Novel on-site follow-up and enhancement program (FEP) improves knowledge, clinical skills and enabling environment of skilled birth attendants in Nepal.

INTRODUCTION: Although great strides have been made in maternal and newborn health in Nepal, the maternal mortality ratio (MMR) is still high at 186 per 100,000 births. Many maternal deaths are preventable if there is access to a skilled birth attendant (SBA). The Ministry of Health and Population of Nepal launched the in-service SBA training program in 2007 and has trained over 10,000 SBAs to date. Evidence shows that one episode of training is not enough to retain skills. Therefore, the Nick Simons Institute (NSI) in collaboration with National Health Training Center (NHTC) devised a Follow-Up and Enhancement Program (FEP) in 2011 where the knowledge, clinical skills, and working environment of SBA graduates were assessed directly at their worksites. FEP allows on-site coaching and feedback so that graduates may continue to improve upon any gaps in their knowledge, skills, and working environment. This study aims to assess the effectiveness of FEP. METHODS: We used a mixed-methods research design. A total of 73 SBAs who had a pre-FEP assessment in 2016 were followed up for a post-FEP assessment in 2017. We also collected data from 3 additional districts (115 SBAs) that had not previously had FEP, to compare SBAs in FEP versus non-FEP districts. Qualitative data was collected from 16 health facilities on the perceptions, motivation, and satisfaction of stakeholders. RESULTS: Of the total 188 SBAs that were sampled, a one-time FEP increased knowledge scores by 9%, clinical skills scores by 29%, and enabling environment scores by 7%. The number of deliveries conducted improved with a one-time FEP, although this increase was not statistically significant. We found a trickle-down effect of working in a facility that has had prior FEP, with SBAs that have never had FEP improving their clinical skills. FEP was found to be a highly accepted program and is beneficial to SBAs, trainers, and the Hospital Management Committee (HFOMC). However, a one-time FEP is not sufficient in retaining clinical skills and knowledge. CONCLUSION: FEP is a highly effective program by both quantitative and qualitative evaluation. Our study suggests that FEP should be frequent and continuous to retain the knowledge and clinical skills of SBAs, motivate them through on-site coaching, and improve their working environment through direct feedback to the Ministry of Health and Population.

Magnetic Resonance Imaging Evaluation of Musculoskeletal Diseases of Ankle and Foot.

Background Ankle and foot pain is a common clinical problem, that may be due to a variety of soft tissue and osseus abnormalities. Magnetic resonance imaging plays vital role for diagnosing internal derangement of the ankle joint, assessing soft tissue structures around the ankle such as tendons, ligaments, nerves and osseus structures. Method Retrospective magnetic resonance imaging evaluation of the ankle and foot was done in 100 patients using 0.3T and 1.5T magnetic resonance imaging. Clinical history included pain, swelling of the ankle and foot, trauma, twisting injury, palpable mass and difficulty in walking. Result Fifty two patients were male and 48 patients female aged 6 months to 70 years. Ligaments tear were the commonest and seen in 22% patients. Tenosynovitis found in 17%, Pigmented villonodular synovitis (PVNS) in 3%, Achilles tendon abnormality in 8%, stress fracture-9%, osteomyelitis-8%, soft tissue vascular malformation in 5%, soft tissue and bone tumor-4%, marrow edema-20%, osteoarthritis-10%, Osteochondral lesion of talus-8%, sinus tarsi syndrome-3%, posterior impingement-5%, plantar fasciitis-2%, Sever disease-2%, peroneus tendon split-2%. The commonest clinical presentation was pain and swelling of the ankle in 42 patients, twisting/inversion injury of the ankle in 23 patients followed by traumatic injury with difficulty in walking in 20 patients and palpable mass in 8 patients. Ligaments injury were mostly associated with inversion/twisting injury. Conclusion Magnetic resonance imaging is advantageous for assessing soft tissue structures around the ankle and foot, such as tendons, ligaments, nerves, masses and occult osseus lesions. It provides a quick, non-invasive tool for the diagnosis of related injuries and guide for the further treatment planning.

Airborne Particulate Matter and Health Condition in Brick Kiln Workers in Kathmandu Valley, Nepal.

Background Air quality monitoring in brick kilns indicates very high concentrations of airborne particulate matter. Air pollution from brick kilns poses an enhanced threat to the environment and to human health. Objective To evaluate airborne particulate matter concentration and health status of brick kiln workers. Method A cross-sectional comparative study was conducted in the Kathmandu valley targeting all brick industries and their workers during January - March 2015 and March - April 2016. A total of 16 brick kilns and 800 participants (400 brick workers as exposed and 400 grocery workers as referent) were selected for study. A direct-reading, Dusttrak model 8533 was used for air sampling. Nepali version questionnaire was applied to obtain epidemiological data. SPSS version 16 was used to perform statistical analysis. Median, mean, range and proportion were calculated and Mann-Whitney U test, Kruskal-Wallis test and chi square (c2) test were applied to test significance. Result Mean values of particulate matter concentrations for brickfields were as follows: Total Suspended Particulate Matter (TSPM): 5.179 mg/m3, PM10: 4.958 mg/m3, respirable suspended particulate matter (RSPM): 4.140 mg/m3, PM2.5: 3.965 mg/m3, and PM1: 3.954 mg/m3. The mean concentrations for grocery workers were; TSPM: 0.089 mg/ m3, PM10: 0.089 mg/m3, RSPM: 0.085 mg/m3, PM2.5: 0.082 mg/m3 and PM1: 0.082 mg/m3. Among brickfield workers, red and green brick loading zones had results that exceeded the ACGIH Threshold Limit Values for TSPM and RSPM. Workers complaints of injury were 52% and 44.2%, and illnesses were 88.5% and 82.2%, respectively among exposed and referent. The occurrence of injuries/illnesses during work showed significant association between exposed and the referent groups at 0.05 level. Conclusion The high level of airborne particulate matter in the brick fields requires action for the protection of workers. The availability of health services within brick industries needs to be enhanced.

How did formative research inform the development of a women's group intervention in rural Nepal?

Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.

Towards a Mobile Intelligent Information System with Application to HIV/AIDS.

The United Nations Security Council reports HIV/AIDS as the fastest growing threat to human development. In addition, the World Health Organization [1] reports that nearly 5 million persons (4.3 million adults and 700,000 children) are newly infected with HIV each year; more than 95% of them found in developing countries. Since STDs as a group are a personal problem which few people feel comfortable discussing, we believe that hand-held PDAs can provide an opportunity for learning about this disease while insuring anonymity. This device will employ the newest technologies including Bluetooth wireless technology, which can transmit and receive data via a short-range radio link using a globally available frequency band (2.4 GHz ISM band), enabling rapid and accurate synchronous and asynchronous data communication. The first generation of Bluetooth permits exchange of data up to a rate of 1 Mbps, even in areas with much electromagnetic disturbance. This emerging technology can facilitate HIV/AIDS outreach around the globe.Recent advances in learning have taken a particularly cognitive perspective and these findings have implications for education in general as well as for the development of intelligent tutoring systems in particular. In the past, effective SmartBookstrade markhave been developed for AIDS education to disseminate the critical knowledge relevant to this epidemic [2].Since 1993, the proliferation of the World Wide Web has created a plethora of new opportunities for the delivery of electronic distance learning systems. However, we feel that it is important that a whatever technology is employed is based on a sound educational theory. A new, comprehensive, web-based learning system called SmartTutor has been developed, at Brooklyn College of The City University of New York [3]. This technology provides a user-friendly, self-paced, easy to modify, software environment intended to serve the user's learning needs and is based on a generic SmartTutor methodology organized around the use of concept mapping. Early assessment of SmartTutor has shown that it is well received by students and helps significantly in their learning processes. It is readily adaptable to the presentation of academic and more general subject matter such as the latest available information on HIV/AIDS. Our new HIV/AIDS SmartTutor will incorporate this SmartTutor paradigm. Our new SmartTutor would provide worldwide access to medical professionals as well as the general public to learn about HIV/AIDS. This new device could also provide a survey tool to facilitate HIV risk assessment. Demonstrations of the SmartTutor learning system will be presented and the continued development of the applications will be discussed.

Improving end of life care: an information systems approach to reducing medical errors.

Chronic and terminally ill patients are disproportionately affected by medical errors. In addition, the elderly suffer more preventable adverse events than younger patients. Targeting system wide "error-reducing" reforms to vulnerable populations can significantly reduce the incidence and prevalence of human error in medical practice. Recent developments in health informatics, particularly the application of artificial intelligence (AI) techniques such as data mining, neural networks, and case-based reasoning (CBR), presents tremendous opportunities for mitigating error in disease diagnosis and patient management. Additionally, the ubiquity of the Internet creates the possibility of an almost ideal network for the dissemination of medical information. We explore the capacity and limitations of web-based palliative information systems (IS) to transform the delivery of care, streamline processes and improve the efficiency and appropriateness of medical treatment. As a result, medical error(s) that occur with patients dealing with severe, chronic illness and the frail elderly can be reduced.The palliative model grew out of the need for pain relief and comfort measures for patients diagnosed with cancer. Applied definitions of palliative care extend this convention, but there is no widely accepted definition. This research will discuss the development life cycle of two palliative information systems: the CONFER QOLP management information system (MIS), currently used by a community-based palliative care program in Brooklyn, New York, and the CAREN case-based reasoning prototype. CONFER is a web platform based on the idea of "eCare". CONFER uses XML (extensible mark-up language), a W3C-endorced standard mark up to define systems data. The second system, CAREN, is a CBR prototype designed for palliative care patients in the cancer trajectory. CBR is a technique, which tries to exploit the similarities of two situations and match decision-making to the best-known precedent cases. The prototype uses the opensource CASPIAN shell developed by the University of Aberystwyth, Wales and is available by anonymous FTP. We will discuss and analyze the preliminary results we have obtained using this CBR tool. Our research suggests that automated information systems can be used to improve the quality of care at the end of life and disseminate expert level 'know how' to palliative care clinicians. We will present how our CBR prototype can be successfully deployed, capable of securely transferring information using a Secure File Transfer Protocol (SFTP) and using a JAVA CBR engine.

Development of a clinical pathways analysis system with adaptive Bayesian nets and data mining techniques.

The use and development of software in the medical field offers tremendous opportunities for making health care delivery more efficient, more effective, and less error-prone. We discuss and explore the use of clinical pathways analysis with Adaptive Bayesian Networks and Data Mining Techniques to perform such analyses. The computation of "lift" (a measure of completed pathways improvement potential) leads us to optimism regarding the potential for this approach.

Development of an expert system for differentiating tension type headaches from migraines.

We created a program, written in the CLIPS language for expert systems, to distinguish migraines from headaches. The system can be web-based, takes seconds to input data and quickly converges to the correct diagnosis. Over time such an application can result in enormous savings to doctors, patients, and health care institutions.

Errors in medical practice: identification, classification and steps towards reduction.

We present a new taxonomy of medical errors, with emphasis on human errors. We illustrate errors due to medication, errors due to diagnosis, errors due to hospital treatment procedures, and errors related to clerical procedures. We also discuss a database of 143 papers on medical errors which we have developed.