLUSION

The provision of 2 units of CCP was associated with a reduction in mortality in patients treated with high titer units within 3 days of COVID-19 diagnosis. Given the results, CCP is a viable, low-cost therapy in resource-constrained states and countries.

Inadequate Bioavailability of Intramuscular Epinephrine in a Neonatal Asphyxia Model

BACKGROUND

Over half a million newborn deaths are attributed to intrapartum related events annually, the majority of which occur in low resource settings. While progress has been made in reducing the burden of asphyxia, novel approaches may need to be considered to further decrease rates of newborn mortality. Administration of intravenous, intraosseous or endotracheal epinephrine is recommended by the Newborn Resuscitation Program (NRP) with sustained bradycardia at birth. However, delivery by these routes requires both advanced skills and specialized equipment. Intramuscular (IM) epinephrine may represent a simple, low cost and highly accessible alternative for consideration in the care of infants compromised at birth. At present, the bioavailability of IM epinephrine in asphyxia remains unclear.

METHODS

Four term fetal lambs were delivered by cesarean section and asphyxiated by umbilical cord occlusion with resuscitation after 5 min of asystole. IM epinephrine (0.1 mg/kg) was administered intradeltoid after 1 min of positive pressure ventilation with 30 s of chest compressions. Serial blood samples were obtained for determination of plasma epinephrine concentrations by ELISA.

RESULTS

Epinephrine concentrations failed to increase following administration via IM injection. Delayed absorption was observed after return of spontaneous circulation (ROSC) in half of the studies.

CONCLUSIONS

Inadequate absorption of epinephrine occurs with IM administration during asphyxial cardiac arrest, implying this route would be ineffective in infants who are severely compromised at birth. Late absorption following ROSC raises concerns for risks of side effects. However, the bioavailability and efficacy of intramuscular epinephrine in less profound asphyxia may warrant further evaluation.

Diagnostic Accuracy of Capillary Blood Glucometer Testing for Gestational Diabetes

PURPOSE

Few pregnant women in low-resource settings are screened for gestational diabetes mellitus (GDM) using the gold standard oral glucose tolerance test (OGTT). This study compared capillary blood glucose testing with 2-h plasma glucose measurements obtained using the 75-g OGTT to screen for GDM at primary healthcare clinics in Mexico.

PATIENTS AND METHODS

Pregnant women who participated in a previous prospective multicenter longitudinal cohort study and who had not been previously diagnosed with diabetes were included. Participants were evaluated using the plasmatic 2-h 75-g OGTT with simultaneous capillary blood glucose measurements using a glucometer. The study endpoint was the comparability of the glucometer results to the gold standard OGTT when collected simultaneously. Sensitivity, specificity, and area under the curve of the glucose measurements obtained for capillary blood compared with venous plasma (gold standard) were calculated to determine diagnostic accuracy.

RESULTS

The study included 947 pregnant women who had simultaneous glucose measurements available (blood capillary [glucometer] and venous blood OGTT). Overall, capillary blood glucose testing was very sensitive (89.47%); the specificity was 66.58% and the area under the curve (95% confidence interval) was 0.78 (0.74-0.81). The sensitivity, specificity and area under the curve of each capillary measurement were: 89.47%, 66.58% and 0.78 (0.74-0.82) for the fasting measurement, 91.53%, 93.24% and 0.92 (0.88-0.96) for the one-hour measurement, and 89.80%, 93.32%, 0.91 (0.87-0.95) for the second-hour measurement, respectively. No adverse events were reported.

CONCLUSION

Capillary OGTT is a valid alternative to the gold standard OGTT for screening of GDM in low-resource situations or in situations where there are other limitations to performing the OGTT as part of primary healthcare services.

Delivering epilepsy care in low-resource settings: the role of technology

INTRODUCTION

The implementation of technology in the field of epileptology has traditionally focused on its use for diagnosis and treatment and has, unsurprisingly, been capital-intensive, making it therefore mainly implementable in advanced high-income countries. Because of technological innovations over the past 20 years there has been almost a paradigm shift, particularly in access to and the potential for implementing relevant technology in lesser developed environments. Nearly 80% of people living with epilepsy live in low and middle-income countries.

AREAS COVERED

The challenge and the purpose of this paper is to discuss how technology can be implemented into lesser-resourced contexts not only cost-effectively but in a cost-saving way while also building capacity and thus sustainability.

EXPERT OPINION

The rate of technological advancement presents the risk of progressive widening of the technology and care gaps between advanced and lesser developed regions. Implementing technology is both about finding relevant appropriate technologies for the individual contexts of a diverse range of countries but also about repurposing low-tech technologies for application in epilepsy care in these areas. Finally exciting advances such as autonomous driving, digital twinning and robotic surgery will likely transform epilepsy care in several lower-resourced settings in the next 5-10 years.

Controlling Droplet Marangoni Flows to Improve Microscopy-Based TB Diagnosis

In developing countries, the most common diagnostic method for tuberculosis (TB) is microscopic examination sputum smears. Current assessment requires time-intensive inspection across the microscope slide area, and this contributes to its poor diagnostic sensitivity of ≈50%. Spatially concentrating TB bacteria in a smaller area is one potential approach to improve visual detection and potentially increase sensitivity. We hypothesized that a combination of magnetic concentration and induced droplet Marangoni flow would spatially concentrate Mycobacterium tuberculosis on the slide surface by preferential deposition of beads and TB–bead complexes in the center of an evaporating droplet. To this end, slide substrate and droplet solvent thermal conductivities and solvent surface tension, variables known to impact microfluidic flow patterns in evaporating droplets, were varied to select the most appropriate slide surface coating. Optimization in a model system used goniometry, optical coherence tomography, and microscope images of the final deposition pattern to observe the droplet flows and maximize central deposition of 1 μm fluorescent polystyrene particles and 200 nm nanoparticles (NPs) in 2 μL droplets. Rain-X^® polysiloxane glass coating was identified as the best substrate material, with a PBS-Tween droplet solvent. The use of smaller, 200 nm magnetic NPs instead of larger 1 μm beads allowed for bright field imaging of bacteria. Using these optimized components, we compared standard smear methods to the Marangoni-based spatial concentration system, which was paired with magnetic enrichment using iron oxide NPs, isolating M. bovis BCG (BCG) from samples containing 0 and 10³ to 10⁶ bacilli/mL. Compared to standard smear preparation, paired analysis demonstrated a combined volumetric and spatial sample enrichment of 100-fold. With further refinement, this magnetic/Marangoni flow concentration approach is expected to improve whole-pathogen microscopy-based diagnosis of TB and other infectious diseases.

Design and development of a mobile-based patient management and information system for infectious disease outbreaks in low resource environments

BACKGROUND

The design of Patient Management and Information Systems during outbreaks of highly infectious diseases in low resource environments poses special challenges. Such systems necessitate special functional and design requirements to support patient care under austere conditions. A primary concern is to minimize spread of the disease to caregivers and non-infected individuals. Patient management in these conditions requires the design and development of systems customized for complex patient and caregiver workflows.

OBJECTIVE

Design and develop a Patient Management and Information System for healthcare facilities on the frontlines of outbreaks of highly infectious diseases in low resource environments.

METHODS

A team composed of clinicians with experience in Ebola care in affected areas of Africa and informaticians developed detailed hardware, software and functionality requirements. These were translated into hardware designs, software architectures, screen and interface designs and implemented using Common Off-The-Shelf hardware. An experimental app development system was used to develop mHealth software modules.

RESULTS

The system was developed and implemented as a proof of concept. Acceptance testing showed that the system met functionality requirements.

CONCLUSION

Useful Patient Management and Information systems can be developed and implemented for frontline use in low-resource environments during outbreaks of highly infectious diseases.

Brief Screening Tool for Stepped-Care Management of Mental and Substance Use Disorders

OBJECTIVE

Stepped mental health care requires a rapid method for nonspecialists to detect illness. This study aimed to develop and validate a brief instrument, the Mental Wellness Tool (mwTool), for identification and classification.

METHODS

Cross-sectional development and validation samples included adults at six health facilities in Mozambique. Mini International Neuropsychiatric Interview diagnoses were the criterion standard. Candidate items were from nine mental disorder and functioning assessments. Regression modeling and expert consultation determined best items for identifying any mental disorder and classifying positives into disorder categories (severe mental disorder, common mental disorder, substance use disorder, and suicide risk). For validation, sensitivity and specificity were calculated for any mental disorder (index and proxy respondents) and disorder categories (index).

RESULTS

From the development sample (911 participants, mean±SD age=32.0±11 years, 63% female), 13 items were selected-three with 0.83 sensitivity (95% confidence interval [CI]=0.79-0.86) for any mental disorder and 10 additional items classifying participants with a specificity that ranged from 0.72 (severe mental disorder) to 0.90 (suicide risk). For validation (453 participants, age 31±11 years, 65% female), sensitivity for any mental disorder was 0.94 (95% CI=0.89-0.97) with index responses and 0.73 (95% CI=0.58-0.85) with family proxy responses. Specificity for categories ranged from 0.47 (severe mental disorder) to 0.93 (suicide risk). Removing one item increased severe mental disorder specificity to 0.63 (95% CI=0.58-0.68).

CONCLUSIONS

The mwTool performed well for identification of any mental disorder with index and proxy responses to three items and for classification into treatment categories with index responses to nine additional items.

Dynamic Acoustic Unit Augmentation with BPE-Dropout for Low-Resource End-to-End Speech Recognition

With the rapid development of speech assistants, adapting server-intended automatic speech recognition (ASR) solutions to a direct device has become crucial. For on-device speech recognition tasks, researchers and industry prefer end-to-end ASR systems as they can be made resource-efficient while maintaining a higher quality compared to hybrid systems. However, building end-to-end models requires a significant amount of speech data. Personalization, which is mainly handling out-of-vocabulary (OOV) words, is another challenging task associated with speech assistants. In this work, we consider building an effective end-to-end ASR system in low-resource setups with a high OOV rate, embodied in Babel Turkish and Babel Georgian tasks. We propose a method of dynamic acoustic unit augmentation based on the Byte Pair Encoding with dropout (BPE-dropout) technique. The method non-deterministically tokenizes utterances to extend the token's contexts and to regularize their distribution for the model's recognition of unseen words. It also reduces the need for optimal subword vocabulary size search. The technique provides a steady improvement in regular and personalized (OOV-oriented) speech recognition tasks (at least 6% relative word error rate (WER) and 25% relative F-score) at no additional computational cost. Owing to the BPE-dropout use, our monolingual Turkish Conformer has achieved a competitive result with 22.2% character error rate (CER) and 38.9% WER, which is close to the best published multilingual system.

Nurse-led implementation of ETAT+ is associated with reduced mortality in a children's hospital in Freetown, Sierra Leone

BACKGROUND

In the wake of the Ebola virus disease (EVD) epidemic in Sierra Leone, secondary care facilities faced an increase in admissions with few members of medical staff available to assess and treat patients. This led to long waiting times in hospital outpatient departments. The study was undertaken in the outpatient department of Ola During Children's Hospital (the tertiary paediatric hospital for Sierra Leone) in the period immediately following the EVD epidemic of 2014-2015.

AIMS

This retrospective analysis of operational programme data aimed to assess whether a quality-improvement approach and task-sharing between medical and nursing staff improved the quality of triage and the timeliness of care.

METHODS

All staff working in the outpatient department were offered a 4-week training course, followed by on-the-job supervision and support for 6 months. Nurses who successfully completed the course were given responsibility for the initial assessment of sick patients and for prescribing and giving initial treatment. Data were collected at three points: before intervention and at 3 and 6 months after initiation of the intervention. All children presenting to the hospital for medical attention between 0800 and 1400 Monday to Friday were included. Triage assessment by the outpatient nurse was compared to that made by a clinically experienced observer, and the time taken for each child to be triaged, assessed and given initial treatment was recorded.

RESULTS

Between months 0 and 6 of the intervention, detection of emergency signs by the triage nurse improved from 30% to 100%, and detection of priority signs improved from 34% to 100%. For children presenting with emergency signs, the median time between triage and full assessment improved from 57 minutes before intervention to 17 minutes at 3 months and 5 minutes at 6 months (p < 0.0005). For the same group, median time between triage and first antibiotic or antimalarial treatment improved from 220 minutes before intervention to 40 minutes at 3 months and 18 minutes at 6 months (p = 0.006).

CONCLUSION

The results indicate that, with appropriate training and support, extending the emergency assessment and treatment of sick children to nursing staff in West African hospitals may improve the accuracy of triage and the time to assessment and treatment of children presenting with signs of serious illness.

Using intermittent pulse oximetry to guide neonatal oxygen therapy in a low-resource context

OBJECTIVE

To evaluate the effectiveness of intermittent pulse oximetry in guiding oxygen therapy in neonates in a low-resource setting.

DESIGN AND SETTING

Prospective validation study at three hospitals in southwest Nigeria. We performed concealed continuous pulse oximetry on participants to evaluate intermittent SpO₂ monitoring.

PATIENTS

We recruited all preterm or low birthweight neonates, and all term neonates who required oxygen therapy, who were admitted to the neonatal ward(s) of the study hospitals during the study period.

MAIN OUTCOME MEASURES

Proportion of time preterm/low birthweight neonates on oxygen spent within, above and below the target SpO₂ range of 90%-95%; and the proportion of time term neonates and neonates not on oxygen spent within and below the target range of 90%-100%.

RESULTS

Preterm/low birthweight neonates receiving oxygen therapy (group A) spent 15.7% (95% CI 13.3 to 18.9) of time in the target SpO₂ range of 90%-95%. They spent 75.0% (63.6-81.1) of time above 95%, and 2.7% (1.7-5.6) of time below 85%. Term neonates and all neonates not receiving oxygen (group B) spent 97.3% (95% CI 96.4 to 98.6) of time within the target range of 90%-100%, and 0.9% (0.3-1.4) of time below 85%. Guidelines recommended SpO₂ monitoring 3 times per day for all patients, however neonates in groups A and B were monitored an average of 4.7 and 5.3 times per day, respectively.

CONCLUSIONS

To better maintain SpO₂ within the target range, preterm/low birthweight neonates on oxygen should have their SpO₂ monitored more frequently than the current 4.7 times per day. In all other neonates, however, monitoring SpO₂ 5.3 times per day appears suitable.

Low-Resource Nucleic Acid Extraction Method Enabled by High-Gradient Magnetic Separation

Nucleic acid-based diagnostic tests often require isolation and concentration of nucleic acids from biological samples. Commercial purification kits are difficult to use in low-resource settings because of their cost and insufficient laboratory infrastructure. Several recent approaches based on the use of magnetic beads offer a potential solution but remain limited to small volume samples. We have developed a simple and low-cost nucleic acid extraction method suitable for isolation and concentration of nucleic acids from small or large sample volumes. The method uses magnetic beads, a transfer pipette, steel wool, and an external magnet to implement high-gradient magnetic separation (HGMS) to retain nucleic acid-magnetic bead complexes within the device's steel wool matrix for subsequent processing steps. We demonstrate the method's utility by extracting tuberculosis DNA from both sputum and urine, two typical large volume sample matrices (5-200 mL), using guanidine-based extraction chemistry. Our HGMS-enabled extraction method is statistically indistinguishable from commercial extraction kits when detecting a spiked 123-base DNA sequence. For our HGMS-enabled extraction method, we obtained extraction efficiencies for sputum and urine of approximately 10 and 90%, whereas commercial kits obtained 10-17 and 70-96%, respectively. We also used this method previously in a blinded sample preparation comparison study published by Beall et al., 2019. Our manual extraction method is insensitive to high flow rates and sample viscosity, with capture of ∼100% for flow rates up to 45 mL/min and viscosities up to 55 cP, possibly making it suitable for a wide variety of sample volumes and types and point-of-care users. This HGMS-enabled extraction method provides a robust instrument-free method for magnetic bead-based nucleic acid extraction, potentially suitable for field implementation of nucleic acid testing.

Design and Implementation of an Ultra-Low Resource Electrodermal Activity Sensor for Wearable Applications ‡

While modern low-power microcontrollers are a cornerstone of wearable physiological sensors, their limited on-chip storage typically makes peripheral storage devices a requirement for long-term physiological sensing—significantly increasing both size and power consumption. Here, a wearable biosensor system capable of long-term recording of physiological signals using a single, 64 kB microcontroller to minimize sensor size and improve energy performance is described. Electrodermal (EDA) signals were sampled and compressed using a multiresolution wavelet transformation to achieve long-term storage within the limited memory of a 16-bit microcontroller. The distortion of the compressed signal and errors in extracting common EDA features is evaluated across 253 independent EDA signals acquired from human volunteers. At a compression ratio (CR) of 23.3×, the root mean square error (RMSErr) is below 0.016 μS and the percent root-mean-square difference (PRD) is below 1%. Tonic EDA features are preserved at a CR = 23.3× while phasic EDA features are more prone to reconstruction errors at CRs > 8.8×. This compression method is shown to be competitive with other compressive sensing-based approaches for EDA measurement while enabling on-board access to raw EDA data and efficient signal reconstructions. The system and compression method provided improves the functionality of low-resource microcontrollers by limiting the need for external memory devices and wireless connectivity to advance the miniaturization of wearable biosensors for mobile applications.

Shake No Bake: A Homemade Ultrasound Gel Recipe for Low-Resource Settings

Commercially produced ultrasound coupling gel is often a scarce resource in rural regions of low-income countries that use sonography as their main imaging modality and, when available, may be cost prohibitive. Various homemade gels were created and tested to assure image quality was not compromised. Glucomannan-based gel and guar gum-based gel had superior physical properties in initial testing and showed no substantial difference compared with commercially available ultrasound gel on subject and phantom imaging and analysis (P > .05 using a 1-tailed sign test). Neither gel required heating, attracted insects, damaged ultrasound transducers, stained samples of clothing, or had harmful effects to subjects.

Accessible continued professional development for maternal mental health

Background

Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD.

Aim

The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors.

Setting

One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study.

Methods

Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians’ Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively.

Results

Participants’ knowledge showed a statistically significant (p < 0.001) improvement between the pre- and post-test results, for all six chapters of the book. However, participants’ attitudes towards mental illness did not show a statistically significant change between the pre- and post-test results.

Conclusion

We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings.

Brain death in low-income countries: a report from Malawi

Most low-income nations have no practice guidelines for brain death; data describing brain death in these regions is absent. Our retrospective study describes the prevalence of brain death among patients treated in an intensive care unit (ICU) at a referral hospital in Malawi. The primary outcome was designation of brain death in the medical chart. Of 449 ICU patients included for analysis between September 2016 and May 2018, 43 (9.6%) were diagnosed with brain death during the ICU admission. The most common diagnostic reasons for admission among these patients were trauma (49%), malaria (16%) and postoperative monitoring after general abdominal surgery (19%). All patients diagnosed with brain death were declared dead in the hospital, after cardiac death. In conclusion, the incidence of brain death in a Malawi ICU is substantially higher than that seen in high-income ICU settings. Brain death is not treated as clinical death in Malawi.

Systematic review: the etiology of esophageal squamous cell carcinoma in low-income settings

Esophageal carcinoma causes over 380 000 deaths per year, ranking sixth worldwide in mortality amongst all malignancies. Globally, the squamous cell subtype is most common and accounts for 80% of esophageal cancers. Nonetheless, esophageal squamous cell carcinoma is much more poorly understood than esophageal adenocarcinoma, including what is driving such high prevalences, why it often presents in young patients, and shows such marked geographical delineations Areas covered: The current literature was searched for articles focusing on aetiopathogenesis of squamous cell esophageal carcinoma via a systematic review, particularly in low-resource settings. This was supplemented by papers of interest known to the authors. Expert commentary: Current putative mechanisms include polycyclic aromatic hydrocarbons, nitrosamines, acetaldehyde, cyclo-oxygenase-2 pathways, androgen and their receptor levels, as well as smoking & alcohol, micronutrient deficiencies and diet, mycotoxins, thermal damage, oral hygiene and microbiotal factors, inhaled smoke, viral infections such as HPV, and chronic irritative states. Etiology is likely multifactorial and varies geographically. Though smoking and alcohol play a predominant role in high-income settings, there is strong evidence that mycotoxins, diet and temperature effects may play an under-recognized role in low and middle-income settings.

Early development of visual attention in infants in rural Malawi

Eye tracking research has shown that infants develop a repertoire of attentional capacities during the first year. The majority of studies examining the early development of attention comes from Western, high-resource countries. We examined visual attention in a heterogeneous sample of infants in rural Malawi (N = 312-376, depending on analysis). Infants were assessed with eye-tracking-based tests that targeted visual orienting, anticipatory looking, and attention to faces at 7 and 9 months. Consistent with prior research, infants exhibited active visual search for salient visual targets, anticipatory saccades to predictable events, and a robust attentional bias for happy and fearful faces. Individual variations in these processes had low to moderate odd-even split-half and test-retest reliability. There were no consistent associations between attention measures and gestational age, nutritional status, or characteristics of the rearing environment (i.e., maternal cognition, psychosocial well-being, socioeconomic status, and care practices). The results replicate infants' early attentional biases in a large, unique sample, and suggest that some of these biases (e.g., bias for faces) are pronounced in low-resource settings. The results provided no evidence that the initial manifestation of infants' attentional capacities is associated with risk factors that are common in low-resource environments.

Teaching obstetric ultrasound at Mulago Hospital - Kampala, Uganda

Background

Mulago Hospital is a high volume referral hospital under the Makerere University School of Medicine and Health Sciences. Basic obstetric ultrasound is a useful skill that can aid patient care.

Objectives

The purpose of the study was to assess the effectiveness of an intervention implemented to teach basic ultrasound skills to medical students and house officers at Mulago Hosptial, Kampala, Uganda.

Methods

Forty participants, including medical students, junior house officers (JHOs), and senior house officers (SHOs) were enrolled in the study. A didactic and practical hands-on teaching session was evaluated using a pre- and post-test that was administered to all participants.

Results

Participants included 12 medical students, 23 JHOs, and 5 SHOs. A significant difference in pre- and post-test scores was demonstrated in the medical students and JHOs (34% to 76%, p <0.0001) and this was retained when the results were stratified into the basic definitions and practical sections of the survey (33% to 71%, p<0.0001). The scores for the senior house officers had a mean increase of 2.3 points.

Conclusion

This original teaching intervention is an effective method to improve knowledge and skills for medical students and house officers at Mulago Hospital in the area of basic obstetric ultrasound.

Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience

BACKGROUND

Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available.

OBJECTIVES

To evaluate the feasibility of integrating a high-intensity ultrasound training program into the formal curriculum for emergency medicine resident physicians in an LMIC.

METHODS

We conducted a pilot ultrasound training program focusing on CPUS for 20 emergency medicine resident physicians in Kumasi, Ghana, which consisted of didactic sessions and hands-on practice. Competency was assessed by comparing pretest and posttest scores and with an Objective Structured Clinical Examination (OSCE) performed after the final training session.

RESULTS

The mean score on the pretest was 61%, and after training, the posttest score was 96%. All residents obtained passing scores above 70% on the OSCE.

CONCLUSION

A high-intensity ultrasound training program can be successfully integrated into an emergency medicine training curriculum in an LMIC.

Reliability and validity of the Lower Limb Function Questionnaire when completed by young adult orthotic and prosthetic device users

Purpose The Lower Limb Function Questionnaire (LLFQ) was developed as a self-report assessment of lower-limb functional ability for orthotic and prosthetic (O&P) device users to be suitable for a wide range of conditions, cultures, and ages. The measure aims to address an existing gap in tools for the assessment of functional ability in this population. The purpose of this study is to evaluate LLFQ reliability and validity in a sample of young adult O&P users. Methods Adolescents from a secondary school in Kenya completed the LLFQ twice, 6 d apart, and test-retest reliability was assessed using intra-class correlation coefficients. Validity evaluations involved Timed Up-and-Go, 6-min walk, 6-min obstacle course, and/or spatiotemporal gait assessments. Oxygen consumption was measured during walk tests. Associations between the LLFQ and each measure were evaluated using Pearson correlation coefficients for construct validity. Results LLFQ reliability was acceptable (ICC = 0.79, 95% CIs 0.64-0.89). Construct validity was demonstrated via moderate correlation (r  >  0.60) with obstacle course distance, gait velocity, stride length, and stance/single support/double support percent of gait cycle. Conclusions Both LLFQ reliability and validity were acceptable in the sample of youth in Kenya. Further testing is required to determine applicability in other cultural contexts. Implications for Rehabilitation The LLFQ may be clinically useful across a variety of cultures and conditions to provide feedback on the effectiveness of rehabilitative treatment or assistive devices for youth with lower limb impairments. The LLFQ may enable specific strengths and challenges to lower limb function to be identified to enable planning of well-targeted rehabilitation.

Smartphone-based diagnostic for preeclampsia: an mHealth solution for administering the Congo Red Dot (CRD) test in settings with limited resources

OBJECTIVE

Morbidity and mortality due to preeclampsia in settings with limited resources often results from delayed diagnosis. The Congo Red Dot (CRD) test, a simple modality to assess the presence of misfolded proteins in urine, shows promise as a diagnostic and prognostic tool for preeclampsia. We propose an innovative mobile health (mHealth) solution that enables the quantification of the CRD test as a batch laboratory test, with minimal cost and equipment.

METHODS

A smartphone application that guides the user through seven easy steps, and that can be used successfully by non-specialized personnel, was developed. After image acquisition, a robust analysis runs on a smartphone, quantifying the CRD test response without the need for an internet connection or additional hardware. In the first stage, the basic image processing algorithms and supporting test standardizations were developed using urine samples from 218 patients. In the second stage, the standardized procedure was evaluated on 328 urine specimens from 273 women. In the third stage, the application was tested for robustness using four different operators and 94 altered samples.

RESULTS

In the first stage, the image processing chain was set up with high correlation to manual analysis (z-test P < 0.001). In the second stage, a high agreement between manual and automated processing was calculated (Lin's concordance coefficient ρc = 0.968). In the last stage, sources of error were identified and remedies were developed accordingly. Altered samples resulted in an acceptable concordance with the manual gold-standard (Lin's ρc = 0.914).

CONCLUSION

Combining smartphone-based image analysis with molecular-specific disease features represents a cost-effective application of mHealth that has the potential to fill gaps in access to health care solutions that are critical to reducing adverse events in resource-poor settings.

[Management of bilateral hand amputations in low-resources setting: the Krukenberg procedure is still indicated]

Double hand amputation leads to complete loss of prehensive function and touch sense. Patients become totally dependent on others for survival. In developing countries, where sophisticated myoelectric prosthesis are not available, the Krukenberg procedure gives to these patients elementary self-sufficiency for daily-life. This procedure can be performed in low-resources setting and requires minimal rehabilitation. However, patient selection and preparation are critical because of an unattractive aesthetic aspect which limits this operation use in occidental countries.

Continuing distance education: a capacity-building tool for the de-isolation of care professionals and researchers

BACKGROUND

There are large disparities in access to health-care professionals (HCP) in low-income African countries, leading to imbalanced and suboptimal health delivery. Part of the difficulty is recruiting and retaining care professionals to work in isolated settings.

AIM

To evaluate the impact of distance continuing education as a way to build capacity, increase satisfaction and enhance the performance of care professionals in these isolated health-care facilities.

SETTING

Care professionals using RAFT (Telemedicine Network in French-speaking Africa) in isolated care facilities.

PROGRAM DESCRIPTION

Within RAFT, an organizational framework and computer-based tools have been developed and evolved to provide useful, qualitative, applicable training material.

PROGRAM EVALUATION

The activity, satisfaction, perceptions and impact of RAFT on remote health-care workers are being monitored. RAFT's potential to improve the recruitment, satisfaction and retention of care professionals in remote settings is widely recognized; however, the actual impact on the performance and quality of care remains to be demonstrated.