Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review.

BACKGROUND: Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery. METHODS: We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary. RESULTS: A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation. CONCLUSIONS: Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

Reliability and validity of pediatric triage tools evaluated in Low resource settings: a systematic review.

BACKGROUND: Despite the high burden of pediatric mortality from preventable conditions in low and middle income countries and the existence of multiple tools to prioritize critically ill children in low-resource settings, no analysis exists of the reliability and validity of these tools in identifying critically ill children in these scenarios. METHODS: The authors performed a systematic search of the peer-reviewed literature published, for studies pertaining to for triage and IMCI in low and middle-income countries in English language, from January 01, 2000 to October 22, 2013. An updated literature search was performed on on July 1, 2015. The databases searched included the Cochrane Library, EMBASE, Medline, PubMed and Web of Science. Only studies that presented data on the reliability and validity evaluations of triage tool were included in this review. Two independent reviewers utilized a data abstraction tool to collect data on demographics, triage tool components and the reliability and validity data and summary findings for each triage tool assessed. RESULTS: Of the 4,717 studies searched, seven studies evaluating triage tools and 10 studies evaluating IMCI were included. There were wide varieties in method for assessing reliability and validity, with different settings, outcome metrics and statistical methods. CONCLUSIONS: Studies evaluating triage tools for pediatric patients in low and middle income countries are scarce. Furthermore the methodology utilized in the conduct of these studies varies greatly and does not allow for the comparison of tools across study sites.

Gender and performance of community treatment assistants in Tanzania.

OBJECTIVE: To examine the effects of gender and demographics of community treatment assistants (CTAs) on their performance of assigned tasks and quantity of speech during mass drug administration of azithromycin for trachoma in rural Tanzania. DESIGN: Surveys of CTAs and audio recordings of interactions between CTAs and villagers during drug distribution. SETTING: Mass drug administration program in rural Kongwa district. PARTICIPANTS: Fifty-seven randomly selected CTAs, and 3122 residents of villages receiving azithromycin as part of the Kongwa Trachoma Project. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Speech quantity graded by Roter interaction analysis system, presence of culturally appropriate greeting and education on facial hygiene for trachoma prevention from coded analysis of audio-recorded interactions. RESULTS: At sites with all female CTAs, each CTA spent more time and spoke more in each interaction in comparison with CTAs at sites with only male CTAs and CTAs at 'mixed gender' sites (sites with both male and female CTAs). At 'mixed gender' sites, males spoke significantly more than females. Female CTAs mentioned trachoma prevention with facial cleanliness more than twice as often as male CTAs; however, both genders mentioned hygiene in <10% of interactions. Both genders had culturally appropriate greetings in <25% of interactions. CONCLUSIONS: Gender dynamics affect the amount of time that CTAs spend with villagers during drug distribution, and the relative amount of speech when both genders work together. Both genders are not meeting expectations for trachoma prevention education and greeting villagers, and novel training methods are necessary.

Patient-centered communication of community treatment assistants in Tanzania predicts coverage of future mass drug administration for trachoma.

OBJECTIVE: Prevention of Trachoma, the leading cause of infectious blindness, requires community treatment assistants (CTAs) to perform mass drug administration (MDA) of azithromycin. Previous research has shown that female CTAs have higher MDA coverage, but no studies have focused on the content of conversation. We hypothesize that female CTAs had more patient-centered communication and higher MDA coverage. METHODS: In 2011, CTAs from 23 distribution sites undergoing MDA as part of the Partnership for Rapid Elimination of Trachoma were selected. CTA - villager interactions were audio recorded. Audio was analyzed using an adaptation of the Roter Interaction Analysis System. The outcome of interest was the proportion of adults receiving MDA in 2011 who returned in 2012. RESULTS: 58 CTAs and 3122 interactions were included. Sites with female CTAs had significantly higher patient-centeredness ratio (0.548 vs 0.400) when compared to sites with male CTAs. Sites with more patient-centered interactions had higher proportion of patients return (p = 0.009). CONCLUSION: Female CTAs had higher proportion of patient-centered communication. Patient centered communication was associated with higher rates of return for MDA. PRACTICE IMPLICATIONS: Greater patient-centered connection with health care providers affects participation in public health efforts, even when those providers are lay health workers.

Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review.

OBJECTIVE: Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs. METHODS: We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria. RESULTS: Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence. CONCLUSION: The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.

SCREEN: A simple layperson administered screening algorithm in low resource international settings significantly reduces waiting time for critically ill children in primary healthcare clinics.

BACKGROUND: In low resource settings, an inadequate number of trained healthcare workers and high volumes of children presenting to Primary Healthcare Centers (PHC) result in prolonged waiting times and significant delays in identifying and evaluating critically ill children. The Sick Children Require Emergency Evaluation Now (SCREEN) program, a simple six-question screening algorithm administered by lay healthcare workers, was developed in 2014 to rapidly identify critically ill children and to expedite their care at the point of entry into a clinic. We sought to determine the impact of SCREEN on waiting times for critically ill children post real world implementation in Cape Town, South Africa. METHODS AND FINDINGS: This is a prospective, observational implementation-effectiveness hybrid study that sought to determine: (1) the impact of SCREEN implementation on waiting times as a primary outcome measure, and (2) the effectiveness of the SCREEN tool in accurately identifying critically ill children when utilised by the QM and adherence by the QM to the SCREEN algorithm as secondary outcome measures. The study was conducted in two phases, Phase I control (pre-SCREEN implementation- three months in 2014) and Phase II (post-SCREEN implementation-two distinct three month periods in 2016). In Phase I, 1600 (92.38%) of 1732 children presenting to 4 clinics, had sufficient data for analysis and comprised the control sample. In Phase II, all 3383 of the children presenting to the 26 clinics during the sampling time frame had sufficient data for analysis. The proportion of critically ill children who saw a professional nurse within 10 minutes increased tenfold from 6.4% to 64% (Phase I to Phase II) with the median time to seeing a professional nurse reduced from 100.3 minutes to 4.9 minutes, (p < .001, respectively). Overall layperson screening compared to Integrated Management of Childhood Illnesses (IMCI) designation by a nurse had a sensitivity of 94.2% and a specificity of 88.1%, despite large variance in adherence to the SCREEN algorithm across clinics. CONCLUSIONS: The SCREEN program when implemented in a real-world setting can significantly reduce waiting times for critically ill children in PHCs, however further work is required to improve the implementation of this innovative program.

Field evaluation of the Cepheid GeneXpert Chlamydia trachomatis assay for detection of infection in a trachoma endemic community in Tanzania.

PURPOSE: To determine the sensitivity, specificity, and field utility of the Cepheid GeneXpert Chlamydia trachomatis (CT) Assay (GeneXpert) for ocular chlamydia infection compared to Roche Amplicor CT assay (Amplicor). METHODS: In a trachoma-endemic community in Kongwa Tanzania, 144 children ages 0 to 9 were surveyed to assess clinical trachoma and had two ocular swabs taken. One swab was processed at Johns Hopkins University, Baltimore MD, using Amplicor, (Roche Molecular Diagnostics) and the other swab was processed at a field station in Kongwa using the GeneXpert Chlamydia trachomatis/Neisseria gonorrhoeae assay (Cepheid). The sensitivity and specificity of GeneXpert was compared to the Amplicor assay. RESULTS: Of the 144 swabs taken the prevalence of follicular trachoma by clinical exam was 43.7%, and by evidence of infection according to Amplicor was 28.5%. A total of 17 specimens (11.8%) could not be processed by GeneXpert in the field due to lack of sample volume, other specimen issues or electricity failure. The sensitivity of GeneXpert when compared to Amplicor was 100% and the specificity was 95%. The GeneXpert test identified more positives in individuals with clinical trachoma than Amplicor, 55% versus 52%. CONCLUSION: The GeneXpert test for C. trachomatis performed with high sensitivity and specificity and demonstrated excellent promise as a field test for trachoma control.

Assessment of hypertension control in a district of Mombasa, Kenya.

As populations move to urban centres across East Africa, lifestyle habits that affect cardiovascular disease have changed, affecting non-communicable disease risk. In particular, the prevalence of hypertension, and associated awareness of this life-threatening condition, has not been studied in Mombasa, Kenya. This paper assesses the rates of prevalence, awareness, treatment and control of hypertension in Old Town, an urban district of the coastal city. We surveyed 469 subjects, gathered via a clustered sampling technique. Age-adjusted prevalence of hypertension was measured at 32.6% (± 2.2) for adults over 18 and was linearly related to age. Results indicate that hypertension awareness was associated with age and sex, as women were substantially more likely to be aware of and to control their hypertension. Only 23.2% (± 2.0) of subjects had knowledge of both the causes of and practical solutions to hypertension, and practical hypertension knowledge was associated with hypertension awareness and gender (women had higher rates of knowledge than men). These results indicate that hypertension is a real public health concern in Old Town, and that younger individuals, particularly males, are least likely to be aware of the dangers of hypertension. Public health measures should focus on this population.