Preventing violence and enhancing mental health among clients of an invitro fertilization clinic in Jordan: results of a pre/post pilot test of the use of cognitive behavioral therapy.

INTRODUCTION: Infertility increases women's risk of intimate partner violence (IPV). Cognitive behavioral therapy (CBT) is commonly used to treat mental health problems among fertility treatment seeking patients. CBT has not been tested for its potential to reduce IPV in this population. We pilot test the use of CBT to prevent IPV and improve patients' mental health in a fertility clinic in Jordan. METHODS: Of 38 eligible fertility-treatment seeking couples, 16 consented and underwent up to 11 CBT sessions (average = 9) over 3 months. Interviews at baseline and 16 weeks post intervention (endline) assessed IPV, quality of life, social support, coping, and fear of spouse. Wilcoxon signed-rank and McNemar's tests were used to assess change in outcomes. RESULTS: At baseline, women's rates of IPV, depression, and anxiety were 75%, 87.5%, and 75% respectively, whereas men's rates of depression and anxiety were each 80%. Average baseline post-traumatic stress disorder (PTSD) symptoms for men and women were 3.3 and 2.7 respectively out of 5. IPV decreased 25% after treatment, and women reported less spousal fear. For both men and women, depression, anxiety, and PTSD symptoms decreased and social support and fertility quality of life improved. CONCLUSION: Psychosocial support should be standard of care for the treatment of infertility given the burden of mental health problems and IPV and the utility of CBT in this patient population. Co-design with couples is needed to identify strategies to bolster participation along with population-based interventions to combat the stigma of infertility and mental health service use and enhance women's status.

Advancing Equity in U.S. Hospital Systems: Employee Understandings of Health Equity and Steps for Improvement.

GOALS: Equity in the U.S. healthcare system remains a vital goal for healthcare leaders. Although many hospitals and healthcare systems have adopted a social determinants of health approach to more equitable care, many challenges have limited the effectiveness of their efforts. In this study, we wanted to explore whether healthcare leaders and providers understand the concept of equity and can link the concepts to practical applications within healthcare systems. METHODS: We explored how hospital leadership and providers at a major public hospital in Atlanta, Georgia, understand equity topics both conceptually and at a practical implementation level. We conducted 28 focus groups for >4 months involving 233 staff members, during which participants were asked about their understanding of various equity-related terms and equity implementation within the hospital. PRINCIPAL FINDINGS: Our findings reveal that there is little consensus among staff regarding the conceptual meanings of various health equity-related terms, and only a small minority of staff can articulate a conceptual definition that reflects current research-based understandings of equity. Furthermore, there is little consensus regarding how staff believes that health equity is practically enacted through various hospital programs, even among interviewees who could correctly articulate equity topics. These findings have no association with a role in the organization or length of time employed at the hospital. PRACTICAL APPLICATIONS: These findings indicate a need for a more nuanced understanding of health equity and further clarification and education on how to implement health equity. Although understanding at the conceptual level is an important first step, conceptual knowledge alone is not enough to support health equity at either the individual staff level or the system level. Our recommendations cover strategic development; education specific to the hospital system and its unique needs; consideration of the specific roles of individuals in the organization; and the designation of diversity, equity, and inclusion staff and offices in a hospital organization.

mHealth intervention to improve the continuum of maternal and perinatal care in rural Guatemala: a pragmatic, randomized controlled feasibility trial.

BACKGROUND/OBJECTIVE: Guatemala's indigenous Maya population has one of the highest perinatal and maternal mortality rates in Latin America. In this population most births are delivered at home by traditional birth attendants (TBAs), who have limited support and linkages to public hospitals. The goal of this study was to characterize the detection of maternal and perinatal complications and rates of facility-level referral by TBAs, and to evaluate the impact of a mHealth decision support system on these rates. METHODS: A pragmatic one-year feasibility trial of an mHealth decisions support system was conducted in rural Maya communities in collaboration with TBAs. TBAs were individually randomized in an unblinded fashion to either early-access or later-access to the mHealth system. TBAs in the early-access arm used the mHealth system throughout the study. TBAs in the later-access arm provided usual care until crossing over uni-directionally to the mHealth system at the study midpoint. The primary study outcome was the monthly rate of referral to facility-level care, adjusted for birth volume. RESULTS: Forty-four TBAs were randomized, 23 to the early-access arm and 21 to the later-access arm. Outcomes were analyzed for 799 pregnancies (early-access 425, later-access 374). Monthly referral rates to facility-level care were significantly higher among the early-access arm (median 33 referrals per 100 births, IQR 22-58) compared to the later-access arm (median 20 per 100, IQR 0-30) (p = 0.03). At the study midpoint, the later-access arm began using the mHealth platform and its referral rates increased (median 34 referrals per 100 births, IQR 5-50) with no significant difference from the early-access arm (p = 0.58). Rates of complications were similar in both arms, except for hypertensive disorders of pregnancy, which were significantly higher among TBAs in the early-access arm (RR 3.3, 95% CI 1.10-9.86). CONCLUSIONS: Referral rates were higher when TBAs had access to the mHealth platform. The introduction of mHealth supportive technologies for TBAs is feasible and can improve detection of complications and timely referral to facility-care within challenging healthcare delivery contexts. TRIAL REGISTRATION: Clinicaltrials.gov NCT02348840 .

From guidelines to local realities: evaluation of oral rehydration therapy and zinc supplementation in Guatemala.

OBJECTIVE: Diarrhea remains a leading cause of morbidity and mortality for children in low- and middle-income countries throughout the Americas. The World Health Organization (WHO) has developed guidelines on incorporating zinc supplementation (ZS) with traditional oral rehydration therapy (ORT) in order to shorten the duration of diarrheal episodes and to reduce poor health outcomes. Guatemala adopted these guidelines in 2011, but they have not yet been fully implemented at the community level. The objectives of this study were: (1) to co-design an ORT/ZS training program for community members with local health promoters that is appropriate to the local context and (2) to understand how attitudes and behaviors of community members changed after receiving training from the study promoters. METHODS: In an observational study, community health promoters in rural Guatemala were trained according to WHO guidelines, and they worked collaboratively with the study team to develop a training curriculum to implement in their community. Community-based surveys, interviews, and focus group discussions were used to assess acceptability, accessibility, and availability of oral rehydration therapy and zinc supplementation. RESULTS: Use of ORT increased from 63% to 95% among community members following training by local health promoters. Satisfaction with the service offered by health promoters increased from 63% to 90% amongst community members trained by the study promoters. However, knowledge and use of zinc supplementation remained low, which was attributable to unavailability of zinc in the study community. CONCLUSIONS: Use of trained community health promoters is an effective way to translate WHO guidelines to local contexts and overcome sociocultural barriers to care. However, the health system's structure must support availability of essential medicines in order to effectively implement those guidelines.

Implementation of a training program for low-literacy promotoras in oral rehydration therapy.

OBJECTIVE: The purpose of this study was to ascertain the effectiveness of a culturally appropriate promotora training program related to oral rehydration therapy and diarrheal management. Factors that influenced the development, implementation, and evaluation of the program provided to low-literacy women in Guatemala are explored. DESIGN AND SAMPLE: Promotora training was conducted with 15 Mayan women from a rural community in the highlands of Guatemala. Women were selected by leaders of the community to participate in the program. MEASURES: Quantitative data were collected and analyzed to determine descriptive statistics and reliability coefficients for the pretests and posttests. A nonparametric Wilcoxon test for paired-samples was conducted. The qualitative data from the program evaluations were analyzed for themes. RESULTS: Mean scores increased from 41.73 (SD = 9.65) to 70.33 (SD = 21.29) on the pretest and posttest. The Cronbach's alpha was 0.54 on the pretest with 0.65 on the posttest. The Wilcoxon test demonstrated a significant difference between the pretest and posttest scores (Z = 3.040, p < .05). CONCLUSIONS: Extremely low-literacy levels played a major role in the ability of the women to successfully complete the requirements of the training program. The curriculum demonstrated effectiveness, but will benefit from replication with a larger sample.

Infertile Jordanian Women's Self-Perception About Societal Violence: An Interpretative Phenomenological Study.

Background: Infertility affects one in six couples globally and is compounded by stigma and violence, particularly for women, in Jordan's culture. While existing research has illuminated societal pressures faced by infertile women, there is, yet no comprehensive understanding of the violence they encounter in their daily lives. Objective: This Interpretative Phenomenological study seeks to unravel the experiences of infertile women regarding societal violence in Jordan. By focusing on different types of community violence - physical, psychological, and emotional - The study aims to provide nuanced insights into the challenges these women confront. It also endeavors to identify contributing factors, including societal attitudes, cultural beliefs, and individual encounters, while informing policy and practice to mitigate this issue. Methods: Employing a qualitative approach, this study conducted semi-structured interviews with purposively sampled infertile women. Thematic analysis was utilized to uncover recurring patterns and themes, facilitating a comprehensive exploration of their experiences. Results: Five main themes were identified: How the surrounding people view me as an infertile woman; I am suffocated by their questions; they interfere in the smallest details; I got burned and turned to ashes, and I have no right to complain; The problem of childbearing and the treatment plan is a matter for me and my husband only; and who supports me and what do I want from those around me? Implications: This study's implications are significant for policy and practice. By foregrounding the prevalent violence faced by infertile women, it underscores the urgency of interventions. Raising awareness, providing education, and extending support can counteract societal stigma and violence. Creating a more compassionate societal fabric can ensure a safer, more inclusive environment for these women.

Mobil Monitoring Doppler Ultrasound (MoMDUS) study: protocol for a prospective, observational study investigating the use of artificial intelligence and low-cost Doppler ultrasound for the automated quantification of hypertension, pre-eclampsia and fetal growth restriction in rural Guatemala.

INTRODUCTION: Undetected high-risk conditions in pregnancy are a leading cause of perinatal mortality in low-income and middle-income countries. A key contributor to adverse perinatal outcomes in these settings is limited access to high-quality screening and timely referral to care. Recently, a low-cost one-dimensional Doppler ultrasound (1-D DUS) device was developed that front-line workers in rural Guatemala used to collect quality maternal and fetal data. Further, we demonstrated with retrospective preliminary data that 1-D DUS signal could be processed using artificial intelligence and deep-learning algorithms to accurately estimate fetal gestational age, intrauterine growth and maternal blood pressure. This protocol describes a prospective observational pregnancy cohort study designed to prospectively evaluate these preliminary findings. METHODS AND ANALYSIS: This is a prospective observational cohort study conducted in rural Guatemala. In this study, we will follow pregnant women (N =700) recruited prior to 18 6/7 weeks gestation until their delivery and early postpartum period. During pregnancy, trained nurses will collect data on prenatal risk factors and obstetrical care. Every 4 weeks, the research team will collect maternal weight, blood pressure and 1-D DUS recordings of fetal heart tones. Additionally, we will conduct three serial obstetric ultrasounds to evaluate for fetal growth restriction (FGR), and one postpartum visit to record maternal blood pressure and neonatal weight and length. We will compare the test characteristics (receiver operator curves) of 1-D DUS algorithms developed by deep-learning methods to two-dimensional fetal ultrasound survey and published clinical pre-eclampsia risk prediction algorithms for predicting FGR and pre-eclampsia, respectively. ETHICS AND DISSEMINATION: Results of this study will be disseminated at scientific conferences and through peer-reviewed articles. Deidentified data sets will be made available through public repositories. The study has been approved by the institutional ethics committees of Maya Health Alliance and Emory University.

Vaccination and vacci-notions: Understanding the barriers and facilitators of COVID-19 vaccine uptake during the 2020-21 COVID-19 pandemic.

Objective: The COVID-19 pandemic continues to place an inordinate burden on U.S. population health, and vaccination is the most powerful tool for curbing SARS-CoV-2 transmission, saving lives, and promoting economic recovery. However, much of the U.S. population remains hesitant to get vaccinated against COVID-19, despite having access to these life-saving vaccines. This study's objective was to examine the demographic characteristics, experiences, and disease- and vaccine-related risk perceptions that influence an individual's decision to adhere to vaccine recommendations for COVID-19. Study design: A telephone survey was performed with a convenience sample of 57 participants. Methods: This mixed-methods study collected quantitative and qualitative responses about seasonal influenza and COVID-19 vaccine intentions to compare vaccine hesitancies between a novel and routine vaccine. Results: The primary facilitators of uptake for the COVID-19 vaccine were personal protection, protecting others, preserving public health, and general vaccine confidence. Concerns about vaccine side effects, concerns about the COVID-19 vaccine trials, misinformation about vaccination, personal aversions to the vaccine, general distrust in vaccination, complacency, and distrust in government were the primary barriers to vaccine uptake. Race was also associated with COVID-19 vaccine intentions. Conclusions: The results of this research have been condensed into four recommendations designed to optimize public health messaging around the COVID-19 vaccine and maximize future vaccine uptake.

Toward co-design of an AI solution for detection of diarrheal pathogens in drinking water within resource-constrained contexts.

Despite successes on the Sustainable Development Goals for access to improved water sources and sanitation, many low and middle-income countries (LMICs) continue to struggle with high rates of diarrheal disease. In Guatemala, 98% of water sources are estimated to have E. coli contamination. This project moves toward a novel low-cost approach to bridge the gap between the microbiologic identification of E. coli and the vast impact that this pathogen has on human health within marginalized communities using co-designed community-based tools, low-cost technology, and AI. An agile co-design process was followed with water quality stakeholders, community staff, and local graphic design artists to develop a community water quality education mobile app. A series of alpha- and beta-testers completed interactive demonstration, feedback, and in-depth interview sessions. A microbiology lab in Guatemala developed and piloted field protocols with lay community workers to collect and process water samples. A preliminary artificial intelligence (AI) algorithm was developed to detect the presence of E. coli in images generated from community-derived water samples. The mobile app emerged as a pictorial and audio-driven community-facing tool. The field protocol for water sampling and testing was successfully implemented by lay community workers. Feedback from the community workers indicated both desire and ability to conduct the water sampling and testing protocol under field conditions. However, images derived from the low-cost $2 microscope in field conditions were not of a suitable quality for AI object detection of E. coli, and additional low-cost technologies are being considered. The preliminary AI object detection algorithm from lab-derived images performed at 94% accuracy in identifying E. coli in comparison to the Chromocult gold-standard.

A Proxy for Detecting IUGR Based on Gestational Age Estimation in a Guatemalan Rural Population.

In-utero progress of fetal development is normally assessed through manual measurements taken from ultrasound images, requiring relatively expensive equipment and well-trained personnel. Such monitoring is therefore unavailable in low- and middle-income countries (LMICs), where most of the perinatal mortality and morbidity exists. The work presented here attempts to identify a proxy for IUGR, which is a significant contributor to perinatal death in LMICs, by determining gestational age (GA) from data derived from simple-to-use, low-cost one-dimensional Doppler ultrasound (1D-DUS) and blood pressure devices. A total of 114 paired 1D-DUS recordings and maternal blood pressure recordings were selected, based on previously described signal quality measures. The average length of 1D-DUS recording was 10.43 ± 1.41 min. The min/median/max systolic and diastolic maternal blood pressures were 79/102/121 and 50.5/63.5/78.5 mmHg, respectively. GA was estimated using features derived from the 1D-DUS and maternal blood pressure using a support vector regression (SVR) approach and GA based on the last menstrual period as a reference target. A total of 50 trials of 5-fold cross-validation were performed for feature selection. The final SVR model was retrained on the training data and then tested on a held-out set comprising 28 normal weight and 25 low birth weight (LBW) newborns. The mean absolute GA error with respect to the last menstrual period was found to be 0.72 and 1.01 months for the normal and LBW newborns, respectively. The mean error in the GA estimate was shown to be negatively correlated with the birth weight. Thus, if the estimated GA is lower than the (remembered) GA calculated from last menstruation, then this could be interpreted as a potential sign of IUGR associated with LBW, and referral and intervention may be necessary. The assessment system may, therefore, have an immediate impact if coupled with suitable intervention, such as nutritional supplementation. However, a prospective clinical trial is required to show the efficacy of such a metric in the detection of IUGR and the impact of the intervention.

Estimating birth weight from observed postnatal weights in a Guatemalan highland community.

OBJECTIVE: Low birth weight is one of the leading contributors to global perinatal deaths. Detecting this problem close to birth enables the initiation of early intervention, thus reducing the long-term impact on the fetus. However, in low-and middle-income countries, sometimes newborns are weighted days or months after birth, thus challenging the identification of low birth weight. This study aims to estimate birth weight from observed postnatal weights recorded in a Guatemalan highland community. APPROACH: With 918 newborns recorded in postpartum visits at a Guatemalan highland community, we fitted traditional infant weight models (Count's and Reeds models). The model that fitted the observed data best was selected based on typical newborn weight patterns reported in the medical literature and previous longitudinal studies. Then, estimated birth weights were determined using the weight gain percentage derived from the fitted weight curve. MAIN RESULTS: The best model for both genders was the Reeds2 model, with a mean square error of 0.30 kg2 and 0.23 kg2 for male and female newborns, respectively. The fitted weight curves exhibited similar behavior to those reported in the literature, with a maximum weight loss around three to five days after birth, and birth weight recovery, on average, by day ten. Moreover, the estimated birth weight was consistent with the 2015 Guatemalan National Survey, no having a statistically significant difference between the estimated birth weight and the reported survey birth weights (two-sided Wilcoxon rank-sum test; [Formula: see text]). SIGNIFICANCE: By estimating birth weight at an opportune time, several days after birth, it may be possible to identify low birth weight more accurately, thus providing timely treatment when is required.

Ethically Managing Risks in Global Health Fieldwork: Human Rights Ideals Confront Real World Challenges.

Global health is an interdisciplinary field engaged with implementation of the human right to health, yet ethical dimensions of the on-the-ground realities of this work have been underexplored. Fieldwork in global health produces knowledge through both primary research and the lessons of practical program implementation. Much of this essential knowledge, which often documents health disparities and other human rights abuses, arises from work in dangerous contexts. Work in such environments entails risk to all participants in the global health enterprise, both local and foreign, but affects them differently. The risks of ethical fieldwork must be considered not only for the well-being of project participants and fieldworkers but also in light of how they shape and constrain global health research and program implementation. Drawing on case examples from the authors' fieldwork, this article marks an effort to begin disentangling the realities of risks in the field and the responsibility borne by the fieldworker to undertake ethical action, recognizing that decisions are often made without established protocols or the immediate availability of guidance from colleagues. We call for further engagement within global health on ethical issues distinctive to the complex and dangerous places in which the promise of a right to health is enacted in the real world.

An open source autocorrelation-based method for fetal heart rate estimation from one-dimensional Doppler ultrasound.

OBJECTIVE: Open research on fetal heart rate (FHR) estimation is relatively rare, and evidence for the utility of metrics derived from Doppler ultrasound devices has historically remained hidden in the proprietary documentation of commercial entities, thereby inhibiting its assessment and improvement. Nevertheless, recent studies have attempted to improve FHR estimation; however, these methods were developed and tested using datasets composed of few subjects and are therefore unlikely to be generalizable on a population level. The work presented here introduces a reproducible and generalizable autocorrelation (AC)-based method for FHR estimation from one-dimensional Doppler ultrasound (1D-DUS) signals. APPROACH: Simultaneous fetal electrocardiogram (fECG) and 1D-DUS signals generated by a hand-held Doppler transducer in a fixed position were captured by trained healthcare workers in a European hospital. The fECG QRS complexes were identified using a previously published fECG extraction algorithm and were then over-read to ensure accuracy. An AC-based method to estimate FHR was then developed on this data, using a total of 721 1D-DUS segments, each 3.75 s long, and parameters were tuned with Bayesian optimization. The trained FHR estimator was tested on two additional (independent) hand-annotated Doppler-only datasets recorded with the same device but on different populations: one composed of 3938 segments (from 99 fetuses) acquired in rural Guatemala, and another composed of 894 segments (from 17 fetuses) recorded in a hospital in the UK. MAIN RESULTS: The proposed AC-based method was able to estimate FHR within 10% of the reference FHR values 96% of the time, with an accuracy of 97% for manually identified good quality segments in both of the independent test sets. SIGNIFICANCE: This is the first work to publish open source code for FHR estimation from 1D-DUS data. The method was shown to satisfy estimations within 10% of the reference FHR values and it therefore defines a minimum accuracy for the field to match or surpass. Our work establishes a basis from which future methods can be developed to more accurately estimate FHR variability for assessing fetal wellbeing from 1D-DUS signals.

Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala.

Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.

Agile Development of a Smartphone App for Perinatal Monitoring in a Resource-Constrained Setting.

Technology provides the potential to empower frontline healthcare workers with low levels of training and literacy, particularly in low- and middle-income countries. An obvious platform for achieving this aim is the smartphone, a low cost, almost ubiquitous device with good supply chain infrastructure and a general cultural acceptance for its use. In particular, the smartphone offers the opportunity to provide augmented or procedural information through active audiovisual aids to illiterate or untrained users, as described in this article. In this article, the process of refinement and iterative design of a smartphone application prototype to support perinatal surveillance in rural Guatemala for indigenous Maya lay midwives with low levels of literacy and technology exposure is described. Following on from a pilot to investigate the feasibility of this system, a two-year project to develop a robust in-field system was initiated, culminating in a randomized controlled trial of the system, which is ongoing. The development required an agile approach, with the development team working both remotely and in country to identify and solve key technical and cultural issues in close collaboration with the midwife end-users. This article describes this process and intermediate results. The application prototype was refined in two phases, with expanding numbers of end-users. Some of the key weaknesses identified in the system during the development cycles were user error when inserting and assembling cables and interacting with the 1-D ultrasound-recording interface, as well as unexpectedly poor bandwidth for data uploads in the central healthcare facility. Safety nets for these issues were developed and the resultant system was well accepted and highly utilized by the end-users. To evaluate the effectiveness of the system after full field deployment, data quality, and corruption over time, as well as general usage of the system and the volume of application support for end-users required by the in-country team was analyzed. Through iterative review of data quality and consistent use of user feedback, the volume and percentage of high quality recordings was increased monthly. Final analysis of the impact of the system on obstetrical referral volume and maternal and neonatal clinical outcomes is pending conclusion of the ongoing clinical trial.

An mHealth monitoring system for traditional birth attendant-led antenatal risk assessment in rural Guatemala.

Limited funding for medical technology, low levels of education and poor infrastructure for delivering and maintaining technology severely limit medical decision support in low- and middle-income countries. Perinatal and maternal mortality is of particular concern with millions dying every year from potentially treatable conditions. Guatemala has one of the worst maternal mortality ratios, the highest incidence of intra-uterine growth restriction (IUGR), and one of the lowest gross national incomes per capita within Latin America. To address the lack of decision support in rural Guatemala, a smartphone-based system is proposed including peripheral sensors, such as a handheld Doppler for the identification of foetal compromise. Designed for use by illiterate birth attendants, the system uses pictograms, audio guidance, local and cloud processing, SMS alerts and voice calling. The initial prototype was evaluated on 22 women in highland Guatemala. Results were fed back into the refinement of the system, currently undergoing RCT evaluation.

Making surgical missions a joint operation: NGO experiences of visiting surgical teams and the formal health care system in Guatemala.

Each year, thousands of Guatemalans receive non-emergent surgical care from short-term medical missions (STMMs) hosted by local non-governmental organizations (NGOs) and staffed by foreign visiting medical teams (VMTs). The purpose of this study was to explore the perspectives of individuals based in NGOs involved in the coordination of surgical missions to better understand how these missions articulate with the larger Guatemalan health care system. During the summers of 2011 and 2013, in-depth interviews were conducted with 25 representatives from 11 different Guatemalan NGOs with experience with surgical missions. Transcripts were analysed for major themes using an inductive qualitative data analysis process. NGOs made use of the formal health care system but were limited by several factors, including cost, issues of trust and current ministry of health policy. Participants viewed the government health care system as a potential resource and expressed a desire for more collaboration. The current practices of STMMs are not conducive to health system strengthening. The role of STMMs must be defined and widely understood by all stakeholders in order to improve patient safety and effectively utilise health resources. Priority should be placed on aligning the work of VMTs with that of the larger health care system.