Below are the citation, abstract and selected extracts from a new paper in the Postgraduate Medical Journal. The full text is freely available here:

http://pmj.bmj.com/content/91/1072/83.full

Postgrad Med J 2015;91:83-91 doi:10.1136/postgradmedj-2014-132965

Review: Point of care information services: a platform for self-directed continuing medical education for front line decision makers.

Lorenzo Moja, Koren Hyogene Kwag.

ABSTRACT

The structure and aim of continuing medical education (CME) is shifting from the passive transmission of knowledge to a competency-based model focused on professional development. Self-directed learning is emerging as the foremost educational method for advancing competency-based CME. In a field marked by the constant expansion of knowledge, self-directed learning allows physicians to tailor their learning strategy to meet the information needs of practice. Point of care information services are innovative tools that provide health professionals with digested evidence at the front line to guide decision making. By mobilising self-directing learning to meet the information needs of clinicians at the bedside, point of care information services represent a promising platform for competency-based

CME. Several points, however, must be considered to enhance the accessibility and development of these tools to improve competency-based CME and the quality of care.

EXTRACTS (selected by Neil PW)

‘Point of care information services: online information sources that are integrated with technological innovations such as real-time information systems and portable electronic devices. Examples: ACP Pier, Best Practice, Clinical Evidence, Dynamed, EBMGuidelines, eMedicine, eTG, Micromedex, and UpToDate’

‘Compared with traditional educational resources such as textbooks, online information sources that are integrated with technological innovations such as real-time information systems and portable electronic devices can better meet the information needs arising from patient–physician interactions.’

‘Learners make larger improvements in the knowledge domain if they are involved in selecting their own learning resources.’

‘Interestingly, when the survey asked participants to list their favourite resources as well as the most recently accessed resource, 7 (ie, UpToDate, Epocrates, Medscape/eMedicine, Lexicomp, DynaMed, Pepid, and Micromedex) and 6 (ie, UpToDate, Medscape/eMedicine, Lexicomp, Epocrates, DynaMed, and Pepid) of the top 10 most frequently cited resources, respectively, were point of care services.’

‘Although health professionals use a wide spectrum of information resources such as consulting their colleagues, PubMed, and Google, there is a strong predilection for point of care resources to provide pre-appraised information.’

‘The advent of Free Open Access Meducation (FOAM) resources has opened a new outlet for the synthesis and exchange of information within the medical community.78 FOAM builds upon social networking websites (eg, blogs, podcasts, tweets, Google hangouts, web-based applications) to create a space for health professionals to discuss, for example, treatment options and best practice strategies as well as critically appraise and evaluate scientific literature.78’

I look forward to learn about your experience and the applicability of the above to low- and middle-income countries.

Best wisehs, Neil

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 news item on the news website openDemocracy. The full text is available here:

https://www.opendemocracy.net/5050/margaret-gyapong-sally-theobald/sexual-and-reproductive-health-issue-you%E2%80%99ve-probably-never-hear

‘Why is one of the most common gynaecological conditions in sub-Saharan Africa, schistosomiasis, misunderstood, under-researched and under-reported?

‘Throughout Africa approximately 200-220 million people are living with schistosomiasis – also known as bilharzia – and 600 million people are at risk of being infected. Schistosomiasis is a waterborne disease, caused by worms that use aquatic snails as their intermediate hosts, and is particularly common in communities living near freshwater lakes, ponds and streams. Owing to the close association with water for washing, bathing and drinking, infection can be a daily occurrence but it can also occur in seasonal drier environments where people are made more vulnerable through necessary and life giving interactions with infested water.

‘Urogenital schistosomiasis – also referred to as female or male genital schistosomiasis (FGS and MGS) –  is common, and even universal in some communities. It is thought that between about 100 and 120 million people are suffering from FGS and MGS which is causing damage to their urinary and reproductive systems. Adolescent girls and women with FGS can experience bleeding and stigmatising discharge from the vagina, genital lesions, nodules in the vulva as well as general discomfort and pain during sex. The damage that FGS causes also include sub-fertility, miscarriage and can effect vulnerability to HIV and the Human Papilloma virus.’

‘… unfortunately it is misunderstood, under-researched and under-reported to the extent that we have little concrete information on prevalence in different countries, inadequate diagnostic systems, and little guidance on how to prevent, manage and treat it…

‘FGS is potentially a sensitive, private, and possibly stigmatising condition and messaging needs to be geared to the realities of women’s gendered experiences. This requires in-depth research to explore the context and community discourse surrounding FGS symptoms and the development of appropriate referral and treatment strategies that are accessible to all women and girls regardless of where they live or how much money or resources they can access. In so doing, strengthening the surveillance and tailored interventions of reproductive health services is something we should all welcome…’

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Below is the citation and abstract of a new paper in Health Policy and Planning. The authors introduce the article by stating: ‘Traditional medicine continues to play an important role in improving and maintaining health in developing countries.’ (Personal note: While there is no doubt that many people who use traditional medicine derive subjective benefit, the impact of traditional medicine on hard outcomes such as maternal and child mortality remains unproven. Indeed, time lost while seeking traditional medicine ‘cures’ often translates into delay in obtaining effective allopathic treatment, with potentially fatal outcomes. What do you think?)

CITATION: Traditional medicine for the rich and knowledgeable: challenging assumptions about treatment-seeking behaviour in rural and peri-urban Nepal

Rikke Stamp Thorsen and Mariève Pouliot

Health Policy Plan. published 29 June 2015, 10.1093/heapol/czv060

http://heapol.oxfordjournals.org/content/early/2015/06/29/heapol.czv060.full?papetoc

ABSTRACT: Traditional medicine is commonly assumed to be a crucial health care option for poor households in developing countries. However, little research has been done in Asia to quantify the reliance on traditional medicine and its determinants. This research contributes to filling in this knowledge gap using household survey data collected from 571 households in three rural and peri-urban sites in Nepal in 2012. Questions encompassed household socioeconomic characteristics, illness characteristics, and treatment-seeking behaviour. Treatment choice was investigated through bivariate analyses. Results show that traditional medicine, and especially self-treatment with medicinal plants, prevail as treatment options in both rural and peri-urban populations. Contrarily to what is commonly assumed, high income is an important determinant of use of traditional medicine. Likewise, knowledge of medicinal plants, age, education, gender and illness chronicity were also significant determinants. The importance of self-treatment with medicinal plants should inform the development of health policy tailored to people’s treatment-seeking behaviour.

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All indicators reflect that e-commerce in SA is still in its infancy compared to the rest of the world‚ says Dieter Febel‚ MD of leading ISP SA Gateway‚ sister company to broad-based distributor Esquire Technologies…..more

Poor training of nurses may have led to severe reactions to a new contraceptive device…..more

The National Department of Health guidelines outline care for adults living with conditions like HIV, diabetes and mental health within primary health care…..more

More than three years after Health Minister Dr Aaron Motsoaledi first announced National Health Insurance (NHI) pilot districts, Health-e News tracks what the NHI has meant on the ground and in people’s lives…..more

Government’s 50-page roadmap seeks to coordinate departments and even the private sector to tackle country’s deadly mix of over and under-nutrition….more

Made by The Open Medicine Project, the free app allows health workers and patients to access the latest national HIV guidelines via smart phones or tablets. These guidelines are automatically updated to reflect the latest Department of Health policies. Guidelines appear alongside a Google Maps-enabled directory of HIV treatment clinics and a feedback mechanism allowing health workers to report problems such as a need for training or drug stock outs….more

Overburdened medical staff who are not trained in ordering stock could be contributing to the stock out problem that has hit SA. Overburdened nurses who have to act as doctors, pharmacists, data capturers and social workers contribute to the problem of stock outs, the SA AIDS Conference heard yesterday…..more

Part of the country’s move towards a National Health Insurance and aimed at reducing maternal and child deaths, teams teams are made up of a number of specialists who provide clinical mentorship and guidance to health facilities. According to the National Department of Health handbook, teams should dedicated a maximum 70 percent of their time to clinical governance, 20 percent to clinical work and 10 percent on teaching and research. The 78-page handbook outlines concepts such as clinical governance, how to track team effectiveness and key interventions for reducing maternal and child deaths….more

Climate change could wipe out all the health gains made in the last 50 years and urgent steps need to be taken to prevent further increases in global temperature….more

The 28-page guidelines outline the diagnosis of a number of sexual transmitted infections (STIs) including public lice, syphilis and genital warts….more

FOR formal retail, Africa is one of the world’s few remaining frontiers. It is one on which SA retailers are making their mark, with the combined footprint of the 13 main contenders now in excess of 1 400 stores.

Shoprite leads the pack, its 320 stores in 14 countries generating R19bn in annual sales, which is 16,4% of the group total. Shoprite CE Whitey Basson, who has long termed Africa “our future growth driver”, is just getting into his stride…..more

A statement (below) by the Cochrane Collaboration notes that WHO has substantially improved its processes for guideline development, but says there is still room for improvement. In particular, it points to the need for research on ‘how to create guidelines for urgent public health problems where evidence may be very scarce or of poor quality’.

As a personal comment, this latter point is clearly the responsibility of the entire health research (and publishing and information sciences) community, and not of WHO specifically. If one is to look specifically at how better to appraise and synthesise evidence that may be scarce of of poor quality, perhaps the first priority is to ensure that all relevant research is indeed identified, so as to avoid the possibility that guidelines fail to include existing research.

Looking more broadly, a holistic approach is needed that not only makes the best use of ‘scarce or poor quality’ research, but also addresses the many underlying *causes* of the scarcity of high quality research – to move progressively towards a global research agenda that aligns with global health priorities.

(This statement is all about the quality of WHO guidelines. The elephant in the room is, of course, not the quality of WHO guidelines but the gap between WHO guidelines and actual policy and practice.)

I look forward to hear from HIFA members on these important issues.

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Cochrane issues statement on WHO guidelines development and governance

http://www.cochrane.org/news/cochrane-issues-statement-who-guidelines-development-and-governance

Cochrane is an international organization that produces high-quality, relevant, accessible systematic reviews and other synthesized research evidence, and promotes evidence-based decision-making.  Cochrane has been an NGO in official relations with the World Health Organization (WHO) since 2011 and an important part of our workplan involves support for the WHO guideline development process.

Cochrane contributors published some of the earliest critiques of the WHO guideline process (Oxman, 2007) which called for guidelines to use reliable, independent research summaries that are free of conflicts of interest (Boyd, 2006).  WHO responded to these criticisms by developing a uniform review process in developing guidelines. This included implementing procedures to manage conflicts of interest. Recent analyses of WHO guidelines (Sinclair, 2013; Burda, 2014) have shown that editorial independence and use of reliable evidence have increased markedly since WHO has implemented these reforms, and highlight that these high standards are essential for WHO’s credibility.

WHO guideline panels have implemented procedures to make the link between recommendations and the underlying evidence more transparent.  There is room for improvement (Alexander, 2013).  Further research is needed to improve methods to create guidelines for urgent public health problems where evidence may be very scarce or of poor quality. Cochrane will continue to offer methodological support and training to WHO as it tackles these challenges.

Cochrane urges WHO to continue strengthening the use of evidence following a rigorous methodology in guideline development.  We recognize that panels should be cognizant of public and member state commentary on the issues, but the guidelines process needs to remain independent and separate from any individual or body with potential conflicts of interest. Involving participants with conflicts of interest in guideline development is likely to influence recommendations, make them less evidence based and impact on their credibility (Cosgrove, 2013).  Cochrane urges the WHO to protect against the influence of conflicts of interest in the guideline development process to ensure that the identification and evaluation of the best available evidence remains at its core.

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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

Yesterday I went to a meeting at DFID to hear about a new programme: ˜Improving Communication of Research and EvEvidence for DevelopmentÃ.

Here is a description: ‘Having the ability to make evidence-informed policy and practice decisions is vital to support efforts to eradicate extreme poverty. DFID has designed the Improving Communication of Research Evidence for development programme (ICRED) to increase the impact of investments in development research, by supporting improved capacity of researchers and intermediaries in DFID priority countries to access, appraise and communicate evidence and rigorous research. Results of this programme are expected to include enhanced capacity of researchers (e.g. academics) and intermediaries (e.g. the media; civil society organisations) in DFID priority countries to routinely gather, appraise and communicate research evidence to inform the public, and increase the use of rigorous evidence for more effective development policy and practice.’

‘DFID will be seeking proposals for a range of projects that aim to build capacity of researchers and intermediaries to access, appraise and communicate evidence and rigorous research to inform development policy and practice. DFID has committed £12 million to this programme, which is expected to become operational during 2015/16, and a further 500,000 for an evaluation stream which will be commissioned following project selection. This programme will help inform DFID and other development research funders on what types of research uptake capacity building approaches are cost effective and have the greatest impact. It is anticipated that project contracts will run for 5 years.’

At the meeting, DFID said they were planning to distribute the 12 million pounds to 3 large projects only. In the Q&A session, I asked if they had considered making part of the money available for smaller organisations/projects, and unfortunately they are not planning to do this. However, they welcome applications from consortia.

HIFA could have a role to play in this programme. We not have the capacity to lead an application, but perhaps if a HIFA Supporting Organisation has the capacity to do this, you may like to consider HIFA as a budget line in a larger proposal. As a DFID representative said yesterday, “If the applicant is tapping into existing networks, that would be a strength”.

If you are interested, please let me know.

Further information here:

https://supplierportal.dfid.gov.uk/selfservice/pages/public/viewPublicNotice.cmd?bm90aWNlSWQ9NjM0NjA=

With best wishes,

Neil

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

I was interested to read this paper in the open-access journal Global Health Science and Practice (isn’t it wonderful that papers relevant to HIFA seem to be increasingly, indeed mostly, open access?). The authors found that knowledge increased post-intervention. But perhaps what is more important is how the intervention compares with other interventions. Indeed, even if an intervention were ineffective, might one expect participants to acquire increased knowledge simply because they know they will be tested? I note that a few HIFA members are among the authors and look forward to their comments.

‘Health workers’ knowledge of contraceptive side effects increased substantially after the refresher training. The mobile phone approach was convenient and flexible and did not disrupt routine service

delivery. Clear limitations of the medium are participants can’t practice clinical skills or have interactive discussions. Also, some participants had trouble with network reception.’

CITATION: Successful mLearning Pilot in Senegal: Delivering Family Planning Refresher Training Using Interactive Voice Response and SMS

Abdoulaye Diedhiou, Kate E. Gilroy, Carie Muntifering Cox, Luke Duncan, Djimadoum Koumtingue, Sara Pacque-Margolis, Alfredo Fort, Dykki Settle, Rebecca Bailey.

http://www.ghspjournal.org/content/early/2015/06/01/GHSP-D-14-00220.full.pdf+html

ABSTRACT

Background: In-service training of health workers plays a pivotal role in improving service quality. However, it is often expensive and requires providers to leave their posts. We developed and assessed a prototype mLearning system that used interactive voice response (IVR) and text messaging on simple mobile phones to provide in-service training without interrupting health services. IVR allows trainees to respond to audio recordings using their telephone keypad.

Methods: In 2013, the CapacityPlus project, funded by the US Agency for International Development, tested the mobile delivery of an 8-week refresher training course on management of contraceptive side effects and misconceptions to 20 public-sector nurses and midwives working in Me´khe´ and Tivaouane districts in the Thie`s region of Senegal. The course used a spaced-education approach in which questions and detailed explanations are spaced and repeated over time. We assessed the feasibility through the system’s administrative data, examined participants’ experiences using an endline survey, and employed a pre- and post-test survey to assess changes in provider knowledge.

Results: All participants completed the course within 9 weeks. The majority of participant prompts to interact with the mobile course were made outside normal working hours (median time, 5:16 pm); average call duration was about 13 minutes. Participants reported positive experiences: 60% liked the ability to determine the pace of the course and 55% liked the convenience. The largest criticism (35% of participants) was poor network reception, and 30% reported dropped IVR calls. Most (90%) participants thought they learned the same or more compared with a conventional course. Knowledge of contraceptive side effects increased significantly, from an average of 12.6/20 questions correct before training to 16.0/20 after, and remained significantly higher than at baseline 10 months after the end of training at 14.8/20, without any further reinforcement.

Conclusions: The mLearning system proved appropriate, feasible, and acceptable to trainees, and it was associated with sustained knowledge gains. IVR mLearning has potential to improve quality of care without disrupting routine service delivery. Monitoring and evaluation of larger-scale implementation could provide evidence of system effectiveness at scale.

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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  

Information leaflets for patients reduce antibiotic prescriptions and their use should be encouraged. This is the main conclusion of a systematic review in BMJ Open. Below is the citation, abstract and selected extract.

The authors used ‘a broad search strategy for a complete and inclusive search’, and yet they found not a single eligible study from a low-income or middle-income country.

CITATION: Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review

Eefje G P M de Bont, Marleen Alink, Famke C J Falkenberg, Geert-Jan Dinant, Jochen W L Cals

Corresponding author: Eefje G P M de Bont – eefje.debont@maastrichtuniversity.nl

BMJ Open 2015;5:e007612 doi:10.1136/bmjopen-2015-007612

http://bmjopen.bmj.com/content/5/6/e007612.full

Published 3 June 2015

ABSTRACT

Objective: Patients’ knowledge and expectations may influence prescription of antibiotics. Therefore, providing evidence-based information on cause of symptoms, self-management and treatment is essential. However, providing information during consultations is challenging. Patient information leaflets could facilitate consultations by increasing patients’ knowledge, decrease unnecessary prescribing of antibiotics and decrease reconsultations for similar illnesses. Our objective was to systematically review effectiveness of information leaflets used for informing patients about common infections during consultations in general practice.

Design, setting and participants: We systematically searched PubMed/MEDLINE and EMBASE for studies evaluating information leaflets on common infections in general practice. Two reviewers extracted data and assessed article quality.

Primary and secondary outcome measures: Antibiotic use and reconsultation rates.

Results: Of 2512 unique records, eight studies were eligible (7 randomised, controlled trials, 1 non-randomised study) accounting for 3407 patients. Study quality varied from reasonable to good. Five studies investigated effects of leaflets during consultations for respiratory tract infections; one concerned conjunctivitis, one urinary tract infections and one gastroenteritis and tonsillitis. Three of four studies presented data on antibiotic use and showed significant reductions of prescriptions in leaflet groups with a relative risk (RR) varying from 0.53 (0.40 to 0.69) to 0.96 (0.83 to 1.11). Effects on reconsultation varied widely. One large study showed lower reconsultation rates (RR 0.70 (0.53 to 0.91), two studies showed no effect, and one study showed increased reconsultation rates (RR 1.53 (1.03 to 2.27)). Studies were too heterogenic to perform a meta-analysis.

Conclusions: Patient information leaflets during general practitioners consultations for common infections are promising tools to reduce antibiotic prescriptions. Results on reconsultation rates for similar symptoms vary, with a tendency toward fewer reconsultations when patients are provided with a leaflet. Use of information leaflets in cases of common infections should be encouraged. Their contributing role in multifaceted interventions targeting management of common infections in primary care needs to further exploration.

SELECTED EXTRACTS (selected by Neil PW)

When asked, most patients appreciate written information10 and indicate they would be less likely to consult if they had more information about managing minor illnesses.11 ,12 In addition, the use of written information may improve information retention up to 50% and patient satisfaction may improve.13 ,14 Patients presenting with a common infection value information on self-management strategies and expected duration of illness. The use of information leaflets to assist a consultation may be a useful tool to convey information, increase patient knowledge and possibly restrict antibiotic prescriptions.

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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

Below are extracts of a news article in the May 2015 issue of Africa Health. The full article is freely available here:

http://www.africa-health.com/articles/may_2015/News.pdf

‘Providers and students in low-resource countries will now have access to high-quality academic learning and teaching materials to help reduce maternal and new-born deaths in sub-Saharan Africa.

‘High-quality, obstetric care is a critical factor in sub-Saharan Africa, but local barriers like the availability of training materials, licensing costs and unreliable Internet access can prevent incoming obstetricians and gynaecologists (Obgyns), and midwives from being trained with the best educational materials available. The materials are available through a new collection created by the University of Michigan’s 1000+ OBGYNs Project – a network of American and African universities preparing to train more than 1000 new Obgyns in the region in 10 years…

‘All materials are publicly available for free, and licensed for students, teachers and practitioners to copy and modify to suit their curricular context…’

Project website: www.1000obgyns.org

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The UK medical charity, Maternal and Childhealth Advocacy International (MCAI), has recently financed and produced two new books on the hospital care of pregnant women, new-born infants, and children with a special focus on resource-limited settings, where access to the internet is limited.

These two practical and evidence-based books (International Maternal and Child Health Care -A practical manual for hospitals worldwide and a Pocket Book of Hospital Care For Maternal Emergencies Including Trauma & Neonatal Resuscitation) have been written and peer reviewed by over 100 experts from around the world, all with experience in hospital settings where there are limited resources, who have freely given their time and expertise. Several authors and reviewers are HIFA and Child 2015 members.

Please see www.mcai.org.uk for more details on both books, including contents and authors.

MCAI is distributing printed copies of these two books free of charge to health workers in public hospitals in low-income countries that provide free care to pregnant women, babies, and children.  To date MCAI has sent 2,227 textbooks books free of charge to 33 countries, including 500 copies to Afghanistan, 500 copies to Somaliland, and 800 copies to The Gambia. We are also selling both books to those in wealthier countries, to help finance the free copies and their distribution.

In the near future, we plan to have the PDFs of both books on our website so that health workers who have access to the Internet can download them free of charge.  The PDF of each book is rather large, 20MB for textbook and 9MB for pocketbook, so download times, especially in settings with weak Internet strength, may be prohibitive. So we also plan to divide the books into smaller sections to aid downloading, especially for those in rural, resource-limited settings.

Both books have several sections and many chapters and it may not be convenient for users to have to download single chapters but the sections may still be too big.

So we would welcome feedback on the best size of downloadable sections so that those most in need can download them within a reasonable time. For example, would 3MB, 2MB or 1MB etc. be feasible?

It would be really helpful if HIFA and Child 2015 members, especially those working in rural hospitals in low-income countries where the Internet is most likely to be weak, could advise us on this matter so that we ensure that PDFs of both books are as useful as possible.

Very many thanks for your advice and we will inform members when the PDFs of both books are available.

David Southall and Rhona MacDonald

Honorary Medical and Honorary Executive Directors

Maternal and Childhealth Advocacy International (MCAI)

www.mcai.org.uk

HIFA profile: David Southall is a retired Professor of Paediatrics and Honorary Medical Director of Maternal and Childhealth Advocacy International (MCAI)    http://www.mcai.org.uk    He is also on the board of the International Child Health Group email: director AT mcai.org.uk

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