Browsing by Author "Egger, Joseph R"

Background: Prolonged and obstructed labor is a leading cause of maternal mortality and morbidity in low resource settings. To prevent prolonged labor, the Uganda Ministry of Health (MOH) recommends using the partograph to monitor mothers in labor. Published literature has reported low rates of partograph use in Uganda, as well as improved partograph use after training. This study aimed to evaluate the effectiveness of LifeNet International’s (LN) partograph training in rural health clinics in Maska, Uganda. Additionally, the study sought to identify factors potentially related to partograph use, and thus to inform future implementations to increase partograph use in these low-resource settings.

Methods: LifeNet works with rural clinics in Uganda by providing training and management strategies to improve healthcare quality for mothers during delivery. In 2017, LifeNet began collaborating with the Duke Global Health Institute (DGHI) to evaluate LN’s impacts in six clinics in Masaka District, Uganda. As part of this evaluation project, this study is evaluating the impact of LN partograph training using direct observation, medical chart data, and facility-level data collected by LN. Additionally, semi-structured interviews were conducted by a DGHI researcher. The pre-training data were collected from May 15th to July 17th, 2017 and post-training from August 23rd, 2017 to January 29th, 2018 for this study. Follow-up direct observation data are scheduled to be collected from May 21st to July 26th, 2018. Quantitative data were analyzed using Stata version 14.2. Interview transcripts were reviewed for themes of health providers’ partograph knowledge and challenges of partograph use in practices.

Results: Before the LN partograph training, an estimated 19.8% of deliveries (42 of 212 observed) in study clinics were monitored with a partograph. A diagonal line drawn on the partograph helps the clinician to recognize possible labor complications (i.e. the action line). Sixteen (38.1%) of those that used partographs reached the action lines, among which five (31.2%) had actions under taken. In the first month after the LN partograph training, partograph use increased to 46.8% and was sustained for the remainder of the observation period. The proportion of partograph use did not change over time after the training (prevalence risk ratio, PRR=1.00, 95%CI: 1.00-1.00). Among all partographs reviewed after the training (n=594), health providers gave two interventions to manage abnormal labors. Mean duration of labor and proportion of prolonged labor did not change over time (risk ratio, RR=1.00, p = 0.561; RR=1.00, p=0.757, respectively). However, mean duration of labor was significantly higher among deliveries in which a partograph was used, compared to deliveries in which no partograph was used (RR=4.39, p<0.001). Furthermore, the proportion of deliveries with prolonged labor was higher in the partograph use group compared with the group that did not use the partograph, but the difference was not statistically significant (RR=5.97, p=0.072).

Based on the interviews with clinical providers in these clinics, there seems to be some education in use of the partograph in their schooling; however, there remained some misunderstanding about partograph use and interpretation. Health providers indicated that lack of accessibility to blank partographs in clinics, heavy workload, and lack of periotic check were challenges in using partographs to monitor labor.

Conclusions: Partograph use increased following the LN training and was sustained for at least five months afterwards. This type of clinical training program may be effective in improving maternal healthcare quality in Last Mile health facilities in resource-poor settings, like Masaka, Uganda.

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Background: Hopefulness is a positive orientation or state of mind that can aid in the recovery and treatment for mental illness, as it can have significant impacts on clinical and psychosocial outcomes. As resource-constrained settings work to implement recovery-oriented care, there is a need to better understand hopefulness among people living with schizophrenia (PLWS) and caregivers in their extended family networks. This study seeks to examine the dyadic relationship of hopefulness and its associated correlates among PLWS and their caregivers in Tanzania. Methods: This study utilized longitudinal data collected as part of a randomized controlled trial testing a culturally-tailored model of Family Psychoeducation in Tanzania. The Herth Hope Index was used to measure hopefulness among PLWS and their caregivers at baseline and three months post-intervention. Univariable and multivariable regression models were conducted to determine correlates of hopefulness at baseline, while the Actor-Partner Interdependence Model (APIM) was employed to examine the longitudinal, dyadic relationship of hopefulness among PLWS and their caregivers. APIM can help determine how an individuals’ level of hope at time 0 impacts his or her own level of hope at time 1 and their partner’s level of hope at time 1. Results: For PLWS and their caregivers, actor effects were less than one (PLWS, β=0.261; caregivers, β=0.318), indicating stability in hopefulness over time. Regarding partner effects, caregivers baseline hopefulness had a positive effect on PLWS hopefulness at follow-up (β=0.100). This indicates that higher caregiver hope at time 0 is associated with higher levels of hope in PLWS at time 1. Baseline hopefulness levels for PLWS had a negative effect on caregiver hopefulness at follow-up (β= -0.106). This suggests that higher PLWS hope at time 0 is associated with lower levels of hope in caregivers at time 1. Conclusions: Hopefulness seems to be interesting to consider because caregiver hopefulness can influence improvements in patient hopefulness over time. Future studies should further explore the dyadic relationship of hopefulness in this population, as hope is a non-pharmacological mechanism of change that is underutilized globally.

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Background: Sepsis is a leading cause of death and disability globally. Despite a high burden of sepsis in sub-Saharan Africa, clinical data for sepsis in that setting are limited. We sought to describe the clinical characteristics, management, and outcomes in a cohort of adults and adolescents with sepsis in northern Tanzania. We also assessed for associations between clinical factors and in-hospital mortality.

Methods: We carried out a prospective observational cohort study at Kilimanjaro Christian Medical Centre in Moshi, Tanzania. We collected data on demographics, baseline clinical characteristics, and management, with an emphasis on hours 0-6 after arrival to the Emergency Department. Log risk regression was carried out to assess for associations between demographic and clinical factors and our primary outcome of in-hospital death. Separate multivariable regression analyses were conducted for both antimicrobial administration by hour 6 and administration of intravenous (IV) fluids >1L by hour 6 and the outcome of in-hospital mortality.

Results: Fifty-eight participants were included in our analysis. Seventeen (29.3%) participants died in-hospital. Baseline characteristics associated with inpatient mortality included inability to drink unassisted, respiratory rate >30 breaths per minute, hypoxia, and altered mentation. Less than half of participants received any antimicrobial by hour 6, and most participants received <1L of IV fluids. HIV antibody testing was performed for only one participant in the first 6 hours. On multivariable analysis, neither antimicrobial administration nor IV fluids >1L by hour 6 was associated with inpatient mortality.

Conclusion: Sepsis in northern Tanzania carries a high risk of in-hospital mortality. Further research is urgently needed to establish the highest-yield interventions suited to the unique characteristics of sepsis in sSA.

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Trials registration

Abstract

Introduction: Information about family history of illness is increasingly important to ensure each patient receive optimal promotion advice, preventive health services and appropriate treatment. MeTree is a web-based tool used to collect family health history directly from participants through a website. Despite growing evidence regarding the importance and efficacy of using family history, and the need for healthcare providers to have family history triage tools for personalized healthcare delivery, tools like MeTree have not been broadly applied in clinical practice. Little is known about its utility in settings with different disease profiles, health care systems and traditions and different cultural and socioeconomic contexts.

Methods: This study enrolled 304 medical students from the University of Ruhuna in Sri Lanka. Participants constructed family pedigree and entered family health history in MeTree with the help of the researcher and a local research assistant. Once participants had created a full family pedigree, they were asked to complete a paper-based questionnaire asking about their experience with MeTree and what perceived to be the benefits of MeTree.

Results: The proportion of males and females were relatively similar, 52.6% and 47.4%, respectively. Family health histories were entered for 3352 relatives in total. All diseases were divided into 21 groups. Diabetes was the most common disease group reported and accounted for 24.58% of all diseases reported. The following two most frequent diseases were hypertension (14.51%) and cardiovascular diseases

(12.06%). Relatives had much higher numbers of all disease groups compared to index participants. Prevalence for each disease was different between index participants and the relatives. Hypertension was present in at least one or more family members in 65.13% of all pedigrees. On average, 29.92% of relatives in each family have diabetes. The mean time to complete entering information into MeTree was 36.3 minutes. The overall feelings and satisfaction level towards MeTree were favorable. Over 90% of participants indicated that MeTree could be generalized in the context of Sri Lanka. Results from t-test at the significance level of 5% didn’t indicate any significant preference for completion time used by males (M = 35.51, SD = 11.47) over completion time used by females (M = 37.04, SD =11.04), t = 0.65, p = 0.5177. A significant effect of grade on completion time wasn’t observed at the p< 0.05 level in the ANOVA procedure either, for the three conditions F (3, 83) = 1.80, p = 0.1539. According to the correlation procedure, completion time and age were not correlated (r = 0.2129, p = 0.13182). Among all questions in the questionnaire, significant difference was only observed between males and females for reported awareness (p=0.0184) and knowledge (p<0.0001) change after being introduced to MeTree.

Conclusions: Most medical students found it easy to use MeTree and considered it a useful experience. The majority of the students thought it possible to generalize MeTree in the context of Sri Lanka, while barriers still needs to be overcome to have a web-based tool like MeTree put into real practice in Sri Lanka.

Introduction

Despite improvements in health service coverage, quality of care (QoC) is often poor in low- and middle-income countries. To improve QoC, accurate measurements of healthcare processes are needed. The aim of this study was to estimate the validity of QoC data from patient medical records for childbirth deliveries by comparing them with direct clinical observation.

Methods

My study was part of a larger parent study of the effects of a healthcare QoC training program at six health facilities in Masaka district, Uganda. My study data were collected in two phases: 1) validation paired data of 321 observations plus the corresponding medical records collected; 2) evaluation data of 1,146 medical records of deliveries while the training intervention was being implemented. Sensitivity, specificity, positive predictive values, and negative predictive values were estimated as the bias parameters. Quantitative bias analysis was conducted by assigning these bias parameters. Prevalence ratio and odds ratio measured the parent study’s program efficacy.

Results

Medical records overestimated providers’ performance on quality indicators. The odds ratio of seven out of eleven indicators changed significantly; while the prevalence ratio of only one indicator varied.

Conclusion

The medical records for childbirth deliveries in Uganda demonstrated poor validity in measuring QoC compared with direct observation. Studies measuring QoC that rely on medical record data should be interpreted carefully, especially for obstetric and neonatal services. Meanwhile, poor record data showed a mixed result on the efficacy of the quality improvement program. Studies using the record data to evaluate the program efficacy should be done carefully, especially in low-resource settings.