Evidence-based Decision Making: Infectious Disease Modeling Training for Policymakers in East Africa.

Background: Mathematical modeling of infectious diseases is an important decision-making tool for outbreak control. However, in Africa, limited expertise reduces the use and impact of these tools on policy. Therefore, there is a need to build capacity in Africa for the use of mathematical modeling to inform policy. Here we describe our experience implementing a mathematical modeling training program for public health professionals in East Africa. Methods: We used a deliverable-driven and learning-by-doing model to introduce trainees to the mathematical modeling of infectious diseases. The training comprised two two-week in-person sessions and a practicum where trainees received intensive mentorship. Trainees evaluated the content and structure of the course at the end of each week, and this feedback informed the strategy for subsequent weeks. Findings: Out of 875 applications from 38 countries, we selected ten trainees from three countries - Rwanda (6), Kenya (2), and Uganda (2) - with guidance from an advisory committee. Nine trainees were based at government institutions and one at an academic organization. Participants gained skills in developing models to answer questions of interest and critically appraising modeling studies. At the end of the training, trainees prepared policy briefs summarizing their modeling study findings. These were presented at a dissemination event to policymakers, researchers, and program managers. All trainees indicated they would recommend the course to colleagues and rated the quality of the training with a median score of 9/10. Conclusions: Mathematical modeling training programs for public health professionals in Africa can be an effective tool for research capacity building and policy support to mitigate infectious disease burden and forecast resources. Overall, the course was successful, owing to a combination of factors, including institutional support, trainees' commitment, intensive mentorship, a diverse trainee pool, and regular evaluations.

Nurses' perceptions of the clinical information system in primary healthcare centres in Qatar: a cross-sectional survey.

BACKGROUND: Qatar is one of the fastest growing countries in the Arabic region. Primary Health Care Corporation (PHCC) is the main provider of primary health services in Qatar and employs 1600 nurses. In 2014, PHCC started to migrate from paper to electronic documentation of patient records using a clinical information system (CIS). Since implementation, the use of CIS and perception of users have not been assessed. OBJECTIVE: This study measured nurses' perceptions regarding the utilisation, quality and user satisfaction with the CIS in PHCC. METHODS: Using a pre-existing survey, a cross-section of nurses from six health centres in Qatar were systematically selected and invited to participate in the study. Eighty-nine surveys were completed (response rate: 98.8%) and descriptive analyses were performed. RESULTS: Nurses' perceptions regarding the utilisation, quality and user satisfaction with the CIS were positive. Nurses indicated that the CIS is a resource for clear, accurate and up-to-date data and that their performance improved due to the CIS. Yet responses to an open-ended question in the survey revealed some concerns related to the CIS, such as patient confidentiality, system downtime and time constraints. CONCLUSION: Ensuring that the CIS is facilitating nurses' work is crucial to guarantee high-quality care to the community. The findings provide foundational data to help PHCC to understand nurses' perceptions and to take steps to overcome challenges that nurses face related to the CIS in their daily practice. This work could also provide direction for future research.

Comparison of sampling methods for hard-to-reach francophone populations: yield and adequacy of advertisement and respondent-driven sampling.

BACKGROUND: Francophones who live outside the primarily French-speaking province of Quebec, Canada, risk being excluded from research by lack of a sampling frame. We examined the adequacy of random sampling, advertising, and respondent-driven sampling for recruitment of francophones for survey research. METHODS: We recruited francophones residing in the city of Calgary, Alberta, through advertising and respondentdriven sampling. These 2 samples were then compared with a random subsample of Calgary francophones derived from the 2006 Canadian Community Health Survey (CCHS). We assessed the effectiveness of advertising and respondent-driven sampling in relation to the CCHS sample by comparing demographic characteristics and selected items from the CCHS (specifically self-reported general health status, perceived weight, and having a family doctor). RESULTS: We recruited 120 francophones through advertising and 145 through respondent-driven sampling; the random sample from the CCHS consisted of 259 records. The samples derived from advertising and respondentdriven sampling differed from the CCHS in terms of age (mean ages 41.0, 37.6, and 42.5 years, respectively), sex (proportion of males 26.1%, 40.6%, and 56.6%, respectively), education (college or higher 86.7% , 77.9% , and 59.1%, respectively), place of birth (immigrants accounting for 45.8%, 55.2%, and 3.7%, respectively), and not having a regular medical doctor (16.7%, 34.5%, and 16.6%, respectively). Differences were not tested statistically because of limitations on the analysis of CCHS data imposed by Statistics Canada. INTERPRETATION: The samples generated exclusively through advertising and respondent-driven sampling were not representative of the gold standard sample from the CCHS. Use of such biased samples for research studies could generate misleading results.

Challenges to Implementing a National Health Information System in Cameroon: Perspectives of Stakeholders.

In the early 90s, the Cameroon Ministry of Health implemented a National Health Information System (NHIS) based on a bottom-up approach of manually collecting and reporting health data. Little is known about the implementation and functioning of the NHIS. The purpose of this study was to assess the implementation of the NHIS by documenting experiences of individual stakeholders, and to suggest recommendations for improvement. We reviewed relevant documents and conducted face-to-face interviews (N=4) with individuals directly involved with data gathering, reporting and storage. Content analysis was used to analyze textual data. We found a stalled and inefficient NHIS characterized by general lack of personnel, a labor-intensive process, delay in reporting data, much reliance on field staff, and lack of incentives. A move to an electronic health information system without involving all stakeholders and adequately addressing the issues plaguing the current system is premature.

Multimorbidity prevalence in the general population: the role of obesity in chronic disease clustering.

BACKGROUND: The role of obesity in the prevalence and clustering of multimorbidity, the occurrence of two or more chronic conditions, is understudied. We estimated the prevalence of multimorbidity by obesity status, and the interaction of obesity with other predictors of multimorbidity. METHODS: Data from adult respondents (18 years and over) to the Health Quality Council of Alberta 2012 Patient Experience Survey were analyzed. Multivariable regression models were fitted to test for associations. RESULTS: The survey sample included 4803 respondents; 55.8% were female and the mean age was 47.8 years (SD, 17.1). The majority (62.0%) of respondents reported having at least one chronic condition. The prevalence of multimorbidity, including obesity, was 36.0% (95% CI, 34.8 - 37.3). The prevalence of obesity alone was 28.1% (95% CI 26.6 - 29.5). Having obesity was associated with more than double the odds of multimorbidity (odds ratio = 2.2, 95% CI 1.9 - 2.7) compared to non-obese. CONCLUSIONS: The prevalence of multimorbidity in the general population is high, but even higher in obese than non-obese persons. These findings may be relevant for surveillance, prevention and management strategies for multimorbidity.

Experiences of French speaking immigrants and non-immigrants accessing health care services in a large Canadian city.

French speakers residing in predominantly English-speaking communities have been linked to difficulties accessing health care. This study examined health care access experiences of immigrants and non-immigrants who self-identify as Francophone or French speakers in a mainly English speaking province of Canada. We used semi-structured interviews to gather opinions of recent users of physician and hospital services (N = 26). Language barriers and difficulties finding family doctors were experienced by both French speaking immigrants and non-immigrants alike. This was exacerbated by a general preference for health services in French and less interest in using language interpreters during a medical consultation. Some participants experienced emotional distress, were discontent with care received, often delayed seeking care due to language barriers. Recent immigrants identified lack of insurance coverage for drugs, transportation difficulties and limited knowledge of the healthcare system as major detractors to achieving health. This study provided the groundwork for future research on health issues of official language minorities in Canada.

Language barriers: use of regular medical doctors by Canada's official language minorities.

OBJECTIVE: To assess use of regular medical doctors (RMDs), as well as awareness and use of telephone health lines or telehealth services, by official language minorities (OLMs) in Canada. DESIGN: Analysis of data from the 2006 postcensal survey on the vitality of OLMs. SETTING: Canada. PARTICIPANTS: In total, 7691 English speakers in Quebec and 12 376 French speakers outside Quebec, grouped into those who experienced language barriers and those with no language barriers. MAIN OUTCOME MEASURES: Health services utilization (HSU) by the presence of language barriers; HSU measures included having an RMD, use of an RMD's services, and awareness of and use of telephone health lines or telehealth services. Multivariable models examined the associations between HSU and language barriers. RESULTS: After adjusting for age and sex, English speakers residing in Quebec with limited proficiency in French were less likely to have RMDs (adjusted odds ratio [AOR] 0.66, 95% CI 0.50 to 0.87) and to use the services of their RMDs (AOR 0.65, 95% CI 0.50 to 0.86), but were more likely to be aware of the existence of (AOR 1.50, 95% CI 1.16 to 1.93) and to use (AOR 1.43, 95% CI 0.97 to 2.11) telephone health lines or telehealth services. This pattern of having and using RMDs and telehealth services was not observed for French speakers residing outside of Quebec. CONCLUSION: Overall we found variation in HSU among the language barrier populations, with lower use observed in Quebec. Age older than 45 years, male sex, being married or in common-law relationships, and higher income were associated with having RMDs for OLMs.

A systematic literature review on response rates across racial and ethnic populations.

OBJECTIVE: To conduct a systematic review examining whether minority ethnic populations participate in surveys as actively as the majority ethnic population. METHODS: A literature and grey literature search was conducted using five online databases as well as government databases and reports, including the search terms: survey response rates or non-response rates and racial or ethnic populations (White, African American, Asian, and Hispanic); survey modes or methods (mail, telephone, face to face, e-mail); and response bias (non-response bias, response bias or social desirability). The search was limited to English language and articles published from January 1990 to June 2009. Article exclusions were based on further inclusion and exclusion criteria. SYNTHESIS: Thirty-five articles were identified on ethnicities and response rates to survey modes. Six articles compared survey mode and response rate for multiple ethnic populations. Response rates ranged from 22.0% to 68.8% in Whites, and in other ethnic groups ranged from 15.4% in African Americans to 70.9% in Latino Americans. Among the 29 articles that presented survey mode and response rate for a specific ethnicity, the highest response rate reported was from African Americans (92.5%) and the lowest was from Cambodian Americans (30.3%). CONCLUSION: Response rate varied across studies but was similar across ethnicities. Response rate may be related to many factors, including survey mode, length of questionnaire, survey language and cultural sensitivity to content. Our review indicates that ethnic populations who participate in surveys are as likely to participate in research as Whites. In literature, data validity across ethnicity is still unknown and should be studied in the future.

Documentation of preventive screening interventions by general practitioners: a retrospective chart audit.

BACKGROUND: Screening and early diagnosis has been shown to reduce the morbidity and mortality associated with certain conditions such as cervical cancer. The role of general practitioners in promoting primary prevention of diseases is particularly important given that they have frequent contact with a large proportion of the population. This study assessed the extent to which general practitioners documented recommended preventive screening interventions among eligible patients. METHODS: We used a retrospective chart audit to assess patient visits to primary care clinics in Calgary, Canada from 2002-2004. We included fee for service physicians who practiced > or = 2 days per week at their current location and excluded those whose primary practice was at walk-in clinics, community health centers, hospitals or emergency rooms. We included charts of patients who during the study period were age 35 years or older and had at least 2 visits to a clinic. We randomly selected and reviewed charts (N = 600) from 12 primary care clinics and abstracted information on 6 conditions recommended for preventive screening. Opportunities for preventive screening were determined based on recommendations of the Canadian Task Force on Preventive Health Care, the American College of Physicians, and the Canadian Cancer Society. Our main outcome measures included cancer screening (mammography and pap smears), immunization (influenza and pneumococcal), and risk factor assessment (cholesterol measurement and smoking cessation consultation). RESULTS: Patient visits to GP clinics present opportunities for preventive screening. However, we found that documentation of interventions was low, ranging from 40.3% (cholesterol measurement) to 0.9% (pneumococcal vaccination) within 1 year, and from 67.4% to 1.8% within the prior 3 years. CONCLUSIONS: Documentation of preventive screening interventions by general practitioners was relatively low compared to the number of patients eligible for preventive screening. Some physicians opt to screen for PSA and DRE which is not recommended by the Canadian Task Force on Preventive HealthCare.

Why many visible minority women in Canada do not participate in cervical cancer screening.

OBJECTIVE: To determine a high-risk group of visible minority women in Canada who do not participate in cervical cancer screening and the reasons why they do not participate. DESIGN: We combined two cycles of a large Canadian health survey, Canadian Community Health Survey (CCHS), to obtain a large sample size of visible minority women. Proportions of 'never having a Papanicalaou (Pap) test' and 'not having a Pap test within the last three years' were then calculated for different ethnic groups using sampling weights advised by Statistics Canada to account for the complex sampling procedure used in CCHS. A logistic regression model was developed to test the association between demographic and health-related variables and not having a Pap test. To identify visible minority women who were at a high risk of not having a Pap test, we stratified these women simultaneously on three variables that were significant in the logistic regression model. RESULTS: Visible minority women were more than twice as likely never to have had a Pap test. Among visible minority women, those who recently immigrated to Canada and did not have a regular physician had the highest risk for not having a Pap test. Common reasons reported for not having a Pap test included believing it was not necessary and simply not getting around to it. CONCLUSION: Visible minority women in Canada may not be participating in regular Pap testing because of cultural beliefs and a lack of an understanding of the importance of Pap testing. A culturally appropriate cervical cancer screening intervention program that involves members of visible minority communities may increase participation of this subgroup of Canadian women. This study provides preliminary information on why visible minority women in Canada do not participate in cervical cancer screening. However, the lumping together of all visible minority may obscure differences between different ethnic groups. Therefore, further research on each ethnic group is required to develop tailored culturally appropriate intervention.

Sex differentials in the use of centres for voluntary counselling and testing for HIV in Cameroon.

Part of the strategic response to HIV in Cameroon, West Africa, has been the institutionalisation of voluntary testing and counselling (VCT) for HIV services across the country. The study addresses the general level of awareness and use of VCT centres in Cameroon. The data were extracted from the national, cross-sectional, 2004 Cameroon Demographic and Health Survey (DHS). The survey collected information on respondents' demographic characteristics and awareness and utilisation of VCT services, through a standard behavioural surveillance survey, administered in face-to-face interviews with males aged 15 years or older and females aged 15 to 49 years. Chi-square and logistic regression were employed for data analysis. A total of 5 280 males and 10 656 females responded to the 2004 Cameroon DHS. More of the male than female respondents had a secondary or higher education (51.8% versus 39%), slightly more of the males than females resided in urban areas (57.3% versus 54.8%), and males were more likely than females to have heard of VCT centres (37.8% versus 26.8%) and were also much more likely to have had an HIV test at a VCT centre (5.9% males versus 1.3% females). The findings indicate that awareness and use of centres offering VCT for HIV is very low in Cameroon. Further research in Cameroon is needed to assess individuals' reasons for not using VCT, as well as studies to identify patterns of information flow regarding the dissemination of knowledge about HIV and AIDS and about VCT centres.