Measuring Knowledge of Community Health Workers at the Last Mile in Liberia: Feasibility and Results of Clinical Vignette Assessments.

INTRODUCTION: Community health workers (CHWs) can provide lifesaving treatment for children in remote areas, but high-quality care is essential for effective delivery. Measuring the quality of community-based care in remote areas is logistically challenging. Clinical vignettes have been validated in facility settings as a proxy for competency. We assessed feasibility and effectiveness of clinical vignettes to measure CHW knowledge of integrated community case management (iCCM) in Liberia's national CHW program. METHODS: We developed 3 vignettes to measure knowledge of iCCM illnesses (malaria, diarrhea, and pneumonia) in 4 main areas: assessment, diagnosis, treatment, and caregiver instructions. Trained nurse supervisors administered the vignettes to CHWs in 3 counties in rural Liberia as part of routine program supervision between January and May 2019, collected data on CHW knowledge using a standardized checklist tool, and provided feedback and coaching to CHWs in real time after vignette administration. Proportions of vignettes correctly managed, including illness classification, treatment, and referral where necessary, were calculated. We assessed feasibility, defined as the ability of clinical supervisors to administer the vignettes integrated into their routine activities once per year for each CHW, and effectiveness, defined as the ability of the vignettes to measure the primary outcomes of CHW knowledge of diagnosis and treatment including referrals. RESULTS: We were able to integrate this assessment into routine supervision, facilitate real-time coaching, and collect data on iCCM knowledge among 155 CHWs through delivery of 465 vignettes. Diagnosis including severity was correct in 65%-82% of vignettes. CHWs correctly identified danger signs in 44%-50% of vignettes, correctly proposed referral to the facility in 63% of vignettes including danger signs, and chose correct lifesaving treatment in 23%-65% of vignettes. Both diagnosis and lifesaving treatment rates were highest for malaria and lowest for severe pneumonia. CONCLUSION: Administration of vignettes to assess knowledge of correct iCCM case management was feasible and effective in producing results in this setting. Proportions of correct diagnosis and lifesaving treatment varied, with high proportions for uncomplicated disease, but lower for more severe cases, with accurate recognition of danger signs posing a challenge. Future work includes validation of vignettes for use with CHWs through direct observation, strengthening supportive supervision, and program interventions to address identified knowledge gaps.

Management of supracondylar fracture of humerus in children by close reduction and immobilization of the elbow in extension and supination.

BACKGROUND: A Supracondylar fracture of the humerus is the most common fracture in children around the elbow and is also called first decade injury. If not treated properly it may lead to disability due to elbow stiffness, and sequel of neuro-vascular injuries like Volkmann ischemic contracture etc. This study was undertaken to determine the outcome of close reduction and immobilization of the elbow in extension and supination in displaced supracondylar fractures of the humerus in children. METHOD: This Quasi-experimental study was conducted in the Department of Orthopaedics, Postgraduate Medical Institute, Lady Reading Hospital Peshawar, from January 2007 to December 2007. The inclusion criteria was Gartland Type III (completely displaced) supracondylar fractures of the humerus and the exclusion criteria was open or closed Gartland type-III fracture associated with neurovascular injury. Close reduction under general anaesthesia was done and the elbow was immobilized in extension by the application of 2 plaster slabs according. The follow up is based on the overall rating using the modified Flynn global criteria. RESULTS: Out of 70 cases, in 56 cases (80%), reduction was acceptable; while in 14 cases (20%) it was unacceptable. Those with unacceptable reduction, 2nd attempt of close reduction were done but only eight were successful and the other six children required open reduction and internal reduction. Those with acceptable reduction went in to union with the carrying angle +/- 5 degrees of the contra-lateral side and full range-of-motion. Excellent result were achieved in 35 cases (50%), good in 15 cases (21.43%), fair in 4 cases (5.71%) and poor in 6 (8.75%) patients. CONCLUSION: The extension method of close reduction and immobilisation with two slabs is safe method and give better cosmetic results in uncomplicated type III injures as compared to the flexion method.

Career goals of trainee physicians in internal medicine.

OBJECTIVE: To survey Internal Medicine trainees' future career choices and factors influencing their decision-making. DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from November 2006 to January 2007. SUBJECTS AND METHODS: A standard questionnaire was administered to the residents and Interns working in the Department of Internal Medicine of The Aga Khan University Hospital. The questionnaire covered demographic details, specialty choice, work-time distribution and factors influencing career choice. Descriptive statistics were applied. RESULTS: A total of 49 doctors participated with 57% females; and 43% males, having 33% interns and 67% residents. A minority (22%) opted for internal medicine, while 78% selected sub-specialties with cardiology (20%) being the most sought- after sub-specialty. Majority (69%) wanted to spend more time in clinical activities compared to administration (18%) or research (13%). Majority (92%) wanted to work in an academic setting. Availability of a structured training program (61%), ability to practice broad area of medicine (41%) and prestige of the specialty (41%) highly influenced their career choices. Forty one (82%) wanted to proceed abroad for further training and 80% wanted to eventually practice in Pakistan. CONCLUSION: Most of the interviewed under-training physicians wanted to pursue sub-specialty. Clinical work was more attractive compared to research. A structured training program was detrimental in affecting their choices. Majority wanted further training abroad but eventual settlement in Pakistan. The study results can help us create the basis for reforming the current training programs.