The health minister wants young people to come up with a catchy title for an mobile app aimed at providing information‚ tools and support for them …. more

When it comes to video messaging services, there are a lot of options to choose from, most notably Skype, Facetime and ooVoo. But there is also the Google Hangouts service. The Google platform offers all the same features as other popular services; plus a few users can’t get anywhere else. So why is “Skype” used as a verb synonymous with “video-calling,” but no one ever talks about “Hanging out?”….more

‘CHWs value feedback and feeling connected to the health system and their community, are motivated by status and community standing, and want to be provided with the necessary tools to perform.’ The authors of this new paper in Human Resources for Health journal describe six key guiding principles:

1. CHWs are motivated by their status and standing in the community and a sense of the value they add

2. CHWs value technical feedback and supportive encouragement from both supervisors and community members

3. Feeling connected to both the health system and the community they serve motivates and validates CHWs in their role

4. Adequate resources—especially drugs—must be in place for CHWs to be motivated and perform

5. Participatory activities in the community that are open to all, enjoyable, purposeful and focused on positive local health outcomes delivered through the CHWs are likely to sustain community interest and engagement and be motivating for CHWs (in Uganda)

6. Interventions supported by ICT that facilitate easy communication, provide contextspecific technical support and engender a sense of connectedness to the health system, supervisors and peers are feasible and acceptable to CHWs in Uganda and Mozambique and likely to increase CHW motivation

Below are the citation and abstract. The full text is freeely available here: http://www.human-resources-health.com/content/pdf/s12960-015-0020-8.pdf  

CITATION: Using theory and formative research to design interventions to improve community health worker motivation, retention and performance in Mozambique and Uganda.

Daniel Llywelyn Strachan, Karin Källander, Maureen Nakirunda, Sozinho Ndima, Abel Muiambo, Zelee Hill and the inSCALE study group

Corresponding author: Daniel L Strachan d.strachan@ucl.ac.uk

Human Resources for Health 2015, 13:25  doi:10.1186/s12960-015-0020-8

Published: 30 April 2015

ABSTRACT (provisional)

Background: Community health workers (CHWs) are increasingly being used in low-income countries to address human resources shortages, yet there remain few effective, evidence-based strategies for addressing the enduring programmatic constraints of worker motivation, retention and performance. This paper describes how two interventions were designed by the Innovations at Scale for Community Access and Lasting Effects (inSCALE) project to address these constraints in Uganda and Mozambique drawing on behavioural theory and formative research results.

Methods: A review of the work motivation and CHW motivation literature—incorporating influences on retention and performance—was conducted on articles sourced through electronic web searches. Formative research with a focus on the barriers and facilitators to CHW motivation, retention and performance was conducted with community health workers and key stakeholders in Uganda and Mozambique. An analytical induction approach to the thematic analysis of transcripts from 98 in-depth interviews and 26 focus group discussions was adopted across the country settings.

Results: From the theoretical review, it was determined that the interventions should promote CHWs as members of a collective by highlighting a sense of shared experience, focus on alignment between worker and programme goals, and emphasise the actions that lead to good performance. The Social Identity Approach was selected as the theory most likely to lead to the development of effective, scalable and sustainable interventions by addressing the identified gap in the literature of the influence of CHW working context. The formative research indicated that CHWs value feedback and feeling connected to the health system and their community, are motivated by status and community standing, and want to be provided with the necessary tools to perform. Two interventions based on these results were developed: a participatory, local community approach and an information communication technology (ICT) approach.

Conclusions: Drawing on contextual data and theory that is sensitive to context can potentially lead to the development of appropriate and effective interventions when aiming to improve the motivation, retention and performance of CHWs in Uganda and Mozambique and other comparable settings. Evaluation of the developed interventions is crucial to assess this potential.

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Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

Misinformation by the tobacco industry has contributed to millions of deaths, and the industry remains strong and defiant. (A recent UK law to enforce plain packaging has been described as ‘bold’ by commentators, because of the anticipated legal challenges from the industry.) This study shows just how far the industry will go to maintain its grip.

“The industry has sought to distort and misinterpret the cultural beliefs of these communities and to reinterpret them to serve the industry’s interests,” said Kelley Lee of Vancouver’s Simon Fraser University, one of the authors of the study. “All to sell a product that kills half of its customers.”

http://www.bmj.com/content/350/bmj.h2281

ABSTRACT

‘Islamic countries are of key importance to transnational tobacco companies as growing markets with increasing smoking rates. We analyzed internal tobacco industry documents to assess the industry’s response to rising concerns about tobacco use within Islamic countries.

‘The tobacco industry perceived Islam as a significant threat to its expansion into these emerging markets. To counter these concerns, the industry framed antismoking views in Islamic countries as fundamentalist and fanatical and attempted to recruit Islamic consultants to portray smoking as acceptable. Tobacco industry lawyers also helped develop theological arguments in favor of smoking.

‘These findings are valuable to researchers and policymakers seeking to implement culturally appropriate measures in Islamic countries under the World Health Organization Framework Convention on Tobacco Control. (Am J Public Health. Published online ahead of print April 16, 2015: e1–e7. doi:10.2105/AJPH.2014.302494)’

Full text (restricted access): http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.302494

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Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

Please find below the abstract of a paper from 2013 that closely supports previous arguments on HIFA that there should be a high-quality, independent international formulary, similar to the British National Formulary and freely available to all prescribers and users of medicines, on the internet, on mobile phones and as a free PDF download. Universal basic information on commonly prescribed medicines, identified by their generic name, would save many lives and reduce suffering.

We have discussed this with both the British National Formulary and the World Health Organization. We pointed out: “If money is an issue, we think we can help you get financial support for this, because we are convinced that a major funder such as the Gates Foundation can be persuaded of the need for such a formulary”. But so far we are not getting through. In the meantime, the HIFA Working Group on Information for Prescribers and Users of Medicines is planning a literature review and survey to assess the availability and use of information for prescribers in low-income countries – the results will assist us with future advocacy efforts.

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CITATION: Int J Clin Pharm. 2013 Jun;35(3):386-92. doi: 10.1007/s11096-012-9744-x. Epub 2013 Mar 28.

Worldwide analysis of factors associated with medicines compendia publishing.

Arguello B, Fernandez-Llimos F.  [Full text is restricted access]

ABSTRACT

Background: Medicines compendia, also called formularies, are the most commonly used drug information source among health care professionals.

Objective: The aim was to identify the countries publishing medicines compendia and the socio-demographic factors associated to this fact. Additionally, we sought to determine the use of foreign compendia in countries lacking their own.

Setting: Global web-based survey.

Method: Healthcare practitioners and researchers from 193 countries worldwide were invited to complete a web-based survey. The questionnaire investigated the existence of a national compendium, or the use of foreign compendia in the absence of one. Demographic and socioeconomic variables were used to predict compendia publishing through a multivariate analysis.

Main outcome measure: Existence of national medicines compendia and foreign compendia used.

Results: Professionals from 132 countries completed the survey (response rate at a country level 68.4%, comprising 90.9% global population). Eighty-four countries (63.6%) reported publishing a medicines compendium. In the multivariate analysis, only two covariates had significant association with compendia publishing. Being a member of the Organisation for the Economic Cooperation and Development was the only variable positively associated with compendia publishing (OR = 37.5; 95% CI = 2.3:599.8). In contrast, the countries that listed French as an official language were less likely to publish a compendium (OR = 0.07; 95% CI = 0.007:0.585). Countries without national compendia reported using the British National Formulary most commonly, followed by the Dictionnaire Vidal.

Conclusion: Publication of medicines compendia is associated with socio-economic development. Countries lacking a national compendium, use foreign compendia from higher-income countries. Creating an international medicines compendium under the leadership of the World Health Organisation, rather than merely a ‘model’, would reduce the risks of using information sources not-adapted to the necessities of developing countries.

THREE KEY MESSAGES

1. Medicines compendia are the most commonly used drug information source for health care professionals

2. There is a need for adapting medicines compendia to meet country development levels and national health care system requirements

3. The WHO Model Formulary is not sufficient for developing countries.

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For more information on the HIFA Working Group on Information for Prescribers and Users of Medicines see:

http://www.hifa2015.org/prescribers-and-users-of-medicines/

Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

So glad you raised the issue of Health Literacy at community level. Reading your message shows the poor knowledge of the people about health. Although our culture ‘Yoruba’ has rich heritage on health and health issues e.g. Ilera loro meaning health is wealth, however there is a breakdown of good community norms infiltrations of bad alternatives. So I believe it is a joint effort of all stakeholders; MoE, MoH, MoI, PHC Board, H/F, INGO, CSO, local NGOs, FBOs, community leaders and the community.

Our organization is privileged currently to implement a one-year project; Strengthening the Ward Health Committe (WHC) to raise voice of accountability at the PHC and LG level below is the background to the project;

https://www.facebook.com/permalink.php?story_fbid=1039908406038390&id=176835959012310

I will encourage all stakeholders empower the community in raising standards of health, to achieve health for all.

Regards, Remi Akinmade

Founder/CEO, CHIEF, Lagos

www.chiefngo.org

Below is the citation and abstract of a new paper in Global Health Action. The full text is freely available here:

http://www.globalhealthaction.net/index.php/gha/article/view/25709

The paper points out that ‘health for all and health equity are the main goals of global health’, and calls for integration of global health into primary medical education, recommending ‘interdisciplinary approaches and interprofessional collaboration’. As a personal comment, I would add that global health education should be integrated also into nursing, midwifery and health science education – indeed the basic concepts (including health equity and the right to health) should be introduced into primary and secondary school education for all children.

CITATION: Glob Health Action. 2015 Apr 21;8:25709. doi: 10.3402/gha.v8.25709. eCollection 2015.

Gaps in studies of global health education: an empirical literature review.

Liu Y, Zhang Y, Liu Z, Wang J.

ABSTRACT

Background: Global health has stimulated a lot of students and has attracted the interest of many faculties, thereby initiating the establishment of many academic programs on global health research and education. global health education reflects the increasing attention toward social accountability in medical education.

Objective: This study aims to identify gaps in the studies on global health education.

Design: A critical literature review of empirical studies was conducted using Boolean search techniques.

Results: A total of 238 articles, including 16 reviews, were identified. There had been a boom in the numbers of studies on global health education since 2010. Four gaps were summarized. First, 94.6% of all studies on global health education were conducted in North American and European countries, of which 65.6% were carried out in the United States, followed by Canada (14.3%) and the United Kingdom (9.2%). Only seven studies (2.9%) were conducted in Asian countries, five (2.1%) in Oceania, and two (0.8%) in South American/Caribbean countries. A total of 154 studies (64.4%) were qualitative studies and 64 studies (26.8%) were quantitative studies. Second, elective courses and training or programs were the most frequently used approach for global health education. Third, there was a gap in the standardization of global health education. Finally, it was mainly targeted at medical students, residents, and doctors. It had not granted the demands for global health education of all students majoring in medicine-related studies.

Conclusions: Global health education would be a potentially influential tool for achieving health equity, reducing health disparities, and also for future professional careers. It is the time to build and expand education in global health, especially among developing countries. Global health education should be integrated into primary medical education. Interdisciplinary approaches and interprofessional collaboration were recommended. Collaboration and support from developed countries in global health education should be advocated to narrow the gap and to create further mutual benefits.

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Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

Below is the citation and abstract of a new paper in the open-access journal Implementation Science. The authors note that research in Cambodia is not fully aligned with health priorities, and call for abstracts of all research undertaken in Cambodia to be available in the local language.

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CITATION: Gaps between research and public health priorities in low income countries: evidence from a systematic literature review focused on Cambodia.

Goyet S1, Touch S2, Ir P3, SamAn S4, Fassier T5, Frutos R6,7, Tarantola A8, Barennes H9,10,11.

Implement Sci. 2015 Mar 11;10(1):32. doi: 10.1186/s13012-015-0217-1.

ABSTRACT

Background: Evidence-based public health requires that research provides policymakers with reliable and accessible information reflecting the disease threats. We described the scientific production of research in Cambodia and assessed to what extent it provides appropriate insights and implications for practice to guide health policymakers and managers and knowledge relevant for translation.

Methods: We conducted a systematic review of scientific articles published on biomedical research in Cambodia. Regression analysis assessed the trends over time and factors associated with actionable messages in the articles’ abstracts.

Results: From 2000 to 2012, 628 articles were published in 237 journals with a significant increase over time (from 0.6/million population to 5.9/million population, slope coefficient 7.6, 95% CI 6.5-8.7, p?<?0.001). Most publications on diseases addressed communicable diseases (n?=?410, 65.3%). Non-communicable diseases (NCD) were under-addressed (7.7% of all publications) considering their burden (34.5% of the disease burden). Of all articles, 67.8% reported descriptive studies and 4.3% reported studies with a high level of evidence; 27.4% of studies were led by an institution based in Cambodia. Factors associated with an actionable message (n?=?73, 26.6%) were maternal health (OR 3.08, 95% CI 1.55-6.13, p?=?0.001), the first author’s institution being Cambodian (OR 1.78, 95% CI 1.06-2.98, p?=?0.02) and a free access to full article (OR 3.07, 95% CI 1.08-8.70, p?=?0.03). Of all articles, 87% (n?=?546) were accessible in full text from Cambodia.

Conclusions: Scientific publications do not fully match with health priorities. Gaps remain regarding NCD, implementation studies, and health system research. A health research agenda would help align research with health priorities. We recommend 1) that the health authorities create an online repository of research findings with abstracts in the local language; 2) that academics emphasize the importance of research in their university teaching; and 3) that the researcher teams involve local researchers and that they systematically provide a translation of their abstracts upon submission to a journal. We conclude that building the bridge between research and public health requires a willful, comprehensive strategy rather than relying solely only publications.

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Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

This is a remarkable study that examines in depth the complexities and difficulties of updating clinical guidelines in a low-income country. This process is critical for WHO and other international health recommendations to be translated into improvements in policy and practice.

‘In September 2011, the IPC researchers were informed by the World Health Organization (WHO) Cambodian office that a revision of the national guidelines was being undertaken. Although there was no official demand for it from the MoH, the IPC researchers endeavored to provide the MoH with locally relevant and evidence-based knowledge on pneumonia…’

CITATION: Knowledge translation: a case study on pneumonia research and clinical guidelines in a low- income country.

Goyet S1, Barennes H, Libourel T, van Griensven J, Frutos R, Tarantola A.

Implement Sci. 2014 Jun 26;9:82. doi: 10.1186/1748-5908-9-82.

http://www.implementationscience.com/content/9/1/82

ABSTRACT

Background: The process and effectiveness of knowledge translation (KT) interventions targeting policymakers are rarely reported. In Cambodia, a low-income country (LIC), an intervention aiming to provide evidence-based knowledge on pneumonia to health authorities was developed to help update pediatric and adult national clinical guidelines. Through a case study, we assessed the effectiveness of this KT intervention, with the goal of identifying the barriers to KT and suggest strategies to facilitate KT in similar settings.

Methods: An extensive search for all relevant sources of data documenting the processes of updating adult and pediatric pneumonia guidelines was done. Documents included among others, reports, meeting minutes, and email correspondences. The study was conducted in successive phases: an appraisal of the content of both adult and pediatric pneumonia guidelines; an appraisal of the quality of guidelines by independent experts, using the AGREE-II instrument; a description and modeling of the KT process within the guidelines updating system, using the Unified Modeling Language (UML) tools 2.2; and the listing of the barriers and facilitators to KT we identified during the study.

Results: The first appraisal showed that the integration of the KT key messages in pediatric and adult guidelines varied with a better efficiency in the pediatric guidelines. The overall AGREE-II quality assessments scored 37% and 44% for adult and pediatric guidelines, respectively. Scores were lowest for the domains of ‘rigor of development’ and ‘editorial independence.’ The UML analysis highlighted that time frames and constraints of the involved stakeholders greatly differed and that there were several missed opportunities to translate on evidence into the adult pneumonia guideline. Seventeen facilitating factors and 18 potential barriers to KT were identified. Main barriers were related to the absence of a clear mandate from the Ministry of Health for the researchers and to a lack of synchronization between knowledge production and policy-making.

Conclusions: Study findings suggest that stakeholders, both researchers and policy makers planning to update clinical guidelines in LIC may need methodological support to overcome the expected barriers.

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Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

A couple of us at Johns Hopkins and beyond are creating an online platform that uses storytelling as a medium of social reform and dialog in health ethics in low and middle-income countries.

We believe that amidst growing inequality in access to medical treatment, malpractice, lack of accountability, loss of human dignity and capricious health policy and practice, a global discourse on the values driving healthcare in the “global south” has become necessary.

Our online forum, which is to launch soon, examines ethical failures, achievements and everything in between. The stories we hope to publish simultaneously probe, heal and offer food for thought without being punitive or judgmental.

Have a story? We are looking for ingenious writers based in a developing country (or with strong ties to one) who can produce first-person (non-fiction) vignettes (150 words or less) that illustrate: an ethical dilemma faced by a person in a health profession (broadly defined) in a developing country, the context, how the person acted and why, and what the aftermath was.

Potential stories of interest could cover a wide range of health issues and come from individuals in hospitals, medical campuses, businesses all along the pharmaceutical supply chain, public health workers, members of NGOs or other public/private health groups, lawyers and lawmakers, and beyond. We also accept narratives and qualitative material that derive from your research and other professional and personal experiences.

While some stories will be squarely entrenched in the “right” or “wrong” ethical camp, we expect the best narratives to straddle the fine line in between. A representative picture or two to accompany your short story would be ideal.

This is an all-volunteer project for the moment (we aren’t paying ourselves either); however, we plan to compensate our regular contributors retroactively upon receiving funding.

Should you be interested, feel free to contact me at pagrawa6@jhu.edu or at valueofabeing@gmail.com. Send us a brief bio and how you think you can contribute.

Regards,

Priyanka

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Value Of A Being

Skype ID: valueofabeing

HIFA profile: Priyanka Agrawal  is a doctor at the Johns Hopkins Bloomberg School of Public Health in the USA. Email address: valueofabeing AT gmail.com

__________

SMS Contraception Messages Reach Thousands of Mozambican Youth

http://www.thehealthcompass.org/sbcc-spotlights/mcenas-sms-client-education-among-youth

New Health COMpass Spotlight  – learn about how Pathfinder International and its partners worked with Mozambican groups to create SMS messages that reached youth and informed them about the family planning options available to them.

Best regards,

Susan

Susan Leibtag

Health COMpass Curator

Below is part of the text of a feature on the WHO website. The full text is freely available here: http://www.who.int/features/2015/hand-hygiene-ebola/en/

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Sierra Leone: Helping health workers protect patients with clean hands

May 2015

In Ebola-affected countries, like Sierra Leone, the lack of running water can make hand hygiene a challenge. Hand hygiene is so important in public health that 5 May every year is marked as Hand Hygiene Day.

Dr Komba Songu-Mbriwa is a doctor on the frontlines of the Ebola fight in Sierra Leone who also knows the challenges of the disease firsthand. He is an Ebola survivor. But today, he says his most important role extends beyond Ebola as a protector of other health workers. His specialty: teaching his colleagues how to protect themselves and other patients from the spread of all infectious diseases when patients are being cared for in health facilities.

“Hands are the main way in which germs spread in health care settings,” says Dr Songu-Mbriwa.

Hand Hygiene Day

Not just in Sierra Leone but across the world, the simplest and most important action to block the spread of disease in health facilities is ensuring that health workers consistently clean their hands properly. It is so important in public health that 5 May every year is marked as Hand Hygiene Day.

More information on Hand hygiene in the control of Ebola and health system strengthening

Overcoming the lack of running water

“More and more of our health workers colleagues understand this,” says Dr Songu-Mbriwa. “But beyond understanding, we must make it easy and accessible for them to clean their hands often. It’s one thing to repeat ‘Wash your hands’, but what if there is no running water?”…

Creating a culture of infection prevention and hand hygiene among health workers in Sierra Leone is essential for stopping the Ebola outbreak. But, he [Dr Komba Songu-Mbriwa] adds, with the right skills consistently applied, his colleagues will be better placed to respond to future outbreaks.

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Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

Below are extracts from a BBC article by David Heymann (professor of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine), with thanks to Global Health NOW. The full text is avialable here:

http://www.bbc.co.uk/news/health-32551089

……..

It has now been over a year since the Ebola outbreak in West Africa was first reported… So what has the outbreak taught us and how prepared are we for the next global health crisis?…

We have learned that the initial response to an outbreak must be robust and complete…

We have also learned that community engagement is of the utmost importance – helping village elders, paramount chiefs and others understand how the disease is transmitted and how it can be stopped, including emphasis on safe burial practices…

The best means of dealing with an international health crisis is prevention – it has been known, for example, since 1976 that it is sub-standard health facility infection control that permits Ebola to spread, yet sub-standard infection control continues in many facilities. Emphasis must be placed on helping health facilities understand and use infection control measures as part of their routine activities…

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Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

On HIFA we have discussed the problem of research being unavailable in the language of the country where it was undertaken. For example, much research undertaken in Portuguese-speaking Mozambique is published in English-language journals and is therefore inaccessible to many of those who need it most.

A few days ago I was interested to read the following new paper in the open-access journal Human Resources for Health:

Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique

I wrote to the lead author and asked whether there is a Portuguese translation available, either of the full text or the abstract, and received a reply saying “we don’t have the resources to translate the abstract or article into Portuguese at this time, though I do agree it would be useful”.

I offered to help to get the abstract translated via HIFA while at the same time raising awareness of this issue so that – eventually – we can build a world where the abstracts of all health research undertaken in Mozambique is available in Portuguese (and the same for other non-English-speaking countries).

I would like to invite expressions of interest to translate the abstract from English to Portuguese, and comments on how we can move towards a world where abstracts are routinely available in the language of the country where the research was undertaken.

Here is the abstract in English:

Abstract

Background: Task shifting is a common strategy to deliver antiretroviral therapy (ART) in resource-limited settings and is safe and effective if implemented appropriately. Consensus among stakeholders is necessary to formulate clear national policies that maintain high-quality care. We sought to understand key stakeholders’ opinions regarding task shifting of HIV care in Mozambique and to characterize which specific tasks stakeholders considered appropriate for specific cadres of health workers.

Methods: National and provincial Ministry of Health leaders, representatives from donor and non-governmental organizations (NGOs), and clinicians providing HIV care were intentionally selected to represent diverse viewpoints. Using open- and closed-ended questions, interviewees were asked about their general support of task shifting, its potential advantages and disadvantages, and whether each of seven cadres of non-physician health workers should perform each of eight tasks related to ART provision. Responses were tallied overall and stratified by current job category. Interviews were conducted between November 2007 and June 2008.

Results: Of 62 stakeholders interviewed, 44% held leadership positions in the Ministry of Health, 44% were clinicians providing HIV care, and 13% were donors or employed by NGOs; 89% held a medical degree. Stakeholders were highly supportive of physician assistants performing simple ART-related tasks and unanimous in opposing community health workers providing any ART-related services. The most commonly cited motives to implement task shifting were to increase ART access, decrease physician workload, and decrease patient wait time, whereas chief concerns included reduced quality of care and poor training and supervision. Support for task shifting was higher among clinicians than policy and programme leaders for three specific task/cadre combinations: general mid-level nurses to initiate ART in adults (supported by 75% of clinicians vs. 41% of non-clinicians) and in pregnant women (75% vs. 34%, respectively) and physician assistants to change ART regimens in adults (43% vs. 24%, respectively).

Conclusions: Stakeholders agreed on some ART-related task delegation to lower health worker cadres. Clinicians were more likely to support task shifting than policy and programme leaders, perhaps motivated by their front-line experiences. Harmonizing policy and programme managers’ views with those of clinicians will be important to formulate and implement clear policy.

Best wishes,

Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org