"The targets are driving the agenda and that probably needs to change": stakeholder perspectives on HIV partner notification in sub-Saharan Africa.

BACKGROUND: Voluntary assisted partner notification (VAPN) in HIV contact tracing is a globally recommended strategy to identify persons who have been exposed to HIV and link them to HIV testing and follow-up. However, there is little understanding about how VAPN is experienced by stakeholders in sub-Saharan African (SSA) contexts. We conducted a multi-level and multi-national qualitative analysis evaluating stakeholder perspectives surrounding VAPN implementation to inform the development of future VAPN policies. METHOD: We conducted in-depth interviews (IDIs) with VAPN stakeholders at global (n = 5), national (n = 6), and community level (n = 4) across a total of seven SSA countries. Eligible participants were ≥ 18 years old and had experience developing, implementing, or overseeing VAPN policies in SSA. We sought to understand stakeholder's perspectives on policy development, implementation, and perceived outcomes (barriers and facilitators). Interviews were audio recorded, transcribed, and analyzed thematically using a combination of inductive and deductive approaches. RESULTS: Between December 2019 and October 2020 we conducted 15 IDIs. While participants agreed that VAPN resulted in a high yield of people newly diagnosed with HIV; they noted numerous barriers surrounding VAPN implementation across global, national, and community levels, the majority of which were identified at community level. Barriers at global and national level included high target setting, contradictory laws, and limited independent research disenfranchising the experiences of implementing partners. The barriers identified at community level included client-level challenges (e.g., access to healthcare facilities and fear of adverse events); healthcare worker challenges (e.g., high workloads); limited data infrastructure; and cultural/gender norms that hindered women from engaging in HIV testing and VAPN services. In response to these barriers, participants shared implementation facilitators to sustain ethical implementation of VAPN services (e.g., contact tracing methods) and increase its yield (e.g., HIV self-testing integrated with VAPN services). CONCLUSION: Overall, stakeholders perceived VAPN implementation to encounter barriers across all implementation levels (global to community). Future VAPN policies should be designed around the barriers and facilitators identified by SSA stakeholders to maximize the implementation of (ethical) HIV VAPN services and increase its impact in sub-Saharan African settings.

Results of the Cologne Corona Surveillance (CoCoS) project- a cross-sectional study: survey data on risk factors of SARS-CoV-2 infection, and moderate-to-severe course in primarily immunized adults.

BACKGROUND: Amidst the COVID-19 pandemic, vaccination has been a crucial strategy for mitigating transmission and disease severity. However, vaccine-effectiveness may be influenced by various factors, including booster vaccination, as well as personal factors such as age, sex, BMI, smoking, and comorbidities. To investigate the potential effects of these factors on SARS-CoV-2 infection and disease severity, we analyzed data from the third round of the Cologne Corona Surveillance (CoCoS) project, a large cross-sectional survey. METHODS: The study was conducted mid-February to mid-March 2022 in Cologne, Germany. A random sample of 10,000 residents aged 18 years and older were invited to participate in an online survey. Information on participants' demographics (age, sex), SARS-CoV-2 infections, vaccination status, smoking, and preexisting medical conditions were collected. The outcomes of the study were: (1) the occurrence of SARS-CoV-2 infection despite vaccination (breakthrough infection) and (2) the occurrence of moderate-to-severe disease as a result of a breakthrough infection. Cox proportional-hazards regression was used to investigate possible associations between the presence/absence of booster vaccination, personal factors and the occurrence of SARS-CoV-2 infection. Associations with moderate-to-severe infection were analyzed using the Fine and Gray subdistribution hazard model. RESULTS: A sample of 2,991 residents responded to the questionnaire. A total of 2,623 primary immunized participants were included in the analysis of breakthrough infection and 2,618 in the analysis of SARS-CoV-2 infection severity after exclusions due to incomplete data. The multivariable results show that booster vaccination (HR = 0.613, 95%CI 0.415-0.823) and older age (HR = 0.974, 95%CI 0.966-0.981) were associated with a reduced hazard of breakthrough infection. Regarding the severity of breakthrough infection, older age was associated with a lower risk of moderate-to-severe breakthrough infection (HR = 0.962, 95%CI0.949-0.977). Female sex (HR = 2.570, 95%CI1.435-4.603), smoking (HR = 1.965, 95%CI1.147-3.367) and the presence of chronic lung disease (HR = 2.826, 95%CI1.465-5.450) were associated with an increased hazard of moderate-to-severe breakthrough infection. CONCLUSION: The results provide a first indication of which factors may be associated with SARS-CoV-2 breakthrough infection and moderate-to-severe course of infection despite vaccination. However, the retrospective nature of the study and risk of bias in the reporting of breakthrough infection severity limit the strength of the results. TRIAL REGISTRATION: DRKS.de, German Clinical Trials Register (DRKS), Identifier: DRKS00024046, Registered on 25 February 2021.

Results of the Cologne Corona Surveillance (CoCoS) study - a cross-sectional study: survey data on risk factors of SARS-CoV-2 infection in adults.

BACKGROUND: The personal, environmental, and behavioral risk factors that play an important role in the spread of SARS-CoV-2 are still largely unclear. At the same time, there is limited evidence on the effectiveness of specific countermeasures for SARS-CoV-2. As a first approach to these questions, we use data from the Cologne Corona Surveillance (CoCoS) study, a large cross-sectional study conducted in Cologne, Germany, in June 2021. METHODS: This study was conducted in Cologne, Germany. Six thousand randomly selected Cologne residents who were 18 years of age or older were invited to participate in this study. Participant information was obtained via an online survey. Previous SARS-CoV-2 infections were recorded using self-reports. Sociodemographic and environmental information such as age, sex, living situation were collected. Potential SARS-CoV-2 risk behaviors were captured (workplace situation, adherence to hygiene regulations, and regular use of public transportation). Adherence to hygiene regulations was surveyed by determining the compliance with the 'AHA'-rules (German acronym that stands for keeping a distance of 1.5 m from fellow citizens, hand disinfection, and wearing a face mask). Binary logistic regression analysis was used to identify risk factors for SARS-CoV-2 infection. RESULTS: A sample of 2,433 study participants provided information. Comparison of the sample with the general population showed representativeness for most sociodemographic characteristics with a preference for higher level of education in the study sample. Younger age, as well as living with minor children (under 18 years) in the same household were associated with a higher number of self-reported SARS-CoV-2 infections. Adherence to hygiene regulations was associated with fewer self-reported SARS-CoV-2 infections in adults. Gender, size of living space per person, workplace situation (work from home versus working with contact to colleagues/customers), and regular use of public transportation showed no significant association with self-reported SARS-CoV-2 infections in multivariable analysis. CONCLUSION: The presented results provide initial indications of which sociodemographic and behavioral factors may be associated with SARS-CoV-2 infection. However, the fact that these factors were recorded without exact dates and could have changed accordingly during the pandemic or after infection limits the strength of the results. TRIAL REGISTRATION: DRKS.de, German Clinical Trials Register (DRKS), Identifier: DRKS00024046, Registered on 25 February 2021.

Results of the Cologne Corona surveillance (CoCoS) study - a prospective population-based cohort study: incidence data and potential underestimation of new SARS-CoV-2 adult infections by health authorities.

BACKGROUND: Current incidence estimates of SARS-CoV-2 in Germany rely to a large extent on case notifications. However, the large number of mild or asymptomatic infections is likely to result in underestimation. Population-based studies can provide valid estimates of the SARS-CoV-2 incidence and thus support health authorities to monitor the epidemiological situation and to initiate, maintain, strengthen or relax effective countermeasures. METHODS: This study was conducted in Cologne, Germany. Six-thousand randomly drawn Cologne residents, 18 years of age or older, were contacted by mail in March 2021. Study envelopes contained a kit for self-administered saliva sample and access details to a questionnaire on sociodemographic characteristics, previous positive SARS-CoV-2 RT-qPCR and completed COVID-19 vaccinations. Participants were again invited for a second round in June 2021, while those who declined participation were replaced by additional randomly drawn Cologne residents in order to reach a total of 6000 potential participants again. The saliva samples were sent to the laboratory by mail and tested for SARS-CoV-2 using RT-qPCR. The incidence estimates were adjusted for sensitivity and specificity of the test procedure and compared with the official numbers of new SARS-CoV-2 cases in the adult Cologne population. RESULTS: The first surveillance round in March 2021 (response rate: 34.08%, N = 2045) showed a SARS-CoV-2 seven-day incidence of 85 cases per 100,000 adult Cologne residents (95% CI: 9 to 319). In the same period, the officially registered cases were 125 per 100,000. The second surveillance round in June 2021 (response rate: 36.53%, N = 2192) showed a seven-day incidence of 27 per 100,000 adult Cologne residents (95% CI: 1 to 142), while the official figures for newly registered SARS-CoV-2 cases in the same period were 15 per 100,000. CONCLUSIONS: The incidence estimates do not indicate relevant underestimation of new SARS-CoV-2 infections based on case notification. Regular use of the surveillance method developed here may nevertheless complement the efforts of the health authorities to assess the epidemiological situation. TRIAL REGISTRATION: DRKS.de, German Clinical Trials Register (DRKS), Identifier: DRKS00024046 , Registered on 25 February 2021.

[Spatio-temporal distribution of COVID-19 in Cologne and associated socio-economic factors in the period from February 2020 to October 2021]. / Die zeitlich-räumliche Verteilung von COVID-19 in Köln und beeinflussende soziale Faktoren im Zeitraum Februar 2020 bis Oktober 2021.

BACKGROUND AND GOALS: Even in the early phase of the COVID-19 pandemic, which took a very different course globally, there were indications that socio-economic factors influenced the dynamics of disease spread, which from the second phase (September 2020) onwards particularly affected people with a lower socio-economic status. Such effects can also be seen within a large city. The present study visualizes and examines the spatio-temporal spread of all COVID-19 cases reported in Cologne, Germany (February 2020-October 2021) at district level and their possible association with socio-economic factors. METHODS: Pseudonymized data of all COVID-19 cases reported in Cologne were geo-coded and their distribution was mapped in an age-standardized way at district level over four periods and compared with the distribution of social factors. The possible influence of the selected factors was also examined in a regression analysis in a model with case growth rates. RESULTS: The small-scale local infection process changed during the pandemic. Neighborhoods with weaker socio-economic indices showed higher incidence over a large part of the pandemic course, with a positive correlation between poverty risk factors and age-standardized incidence. The strength of this correlation changed over time. CONCLUSION: The timely observation and analysis of the local spread dynamics reveals the positive correlation of disadvantaging socio-economic factors on the incidence rate of COVID-19 at the level of a large city and can help steer local containment measures in a targeted manner.

Plasma interferon-γ-inducible protein 10 (IP-10) levels correlate with disease severity and paradoxical reactions in extrapulmonary tuberculosis.

BACKGROUND: With 1.5 million deaths worldwide in 2018, tuberculosis (TB) remains a major global public health problem. While pulmonary TB (PTB) is the most common manifestation, the proportion of extrapulmonary TB (EPTB) is increasing in low-burden countries. EPTB is a heterogeneous disease entity posing diagnostic and management challenges due to the lack of reliable biomarkers. In this study, we prospectively evaluated clinical data and treatment response which were correlated with different biomarkers. METHODS: The study was conducted at the University Hospital of Cologne. 20 patients with EPTB were enrolled. We analyzed plasma interferon-γ-inducible protein 10 (IP-10) levels in plasma by ELISA for up to 12 months of treatment. In addition, the QuantiFERON®-TB Gold Plus (QFT® Plus) test was performed during the course of treatment. Clinical data were assessed prospectively and correlated with QFT® Plus and IP-10 levels. RESULTS: Plasma IP-10 levels were found to be significantly increased (p < 0.001) in patients with extensive disease compared to patients with limited disease (cervical lymph node TB) or healthy controls. In patients with clinically confirmed paradoxical reaction (PR), a further increase of IP-10 was noted. IFN-γ measured by the QFT® Plus test did not decrease significantly during the course of treatment. Of note, in four EPTB patients (20%) without radiographic pulmonary involvement, sputum culture was positive for Mycobacterium tuberculosis. CONCLUSION: Our data demonstrate that IP-10 may be a valuable biomarker for estimation of disease severity in EPTB and monitoring of the disease course in extensive forms. However, IP-10 may be less suitable for diagnosis and monitoring of EPTB patients with limited disease. The QFT® Plus test does not appear to be a suitable marker for therapy monitoring. Sputum should be examined in EPTB patients even in case of normal diagnostic imaging of the chest.

Risk factors for antibiotic resistance development in healthcare settings in China: a systematic review.

Antibiotic resistance (ABR) threatens the effectiveness of infectious disease treatments and contributes to increasing global morbidity and mortality. In this study, we systematically reviewed the identified risk factors for ABR among people in the healthcare system of mainland China. Five databases were systematically searched to identify relevant articles published in either English and Chinese between 1 January 2003 and 30 June 2019. A total of 176 facility-based references were reviewed for this study, ranging across 31 provinces in mainland China and reporting information from over 50 000 patients. Four major ABR risk factor domains were identified: (1) sociodemographic factors (includes migrant status, low income and urban residence), (2) patient clinical information (includes disease status and certain laboratory results), (3) admission to healthcare settings (includes length of hospitalisation and performance of invasive procedures) and (4) drug exposure (includes current or prior antibiotic therapy). ABR constitutes an ongoing major public health challenge in China. The healthcare sector-associated risk factors was the most important aspect identified in this review and need to be addressed. Primary health care system and ABR surveillance networks need to be further strengthened to prevent and control the communicable diseases, over-prescription and overuse of antibiotics.

Role of community health volunteers in identifying people with elevated blood pressure for diagnosis and monitoring of hypertension in Malawi: a qualitative study.

BACKGROUND: In recent years, there has been greater recognition of the important role of community health volunteers in many countries and their important role informs many health programs. This include health education, provision of services such as screening, monitoring and referral to health facilities. Their roles are better understood in the areas of communicable diseases like HIV infection, Tuberculosis and Malaria however little is known about their role in non-communicable diseases. This study seeks to explore perception of CHVs' functions, tasks, and their fulfilment in identifying people with elevated blood pressure for diagnosis and monitoring of hypertension in Lilongwe, Malawi. METHODS: This was a qualitative naturalistic research design utilizing observation and semi-structured interviews with community health volunteers working in Lilongwe, Malawi. Interviews were carried out with the researcher. Participants were recruited from the ZaMaC project. An interview guide was developed with a category-guided deductive approach. The interviews were recorded through note taking. Data analysis was performed using content analysis approach. RESULTS: Community health volunteers have multiple roles in prevention and monitoring of hypertension. They act as health educators and provide lifestyle counselling. They screened for hypertension and monitored blood pressure and assisted community members to navigate the health system such as linkage to health facilities. These roles were shaped in response to community needs. CONCLUSION: This study indicates the complexities of the roles of community health volunteer in identifying people with elevated BP for diagnosis and monitoring of hypertension. Understanding community health volunteers' roles provides insight into their required competencies in provision of their daily activities as well as required training to fill in their knowledge gaps.

"Deadly", "fierce", "shameful": notions of antiretroviral therapy, stigma and masculinities intersecting men's life-course in Blantyre, Malawi.

BACKGROUND: Stigma and masculinity represent persistent barriers in delivering successful HIV interventions to men. Our study examined community perceptions of HIV and anti-retroviral therapy (ART) and their implications for men on ART across the life course in Blantyre, Malawi. METHODS: Our qualitative study is based on 72 face-to-face semi-structured interviews. Participants were selected purposively and included men on ART (with suppressed and unsuppressed viral loads), adult male community members irrespective of HIV status and other HIV stakeholders such as health personnel and program implementers. Interviews were conducted in Chichewa and English, transcribed verbatim and analyzed thematically in NVivo 12. We applied the socio-ecological model as our theoretical framework as well as a "life-course" perspective. RESULTS: Our findings highlight lingering negative perceptions towards ART in general and towards PLHIV irrespective of viral load suppression. With intersecting notions of masculinity and stigma, men's descriptions of anticipated stigma in their relationships and when visiting health facilities dominated. Stigma was experienced at the personal, interpersonal, facility and community level. Yet, men living with HIV were perceived differently throughout the life-course, with young sexually active men seen as the most stigmatized group and older men seen as drawing resilience from a greater range of masculine norms. Some men of all ages displayed "transformative" masculinities independent of stigma and community expectations. CONCLUSIONS: We propose the "life-course" as a useful concept for studies on masculinity, HIV and stigma. Considering gendered constructions of "respectable" midlife-older age vis-à-vis younger age, and how they influence stigma as well as uptake and adherence to ART might lead to more targeted services for men that build on "transformative masculinities".

Protocol of the Cologne Corona Surveillance (CoCoS) Study- a prospective population-based cohort study.

BACKGROUND: Surveillance strategies are critical to cope with the current SARS-CoV-2 pandemic and to evaluate, as well as adjust government-imposed countermeasures. Incidence estimates are widely based on laboratory confirmed cases reported by health authorities. Prevalence and incidence data of SARS-CoV-2 is still scarce, along with demographic and behavioural factors associated with infection risk. METHODS: The Cologne Corona Surveillance Study will be conducted in the City of Cologne, which is the fourth-largest city in Germany with a population of approximately 1.1 million. Researchers will apply self-sampling surveillance to a rolling cohort of Cologne residents. Random samples of 6000 Cologne residents 18 years of age and older will be drawn from the registration office. Upon receiving the information and saliva sample kit, participants will be asked to fill out a questionnaire online or via phone, sign written informed consent, and send back written consent, as well as saliva sample. The saliva samples will be tested for SARS-CoV-2 by reverse PCR. The questionnaire will be administered to gather information about personal characteristics such as health status and risks. A second round of testing will take place 6 weeks after the first. DISCUSSION: Self-administered saliva sampling proved to be a legitimate and feasible alternative to nasopharyngeal swabs taken by health professionals. However, it is unclear whether the targeted response rate of 40% can be achieved and whether the results are representative of the population. TRIAL REGISTRATION: DRKS.de, German Clinical Trials Register (DRKS), Identifier: DRKS00024046 , Registered on 25 February 2021.

Principles of condom provision programs in prisons from the standpoint of European prison health experts: a qualitative study.

BACKGROUND: Condom provision is one of the most effective harm reduction interventions to control sexually transmitted infections (STIs) including HIV/AIDS and viral hepatitis in prisons. Yet, very few countries around the world provide prisoners with condoms. The present study aimed to elucidate principles of effective prison-based condom programs from the perspective of European public health and prison health experts. METHODS: As a part of the "Joint Action on HIV and Co-infection Prevention and Harm Reduction (HA-REACT)" twenty-one experts from the field of prison health from eight European countries were invited to discuss the principles of condom provision programs in prisons within two focus groups. The audio records were transcribed verbatim, coded, categorized, and analyzed using thematic analysis method. RESULTS: Six components emerged from the analysis as essential for successful condom programs in prisons: (1) highlighting the necessity of condom provision in prisons, (2) engagement of internal and external beneficiaries in all stages of designing and implementing the program, (3) conducting a pilot phase, (4) condom program in a comprehensive package of harm reduction interventions, (5) vending machine as the best method of condom distribution in prisons and (6) assuring the sustainability and quality of the intervention. CONCLUSION: Results of the present study can help prison health policy makers to design and conduct acceptable, accessible and high-quality prison-based condom provision programs, and consequently to mitigate the burden of STIs in prisons. Having access to high-quality healthcare services including condom provision programs is not only the right of prisoners to health, but also is a move towards achieving the sustainable development goal 3 of "leaving no one behind."

Availability, Accessibility, and Coverage of Needle and Syringe Programs in Prisons in the European Union.

Needle and syringe programs (NSPs) are among the most effective interventions for controlling the transmission of infection among people who inject drugs in prisons. We evaluated the availability, accessibility, and coverage of NSPs in prisons in European Union (EU) countries. In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, we systematically searched 4 databases of peer-reviewed publications (MEDLINE (PubMed), ISI Web of Science, EBSCO, and ScienceDirect) and 53 databases containing gray literature to collect data published from January 2008 to August 2018. A total of 23,969 documents (17,297 papers and 6,672 gray documents) were identified, of which 26 were included in the study. In 2018, imprisonment rates in 28 EU countries ranged between 51 per 100,000 population in Finland and 235 per 100,000 population in Lithuania. Only 4 countries were found to have NSPs in prisons: Germany (in 1 prison), Luxembourg (no coverage data were found), Romania (available in more than 50% of prisons), and Spain (in all prisons). Portugal stopped an NSP after a 6-month pilot phase. Despite the protective impact of prison-based NSPs on infection transmission, only 4 EU countries distribute sterile syringes among people who inject drugs in prisons, and coverage of the programs within these countries is very low. Since most prisoners will eventually return to the community, lack of NSPs in EU prisons not only is a threat to the health of prisoners but also endangers public health.

Prisoners should not be left behind in HCV research and policies.

With a worldwide prevalence of 15.4%, hepatitis C virus (HCV) has been estimated to be the most prevalent major infectious disease in prisons. The exceptionally high prevalence of HCV in prisons is attributable to common risk behaviors including sharing contaminated tattooing equipment and drug paraphernalia, as well as lack of HCV control interventions including needle and syringe programs. Despite the importance of attention to prisoners as a highly at-risk population to acquire and transmit HCV, the number of HCV research and policy documents ignoring prisoners is increasing. Highlighting this issue, the present manuscript discusses how excluding prisoners from HCV-related research and policies will jeopardize the global HCV elimination goals set forth by the global community.

[Contact Investigation in Active Tuberculosis and Management of Latent TB Infection: 5-year Analysis at a German City Health Authority]. / Kontaktuntersuchungen bei aktiver Tuberkulose und Management latenter Tuberkulose: 5 Jahres-Analyse an einem deutschen Großstadt Gesundheitsamt.

BACKGROUND: As part of the German TB control program, health authorities conduct investigations among contacts of patients with active tuberculosis based on the infection prevention legislation, to identify potential infections among these persons. The aim of this study was to analyze retrospectively procedures of the city health authority Cologne, in cases of newly diagnosed latent TB infection (LTBI) over a 5-year period. METHODS: Data from the Cologne City Health Authority on contact investigations of TB cases between July 1st 2012 und December 31st 2016 were analyzed. In the absence of signs for active TB and a positive result of the interferon gamma release assay (QFT), LTBI was diagnosed in contact persons. Those with positive test results aged 16 and above and registered in Cologne were included. RESULTS: Out of 3859 contact persons, 430 met the inclusion criteria: in 174/430 cases chemo-preventive therapy (CPT) was recommended and 65 (35.1 %) actually took the course of CPT; in 117 cases, no records of CPT were found in the files and 22/430 persons with LTBI developed active TB within the observation period. CONCLUSION: If the full potential of LTBI treatment on the basis of the recommendations of WHO's "End TB-Strategy" is to be realized, the present study reveals the need to continuously improve documentation and management of LTBI in this setting.

Evaluation of e-learning for medical education in low- and middle-income countries: A systematic review.

In low- and middle-income countries (LMICs), e-learning for medical education may alleviate the burden of severe health worker shortages and deliver affordable access to high quality medical education. However, diverse challenges in infrastructure and adoption are encountered when implementing e-learning within medical education in particular. Understanding what constitutes successful e-learning is an important first step for determining its effectiveness. The objective of this study was to systematically review e-learning interventions for medical education in LMICs, focusing on their evaluation and assessment methods. Nine databases were searched for publications from January 2007 to June 2017. We included 52 studies with a total of 12,294 participants. Most e-learning interventions were pilot studies (73%), which mainly employed summative assessments of study participants (83%) and evaluated the e-learning intervention with questionnaires (45%). Study designs, evaluation and assessment methods showed considerable variation, as did the study quality, evaluation periods, outcome and effectiveness measures. Included studies mainly utilized subjective measures and custom-built evaluation frameworks, which resulted in both low comparability and poor validity. The majority of studies self-concluded that they had had an effective e-learning intervention, thus indicating potential benefits of e-learning for LMICs. However, MERSQI and NOS ratings revealed the low quality of the studies' evidence for comparability, evaluation instrument validity, study outcomes and participant blinding. Many e-learning interventions were small-scale and conducted as short-termed pilots. More rigorous evaluation methods for e-learning implementations in LMICs are needed to understand the strengths and shortcomings of e-learning for medical education in low-resource contexts. Valid and reliable evaluations are the foundation to guide and improve e-learning interventions, increase their sustainability, alleviate shortages in health care workers and improve the quality of medical care in LMICs.

Technology Acceptance and Information System Success of a Mobile Electronic Platform for Nonphysician Clinical Students in Zambia: Prospective, Nonrandomized Intervention Study.

BACKGROUND: Zambia is still experiencing a severe shortage of health workers, which is impacting the national health care system. Very few people are trained, educational infrastructure is inadequate, and senior human resources for training are not yet sufficient to produce the number of health care workers needed, especially for currently underserved rural areas. Therefore, to strengthen the medical education program of medical licentiates, we implemented a tablet-based electronic learning platform (e-platform) with a medical decision-support component. OBJECTIVE: As the primary objective, this study aimed to explore the acceptance and information system (IS) success of an e-platform focused on offline-based tablet usage for nonphysician clinical students in a low-resource context in Zambia, Africa. Furthermore, we aimed to evaluate student demographic factors and prior technological experience, as well as medical lecturers' acceptance of technology of the e-platform. METHODS: We collected data for the study before and after the intervention. Before the intervention, we collected student demographic data and prior technological experience using a questionnaire. After the intervention, we collected results of the questionnaire on technology acceptance of students and IS success of the e-platform, as well as technology acceptance of medical lecturers. We calculated statistical measures such as means, standard deviations, and correlations of investigated variables. The study report was compiled using the Consolidated Standards of Reporting Trials-Electronic Health checklist. RESULTS: Overall, questionnaire results of students and medical lecturers indicated acceptance of the e-platform and showed higher ratings for overall net benefits and information quality (students) and perceived ease of use and perceived usefulness (medical lecturers) as compared with ratings of other categories. The lowest scores were conveyed for system use and service quality (students) and attitude and behavioral intention (medical lecturers). CONCLUSIONS: Acceptance of the e-platform as a learning technology for strengthening medical education in a low-resource context in Zambia was generally high for students and medical lecturers, but shortcomings were also identified. Results indicated low overall usage of the e-platform as a learning and teaching tool. One hindering factor was the tablets' overall weak reliability with regard to its service life and battery life span, and another was the teachers' low engagement with the e-platform. Next steps may include other hardware and more technology-based training for medical lecturers. The evaluation results indicated that the e-platform may open new promise for further strengthening and expanding medical education in this context, especially with more affordable and viable technologies that are available.

E-Learning for Medical Education in Sub-Saharan Africa and Low-Resource Settings: Viewpoint.

E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population's health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.

Listening to their voices: understanding rural women's perceptions of good delivery care at the Mibilizi District Hospital in Rwanda.

BACKGROUND: Poor quality maternity care may lead to increased maternal dissatisfaction, and subsequent decreased utilization of health services or both. In a responsive health system, determining suitable delivery care, in the mother's opinion, may lead to an improved quality of services and the mother's satisfaction. In Rwanda, there is still limited knowledge and inadequate research regarding patient satisfaction and preferences, especially for women's perceptions and needs during childbirth. This study captures rural women's perception of good delivery care to understand aspects of care they consider important during childbirth. METHODS: This qualitative study was conducted in the Mibilizi District Hospital catchment area located 350 km from the capital, Kigali, in the Western Province of Rwanda. It includes 25 in-depth interviews with purposively sampled rural mothers who had delivered in the hospital and five hospital midwives. Content analysis was performed manually. RESULTS: With regard to interpersonal relations at the health facility, the women agreed on the need for respectful treatment in areas of sufficient privacy and had distinct preferences for the gender of the birth attendant, or husband's presence during delivery. The women make a great effort to deliver in a health care facility and therefore, they expect to be assisted in a professional and safe manner. These expectations can be met on a personal level, but at times are counteracted by structural deficiencies and staff shortages. CONCLUSIONS: In gathering rural women's perceptions of good delivery care, this study reveals what mothers in remote areas in Rwanda consider important during child birth. The women's expectations, suggestions, and needs can enhance providers' awareness of the women's priorities during childbirth and serve as a guidepost for health services to increase the quality, acceptability and uptake of maternal health services.

Health care provision for refugees in Germany - one-year evaluation of an outpatient clinic in an urban emergency accommodation.

BACKGROUND: In 2015, Germany recorded the highest rates of refugees since the early 1990s. Access to medical care is a legally regulated fundamental element of aid for refugees. In practice, there are several hurdles such as language barriers and legal regulations. In response to the massively increased need, special outpatient services for refugees were started in several German cities. In Cologne, an outpatient clinic (OPD) was established in the largest emergency accommodation centre for refugees supported by the Cologne municipality and operated by the German Red Cross and physicians from the Association of Statutory Health Insurance Physicians. This study reports experiences of the first year of the OPD regarding structure, processes and utilization. METHODS: Employing mixed methods, between May and December 2015 cross sectional pseudonymized data from patients' contacts were collected, coded in the International Classification of Primary Care (ICPC) and evaluated. Infrastructure, equipment, process organisation and function of the OPD were assessed during five participatory observations and triangulated with results of a self-administered questionnaire for staff and four qualitative interviews with key informants. RESULTS: During the observation period a total of 2205 persons (67% male) stayed in the emergency accommodation and 984 patient contacts (51% male) were registered, mainly by young persons from Western Balkan countries and Syria. Medical treatment was sought primarily for acute respiratory-, loco-motor-system- and skin symptoms followed by chronic physical diseases. Headache, back and neck pain and acute respiratory infection were the most frequent diagnoses. Questionnaires and interviews among staff revealed language barriers and psycho-trauma as the most frequently reported challenges. Equipment and staffing was adequate, but patient documentation was not systematic, leading to loss of information. CONCLUSION: To facilitate refugees' appropriate access to health care, the OPD was seen as functional for this refugee accommodation centre. Need was recognised for standardized, data protective documentation and a health passport for clients for medical information. Psychological support for refugees needs expansion taking legal circumstances and coverage of costs into consideration. To improve patient communication employees working with refugees should be offered an introduction to culturally sensitive understanding of health and illness.

Lessons learnt from the MAGNET Malawian-German Hospital Partnership: the German perspective on contributions to patient care and capacity development.

BACKGROUND: Malawi is a low-income country with one of the highest HIV prevalence rates worldwide (Kendig et al., Trop Med Health 41:163-170, 2013). The health system depends largely on external funding. Official German development aid has supported health care in Malawi for many years (German Embassy Lilongwe, The German Development Cooperation in Malawi), including placing medical doctors in various departments of the Kamuzu Central Hospital (KCH) in Lilongwe. In 2008, a hospital partnership called MAGNET (Malawi German Networking for Capacity Building in Treatment, Training and Research at KCH) evolved as part of the German ESTHER network. The partnership was abruptly terminated in 2015. METHODS: We reviewed 35 partnership documents and conducted an online survey of partnership stakeholders to retrospectively assess the hospital partnership based on the Capacity WORKS model of the German Corporation for International Cooperation (GIZ). This model evaluates systems' management and implementation to understand and support the functioning of cooperation within societies. Based on this model, we considered the five success factors for cooperation management: (1) strategy, (2) cooperation, (3) steering, (4) processes, and (5) learning and innovation. In an online survey, we used an adapted version of the partnership evaluation tool by the Centers for Disease Control and Prevention (CDC). RESULTS: From 2008 to 2015, the MAGNET partnership contributed to capacity building and improved patient care in the KCH Medical Department through clinical care, technical support, teaching and trainings, and operations research based on mutually agreed upon objectives. The MAGNET partnership was implemented in three phases during which there were changes in leadership in the Medical Department and the hospital, contractual policies, funder priorities and the competing influences of other actors. Communication and follow up among partners worked best during phases when a German doctor was onsite. The partnership was judged as a positive driver for change and support within the Medical Department, but eventually failed to implement self-sustainable, robust processes within the partnership to cope with multiple changes and challenges. CONCLUSION: The MAGNET partnership made a considerable contribution to patient care, continuous medical education and operations research at KCH, despite its abrupt termination. Changes in the institutional infrastructure, donor policy and interpersonal relations contributed to the loss of shared expectations and the end of the project. Institutional-hospital partnerships, like MAGNET, can make a valuable contribution to health care provision and hence a wider health agenda, provided there is a flexible, mutually agreed upon strategy, personal commitment, continuous communication and robust processes. However, partnership projects remain vulnerable to the influences of external actors and structures. Ministries of Health and donor agencies should appreciate the particular strength of hospital partnerships.