Capacity Building and Innovation in Caring for Non-communicable Diseases in Maternal Global Health: The Example of Haiti.

Non-communicable diseases (NCDs) are important contributors to maternal morbidity and mortality worldwide. Yet, data on their prevalence and related outcomes in low-income countries are currently lacking. Additionally, screening and treatment protocols adapted for resource-limited settings are urgently required. This collaborative research initiative on the screening and management of hypertensive disorders of pregnancy and gestational diabetes was conducted in Saint-Nicolas Hospital in Saint-Marc, Haiti. The report discusses methods used to overcome several local challenges to implementation of care for NCDs. It also describes how collaborative research initiatives are efficient strategies to innovate and build research capacity for NCD care delivery during pregnancy in low-income countries.

Piloting a Faculty Development Program in a Rural Haitian Teaching Hospital.

Background: Faculty development for nurse and physician educators has a limited evidence base in high income countries, and very little research from low- and middle-income countries. Health professions educators in many global settings do not receive training on how to educate effectively. Objective: To pilot and assess a faculty development program aimed at nurse and physician educators at a teaching hospital in rural Haiti. Methods: We developed a program covering a total of 22 topics in health professions education, including applied learning theory as well as nurse and physician targeted topics. We assessed impact through participant assessment of personal growth, participant evaluation of the program, knowledge testing pre and post program, and structured observations of program participants providing teaching during the program. Findings: Nineteen out of 37 participants completed the program. While participant reviews were uniformly positive, a pre- and post-test on general educational topics showed no significant change, and the effort to institute observation and feedback of teaching did not succeed. Conclusions: Our project showcases some benefits of faculty development, while also demonstrating the challenges of instituting faculty development in situations where participants have limited time and resources. We suspect more benefits may emerge as the program evolves to fit the learners and setting.

Prevalence and perinatal outcomes of non-communicable diseases in pregnancy in a regional hospital in Haiti: A prospective cohort study.

BACKGROUND: The prevalence of non-communicable diseases (NCDs) is rising in low and middle-income countries (LMIC). We aimed to report on the prevalence of NCDs in pregnancy and their associated perinatal outcomes in a regional hospital in Haiti. METHODS: We conducted the "Diabète et hYpertension Artéerielle et leurs issues MAternelles et Néonatales" (DYAMAN) prospective cohort study in a regional hospital in Haiti. Pregnant women presenting to care at 24-28 weeks were screened and treated for diabetes (DM) and hypertensive disorders of pregnancy (HDP) using setting-adapted protocols. Prevalence of NCDs and associated maternal-neonatal outcomes were described. RESULTS: 715 women were included, of which 51 (7.1%) had DM, 90 (12.6%) had HDP, and 30 (4.2%) had both DM and HDP (DM/HDP). Of 422 (59%) women delivered in hospital, 58 (13.7%) had preeclampsia, including 5 (8.6%) with eclampsia. Preterm birth <32 weeks was more common in the HDP than the control, DM, and DM/HDP groups. More low birth weight babies (n = 20, 25.6%) were born to the HDP group than to the control (n = 20, 7.1%), DM (n = 1, 2.7%), and DM/HDP (n = 3, 12%) groups (P < 0.001). Macrosomia and hypoglycemia affected 5 (8%) neonates of women with DM. Perinatal mortality, affecting 36/1000 births, was mainly driven by maternal NCDs. CONCLUSIONS: NCDs in pregnancy led to adverse maternal and perinatal outcomes. This study will help to prepare future refinements aimed at optimizing the management of NCDs in pregnancy in LMIC. Research is required to understand barriers to patient attendance at antenatal follow-up, treatment escalation for hyperglycemia, and in-hospital delivery.

Revitalizing Graduate Medical Education in Global Settings: Lessons From Post-Earthquake Haiti.

Following the massive 7.0-magnitude earthquake that devastated much of the Haitian capital city of Port-au-Prince on January 12, 2010, the Haitian health system and its medical education programs were fragmented, fragile, and facing a significant, overwhelming demand for clinical care. In response, the authors of this paper and the institutions they represent supported the development of a teaching hospital that could fill the void in academic training capacity while prioritizing the health of Haiti's rural poor-goals aligned with the Haitian Ministry of Health (MOH) strategy. This bold initiative aimed to address both the immediate and long-term health care needs within post-disaster Haiti through a strategic investment in graduate medical education (GME). Here, the authors describe their approach, which included building consensus, aspiring to international standards, and investing in shared governance structures under Haitian leadership. The Haitian MOH strategy and priorities guided the development, implementation, and expansion of solutions to the ongoing crisis in human resources for health within the acute context. Local leadership of this initiative ensured a sustained and transformative model of GME that has carried Haiti beyond acute relief and toward a more reliable health system. The enduring success can be measured through sustained governance systems, graduates who have remained in Haiti, standardized curricula, a culture of continuous improvement, and the historic achievement of international accreditation. While ongoing challenges persist, Haiti has demonstrated that the strategy of investing in GME in response to acute disasters should be considered in other global settings to support the revitalization of tenuous health systems.

The Haiti Humanitarian Response Course: A Novel Approach to Local Responder Training in International Humanitarian Response.

INTRODUCTION: Countries most affected by disasters are often those with limited local capacity to respond. When local capacity is overwhelmed, international humanitarian response often provides needs-based emergency response. Despite global progress in education and the development of international humanitarian response standards, access to training and integration of local actors in response mechanisms remains limited. In May 2017, the Haiti Humanitarian Response Course (HHRC) was implemented in Mirebalais, Haiti to increase local capacity and allow for effective future engagement with international humanitarian actors in a country prone to disasters. REPORT: In collaboration with the Hôpital Universitaire de Mirebalais' (HUM; Mirebalais, Haiti) Department of Medical Education and Emergency Medicine (EM) residency program, four physicians from the Division of Global Emergency Care and Humanitarian Studies at Brigham and Women's Hospital (Boston, Massachusetts USA) facilitated the course, which included 53 local physicians and staff. Following 15 hours of online pre-course preparation, through didactics and practical small-group exercises, the course focused on key components of international humanitarian response, minimum standards for effective response, and the roles of key response players. The course was free to participants and taught in English and French. DISCUSSION: The HHRC reduced the barriers often faced by local actors who seek training in international humanitarian response by offering free training in their own community. It presents a novel approach to narrow critical gaps in training local populations in international humanitarian response, especially in environments prone to crises and disasters. This approach can help local responders better access international humanitarian response mechanisms when the local response capacity is exhausted or overwhelmed. CONCLUSION: The HHRC demonstrates a potential new model for humanitarian and disaster training and offers a model for similar programs in other disaster-prone countries. Ultimately, local capacity building could lead to more efficient resource utilization, improved knowledge sharing, and better disaster response.

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond.

Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

Addressing the immediate need for emergency providers in resource-limited settings: the model of a six-month emergency medicine curriculum in Haiti.

BACKGROUND: In many resource-limited settings, emergency medicine (EM) is underdeveloped and formal EM training limited. Residencies and fellowships are an ideal long-term solution but cannot meet immediate needs for emergency providers, while short-term programs are often too limited in content. We describe a third method successfully implemented in Haiti: a medium-duration certificate program to meet the immediate need for emergency specialists. METHODS: In conjunction with the Haitian Ministry of Health and National Medical School, we developed and implemented a novel, 6-month EM certificate program to build human resources for health and emergency care capacity. The program consisted of didactic and supervised clinical components, covering core content in EM. Didactics included lectures, simulations, hands-on skill-sessions, and journal clubs. Supervised clinical time reinforced concepts and taught an EM approach to patient care. RESULTS: Fourteen physicians from around Haiti successfully completed the program; all improved from their pre-test to post-test. At the end of the program and 9-month post-program evaluations, participants rated the program highly, and most felt they used their new knowledge daily. Participants found clinical supervision and simulation particularly useful. Key components to our program's success included collaboration with the Ministry of Health and National Medical School, supervised clinical time, and the continual presence of a course director. The program could be improved by a more flexible curriculum and by grouping participants by baseline knowledge levels. CONCLUSION: Medium-duration certificate programs offer a viable option for addressing immediate human resource gaps in emergency care, and our program offers a model for implementation in resource-limited settings. Similar options should be considered for other emerging specialties in resource-limited settings.

Strengthening Primary Care Through Family Medicine Around the World Collaborating Toward Promising Practices.

BACKGROUND AND OBJECTIVES: There is a limited evidentiary base on the development of family medicine in different contexts and countries. The lack of evidence impedes our ability to compare and characterize family medicine models and identify areas of success that have led to the effective provision of care. This paper offers a comparative compilation and analysis of the development of family medicine training programs in seven countries: Brazil, Canada, Ethiopia, Haiti, Indonesia, Kenya, and Mali. METHODS: Using qualitative case studies, this paper examines the process of developing family medicine programs, including enabling strategies and barriers, and shared lessons. An appreciative inquiry framework and complex adaptive systems thinking inform our qualitative study. RESULTS: Committed partnerships, the contribution of champions, health policy, and adaptability were identified as key enablers in all seven case studies. The case studies further reveal that some enablers were more salient in certain contexts as compared to others, and that it is the interaction of enablers that is crucial for understanding how and why initiatives succeeded. The barriers that emerged across the seven case studies include: (1) resistance from other medical specialties, (2) lack of resources and capabilities, (3) difficulty in sustaining support of champions, and (4) challenges in brokering effective partnerships. CONCLUSIONS: A key insight from this study is that the implementation of family medicine is nonlinear, dynamic, and complex. The findings of this comparative analysis offer insights and strategies that can inform the design and development of family medicine programs elsewhere.

Development of a neurology rotation for internal medicine residents in Haiti.

In many low-income countries where there are few or no neurologists, patients with neurologic diseases are cared for by primary care physicians who receive no formal training in neurology. Here, we report our experience creating a neurology rotation for internal medicine residents in rural Haiti through a collaboration between a public academic medical center in Haiti and a visiting neurologist. We describe the structure of the rotation and the factors that led to its development.

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond / A contribuição da Medicina de Família e dos líderes em Medicina de Família para o desenvolvimento da Atenção Primária à Saúde nas Américas - de Alma-Ata à Astana e além

Abstract Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

Resumo Desde 2012, o Centro Besrour de Medicina Global de Família, na Faculdade de Medicina de Família do Canadá, reúne seus parceiros das Américas anualmente para refletir sobre a evolução da Medicina de Família no continente desde Alma-Ata e para os desafios futuros. Os médicos de família são apenas um elemento de um forte sistema de saúde. A Medicina de Família fornece ingredientes-chave para responder às necessidades de saúde da população, especialmente à medida em que os países passam pela transição epidemiológica para enfrentar um fardo maior de doenças crônicas e de multimorbidade. Neste artigo, fornecemos uma visão geral de alto nível do estado da Medicina de Família no continente. Em seguida, analisamos as tendências na educação dos médicos de família para enfrentar esse cenário em mudança, incluindo a ênfase no papel de líder dos futuros médicos de família. Os programas de pós-graduação em Medicina de Família nas Américas estão enfatizando cada vez mais o ensino do cuidado colaborativo, a fim de criar equipes de saúde verdadeiramente interdisciplinares para o benefício dos pacientes.