Midwife-led obstetric triage to increase providers' knowledge and improve timeliness of care: A pre and posttest design.

BACKGROUND: Research in low- and middle-income countries has shown that maternal mortality is directly related to inadequate or absent obstetric (OB) triage systems. Standard triage systems and knowledge on triaging for obstetric emergencies are often absent or lacking in most healthcare systems in Liberia. OBJECTIVE: The objective of this research was to address the third delay defined as receiving adequate, quality care when a facility is reached by increasing knowledge through the establishment of a midwife-led, hospital-based OB triage system to stratify care based on risk and imminence of birth and to improve timely assessment at two district referral hospitals. METHODS: A quasi-experimental study design using a pre/post survey was employed for a midwife-led OB triage training course. Using a train-the-trainer model, five midwives were trained as champions, who in turn trained an additional 62 providers. Test results were analyzed with the R statistical software using paired sample t-test and descriptive statistics. RESULTS: Pretest results revealed a knowledge and practice gap among OB providers on key components of the standard triage package. However, post-test mean scores were significantly higher (M = 79.6, SD = 2.32) than pre-test mean scores (M = 59.0, SD = 2.30) for participants following a 2-day training (p = <0.001). DISCUSSION: Following a structured OB triage training, participants showed significant improvement in post-test OB triage scores. CONCLUSION: Standard OB triage protocols incorporated into the policies and procedures of obstetric wards have the potential to improve knowledge and practice, addressing the third delay and reducing preventable, obstetrics-related deaths.

Interruption of tuberculosis detection and care during the Ebola virus disease epidemic (2014-2015) in Liberia: time-series analyses for 2013-2017.

OBJECTIVE: Interrupted time-series analyses, using 5 years of routinely collected health information system data, were conducted to estimate the magnitude of impact of the 2014-2015 Ebola virus disease (EVD) epidemic and determine trends in tuberculosis (TB) care services in Liberia. METHODS: A segmented linear regression model was used to generate estimates and predictions for trends for three TB service indicators before, during, and after EVD, from January 2013 to December 2017. RESULTS: It was found that the number of presumptive TB cases declined significantly at the start of the EVD outbreak, with an estimated loss of 3222 cases (95% confidence interval (CI) -5691 to -752; P = 0.014). There was also an estimated loss of 709 cases per quarter post-EVD (95% CI -1346 to -71; P = 0.032). However, over the post-EVD period, quarterly increases were observed in the proportion of smear-positive to presumptive cases (1.45%, 95% CI 0.38% to 2.5%; P = 0.011) and the proportion of treatment success to TB cases evaluated (3.3%, 95% CI 0.82% to 5.79%; P = 0.013). CONCLUSIONS: These findings suggest that the EVD outbreak (2014-2015) negatively affected TB care services. Rigorous quantitative analyses can be used to assess the magnitude of interruption and advocate for preparedness in settings with limited healthcare capacity.

Participatory Design and Process Testing to Optimize Utility, Usability, and Acceptability of a Mobile Game for Promoting Evidence-Driven Public Health Decision-Making in Resource-Constrained Settings.

Innovative game-based training methods that leverage the ubiquity of cellphones and familiarity with phone-based interfaces have the potential to transform the training of public health practitioners in low-income countries such as Liberia. This article describes the design, development, and testing of a prototype of the Figure It Out mobile game. The prototype game uses a disease outbreak scenario to promote evidence-based decision-making in determining the causative agent and prescribing intervention measures to minimize epidemiological and logistical burdens in resource-limited settings. An initial prototype of the game developed by the US team was playtested and evaluated by focus groups with 20 University of Liberia Masters of Public Health (UL MPH) students. Results demonstrate that the learning objectives-improving search skills for identifying scientific evidence and considering evidence before decision-making during a public health emergency-were considered relevant and important in a setting that has repeatedly and recently experienced severe threats to public health. However, some of the game mechanics that were thought to enhance engagement such as trial-and-error and choose-your-own-path gameplay, were perceived by the target audience as distracting or too time-consuming, particularly in the context of a realistic emergency scenario. Gameplay metrics that mimicked real-world situations around lives lost, money spent, and time constraints during public health outbreaks were identified as relatable and necessary considerations. Our findings reflect cultural differences between the game development team and end users that have emphasized the need for end users to have an integral part of the design team; this formative evaluation has critically informed next steps in the iterative development process. Our multidisciplinary, cross-cultural and cross-national design team will be guided by Liberia-based public health students and faculty, as well as community members who represent our end user population in terms of experience and needs. These stakeholders will make key decisions regarding game objectives and mechanics, to be vetted and implemented by game design experts, epidemiologists, and software developers.