Research and Evaluation of Global Family Medicine

Research and Evaluation of Global Family Medicine

This theme focuses on meaningful research of global health problems and evaluation of global health programs.

Workshop Topics

A model to evaluate Global Health training in Graduate Medical Education using Standardized Patient Encounters

There is an increasing interest towards global health training at all levels of medical education. According to AAFP, there currently are 100 family medicine residencies with GH training and 6 with GH fellowships. These global health experiences vary in their content and depth making it difficult to compare quality and impact on learners. The benefits of GH training reported in publications have been largely based on subjective measures. Although improved cultural competency is a presumed outcome of GH education, little objective, quantifiable data exists. Over the past 5 years University of Massachusetts has developed a model to evaluate global health education in an objective way using standardized patient experiences designed for cross-cultural communication skill assessment. In our presentation we will provide information on trends in global health education and the information gap that exists. We will then describe our unique evaluations methods, standardized patient encounters, and preliminary data.

Cultural Value of Multivitamin and Antibiotic Use in the Dominican Republic

On a global scale, medication overuse/misuse and inappropriate prescribing can result in patient harm. Over the past 12 years, clinical experience in the Dominican Republic suggests the community’s strong desire of receiving vitamins as usual care, leading to over-prescribing of vitamins without clear evidence of medical efficacy. Additionally, our prior research indicates frequent use of antibiotics outside of usual indications, which raises the risk of antibiotic-resistant bacteria within the community. Our study aims to uncover the cultural and personal motives responsible for the high value placed on vitamins and antibiotics within the community. By surveying patients, we also intend to appraise whether ending provision of vitamins would affect overall clinic attendance. This is to help determine whether there are other cost-effective approaches to meet community members’ needs without these medications. These results will allow us to consider prioritizing funds for evidence based medical needs.

Emergency obstetric skill retention pilot: Ethiopian midwives 18 months post Advanced Life Support in Obstetrics® course

Advanced Life Support in Obstetrics (ALSO®) is a short, hands-on course to improve management of obstetric emergencies such as postpartum hemorrhage. Although ALSO training has been shown to improve self-confidence and management of postpartum hemorrhage, no assessment of skills retention over time has been done. Studies of other emergency training courses show diminishment of skills over time, suggesting the need for repeated training or drills (ref). Our study was a pilot to evaluate retention of ALSO skills in Ethiopian midwives 18 months after initial training. We will present information about the initial training, design and execution of our study, results of the skills assessments, qualitative feedback from participants, and recommended preparations prior to a larger study.

Epidemiology of Disease in the Peruvian Andes

Healing Peru (NGO), LSU New Orleans Health Science Center and other volunteers from theU.S.have been going to Peru for the last few years with the goal of providing healing and relief of suffering to remote Andean communities in Peru. Many of these communities are located between 12000 to 14000 feet above sea level. For the first time, Fast Electronic Medical Record (FEMR) was implemented in our rural clinics in the Peruvian Andes. FEMR offered us ability to collect important demographic and health information regarding the regional population. These data may provide detailed information on epidemiology of disease in the Peruvian Andes. We will compare information obtained with known regional data in order to verify whether this may represent an opportunity for future development of clinical outreach as well as targeted research toward improving local engagement and adding value to subsequent community endeavors.

Evaluation of Education and Training Programs in Global Health: Challenges, Successes and Pitfalls

In a data driven world, it has become increasingly important to demonstrate that global health programs have met desired outcomes. Yet outcomes in Family Medicine training and education programs are exceeding difficult to measure. In our programs, we have strived to change the undergraduate training environment by instituting a competency-based curriculum, and the learning environment to include more active participation by the learner. In post-graduate programs, we have worked to instill the core principles of Family Medicine in trainees, and many of the concepts, such as continuity, are new to the healthcare system. We have also retrained rural doctors in remote areas. In 4 different types of programs in Cambodia, Laos, Myanmar and Vietnam we have designed evaluations to demonstrate progress toward goals. We have used multiple methodologies including direct observation, surveys, focus groups, 360 evaluations and interviews. We will share our methods and outcomes, and discuss challenges and pitfalls.

Evaluation of the Implementation of Community Oriented Primary Care (COPC) Model through the Family Medicine Department at Christian Medical College, Vellore, India

The family medicine department at CMC has worked in collaboration with UICOMR’s department of family and community medicine to develop and operationalize a COPC model in five underserved communities served by CMC. At the time of submission, data has been entered into a database for 222 households with a total of 898 individual family members. Data collection is on-going. This workshop will discuss operationalization of the COPC model through an iterative process of developing a logic model, which includes goals, objectives, short-term and long-term outcomes, and measures of success. Our discussion will include 1) collection of socio-demographic and health risk data from all members in each household in each of these communities, 2) key findings from preliminary data analysis, 3) identification of the primary health needs in each community, 4) plans for use of the data to develop strategies and programs to address these health needs.

Exploring the global impact of gender biases in cancer registration on reported gender disparities in cancer incidence

Context: Gender-inequalities can lead to gender-disparities in health; however, still unclear are the underpinnings of sex-differences in incidence of cancer worldwide. Methods: We combined country-level data from the UN gender inequality index (GII), the World Health Organization’s Cancer-Incidence-in-Five-Continents, and the Global-Adult-Tobacco-Survey. For smoking-related cancers, we used unexpected deviance (e.g., large gender-inequality and differences in smoking, but low cancer-incidence sex-ratio [SR]) to identify cancer registries with possible gender-biases in data quality. Results: Among countries with moderate-level GII, Ecuador that shows similar patterns of smoking in males and females, has a SR that imitates lowest GII countries (e.g., Scandinavia). In Bahrain and Kuwait, smoking prevalence is high in males, but SRs of cancers are lower than Finland, Belgium and Austria. Among countries with high GII, Qatar shows the possibility of higher gender-bias in cancer registration. Conclusions: Gender-biases in registry data quality may be an important determinant of worldwide variation in gender-disparities in cancer incidence.

Finding the Sweet Spot: Comparing methods of diabetes mellitus screening during short-term clinics in the Dominican Republic

Nearly 50% of adult patients seen at our medical outreach project in Santo Domingo present with elevated blood pressure, and an unknown number may have a risk of glucose intolerance or diabetes. Two methods for identifying individuals with glucose intolerance or diabetes are feasible in our clinic: fingerstick blood glucose and hemoglobin A1c (HgbA1c) levels. This project compares a point-of-care HbgA1c measurement to a finger-stick blood glucose level and determines the relative value of each test in assessing glycemic status among adult patients who present with high blood pressure or a history of diabetes to our medical outreach clinics in Santo Domingo. Our goal is to identify patients affected by abnormal glucose metabolism within the setting of a short-term clinic by using the most effective and cost-efficient method of diabetes screening at medical outreach clinics in developing countries such as the Dominican Republic.

Global Medical Education: There’s an App for That

Tanzania is addressing healthcare workforce shortages by rapidly expanding medical school class sizes. A key challenge is limited teacher and resource capacity. As mobile technology tools become more available globally, they offer promise to address these challenges. A team of American and Tanzanian faculty explored the student experience using Google Classroom at two medical schools in Tanzania. Students were surveyed about baseline technology access, skills, and perceptions, as well as post-implementation attitudes regarding the benefits and challenges of Google Classroom. We found that mobile technology access and skills were readily available. Students had favorable opinions of the Google Classroom tool. They identified easy access to information, the sharing of resources, and improved feedback and communication with faculty as benefits. Key challenges were lack of reliable internet access and speed. Future steps include ongoing data collection to measure the impact of Google Classroom and exploring educational quality outcomes.

GLOCAL Health:Think Globally and Implement Locally

70,000 refugee arrive in the United States per year from various countries with diverse religious, cultural and educational background. It is therefore imperative for current and future generations of family physicians to develop and/or equip themselves with tools to effectively treat this rapidly growing sect of patient population. At our clinic more than 80 % patients are recently migrated refugees. therefore we embarked on studying different observations and its causal relations. Salient amongst them are birthweight patterns in refugee population and increase perinatal complications ; challenges faced with management of diabetes as well as immunization rates in refugee populations with different backgrounds. We have presented some of this initial work at Mayo clinic first delivery of science summit and now I plan to expand and make it interactive brainstorming workshop for the attendees to expand the horizons in understanding this wildly unknown portion of healthcare.

How are you growing? : A Survey on the Current Limitations of the Chispuditos Micronutrient Supplement

In San Jose Del Negrito, Honduras, malnutrition and growth stunting in children was between 35-50% when the Chispuditos program began in 2011. Chispuditos is a soy-based micronutrient supplement resembling porridge. The addition of one daily serving of Chispuditos to children’s diets was hypothesized to increase the children’s height, weight, and hemoglobin. However, preliminary data shows improvements in hemoglobin but not height and weight. It is unknown if this micronutrient feeding supplement is able to ameliorate stunting. A survey is made to determine the type and amounts of food eaten by children and the distribution and use of Chispuditos. Around 150 surveys will be implemented during the summer of 2017. We hypothesize that the findings will be that despite the supplement, children are not consuming enough calories to achieve improved growth. This may be due to Chispuditos being used as a meal substitute or sharing of Chispuditos with other family members.

Hypertension in a OneWorld Health rural Nicaraguan ambulatory clinic: Prevalence and Management

Given the rising threat of non-communicable diseases to population health globally, the Pan-American Health Organization (PAHO) has increased its effort toward improving the management of hypertension in Latin American and Caribbean regions1,2. A retrospective study was performed on a random sampling of 350 charts from a rural Nicaraguan ambulatory clinic to determine the prevalence of patients with hypertension in the town of El Viejo and surrounding area. Information collected and analyzed included age, date of visit, living zone of the patient, comorbidities, chief complaint, medications prescribed, adherence, and follow up. This study provides insight into acute and chronic disease states in rural Nicaragua and how they are being managed in the ambulatory setting. Such studies serve as the basis for future developments and interventions aimed at improving the management of non-communicable diseases in low-middle income countries. Research methodology and approach to epidemiologic survey in this settling will also be discussed.

Long Term Follow Up of Short Term Emergency Ultrasound Training in Tanzania

Numerous studies have shown a positive immediate impact in short term bedside ultrasound trainings for providers in resource limited settings but long term impact of these trainings has not been well evaluated. In September, 2015 a team of ultrasound trained family and emergency medicine physicians from the USA and Tanzania performed a 5 day emergency ultrasound course for eight physicians in the remote area of Mbeya, Tanzania. In April 2017 the training team returned to the site for follow up evaluation including standardized exams, log book review and provider surveys. Positive findings included continued functionality and use of the bedside ultrasound machines by at least some trained providers. Impact on clinical decision making was documented. However, bedside ultrasound had not yet been incorporated into the standard evaluation of trauma patients as planned. A detailed analysis of site feedback, implementation challenges and recommendations for similar future trainings will be presented.

Maternity care - a balance between culture and medicine

Maternal morbidity and mortality is still a challenge globally. Efforts to reduce these rates have been addressed in various ways. The women of Somalia face similar and unique challenges. According to the World Health Organization, internal conflict and famine and a collapsed health sector left 80% of the population without access to basic health services. This prompted a Somali Reproductive Health National Strategy and Action Plan 2010-2015 to be established. Since our clinic cares for Somali patients, it was important to us to find ways to improve maternity care in this population. Because of the limited health resources in Somalia as well as their unique cultural and religious practices, their views on prenatal care and contraception were very different from our Western views. Our clinic has over the years, developed innovative ways to respectfully work with our patients with to improve our prenatal visits and contraception rates.

Measure twice, treat once: Using WHO STEPS tools as part of program development abroad

Family medicine is expanding globally. Our model of prevention and community-minded care is well suited to improve health systems worldwide. But before we can improve the system, we need to understand the problem. This talk will outline the WHO STEPwise program, and demonstrate its practical approach to needs evaluation. The findings can then be easily compared to other regions and used to demonstrate to policymakers the need for intervention. A case study from a rural district of central Viet Nam will be used to demonstrate the free and existing tools available from the WHO.

Multi-interventional approaches to child malnutrition in rural Guatemala: a deeper look at cost effective, culturally competent care

Maternal undernutrition contributes to approximately 800,000 neonatal deaths each year due to small-for-gestational age births. Wasting, stunting, and micronutrient deficiencies cause an additional estimated 3.1 million child deaths annually [1]. Guatemala faces the highest rate of stunting in Latin America with 66% of indigenous children stunted [2,3]. The Organization for the Development of the Indigenous Maya has developed a four-pronged program to combat child malnutrition in indigenous villages. It focuses on culturally and linguistically appropriate pre- and postpartum medical care, maternal and child health nutrition education, micronutrient and targeted fortified food supplementation, and social support for mothers based on the Centering Pregnancy model. In this presentation, we evaluate the successes and challenges of this program, which was able to see a drastic reduction in acute and chronic malnutrition. We also evaluate graduating participants’ perspectives on the program to gauge retention and the integral factors for programmatic success.

Recognizing the rise of Informatics in Global Health, a new the Frontier

In a world where disease has no borders and access to Health information is crucial, the integration of patient data, information science applications, and the experties of health professionals has created a global move towards providing higher quality patient care througth better management and acess to information .As a result, global public health informatics has become key to health security, providing healthcare practioners and decision makers access to critical health information by using best practices and princicples in informatics science to improve global public health practice, research and learning.(1) The Center for Biomedical Informatics, Regenstrief Institute at Indiana University, supports a Global Health Informatics program, works with colleagues around the word to supports the development and implementation of principles and open technologies designed for use in resource-limited settings. It has been instrumental empowering communities to embrace appropriate IT technologies to support care delivery cycle as well as health equity (2).

Screening refugee patients - Challenges and Opportunities

Depression is a common worldwide disorder. According to the World Health Organization February 2017, globally, more than 300 million people of all ages suffer from depression. It is the leading cause of disability worldwide. There are many challenges in addressing depression including cultural attitudes towards mental health, underreporting, lack of resources, and lack of trained health-care providers. Our clinic is a designated site for refugee initial health exams. Most of the refugees we care for come from the Middle East and Northern Africa – of note, these countries have some of the highest rates of depression. Since this population is at risk, I wanted to identify the rates of depression, examine any differences in rates against other populations and explore resources in our community to offer support and treatment for those individuals. In addition, after review of these learnings, to create a clinic protocol to better serve our refugee patients.

Teaching Electronic Fetal Monitoring to the Residents in training at The Clinical Center of Vojvodina, Department of Perinatology Clinic of Gynecology and Obstetrics in Novi Sad, Serbia

This poster highlights that our methods of instruction used with the Serbian OBGYN residents lead to enhanced retention of knowledge. After IRB approval, residents were consented and given a 10 pretest questions, instructed with a PowerPoint, case studies, NOELLE Simulator, and received the same 10 questions for a posttest. The results of the pretest by 20 OB residents showed mean correct answers of 7.60, while 16 performed the posttest with mean correct answers of 8.31. While the results for the pretest in 13 non OB residents showed mean correct answers of 5.61, 14 performed the posttest with mean correct answers of 8.54. Collectively, 33 residents pretest had mean correct answers of 6.81 and 30 residents posttest had mean correct answers of 8.46. These results reflect evidence and confidence that teaching the planned Advanced Life Support of Obstetric Provider Course can effectively enhanced learning and retaining knowledge for the Serbian residents.

Towards more sustainable programming for global health missions

Medical outreach to disadvantaged or hard-to-reach areas is the focus for global health missions. How is population health momentum sustained after the missions? Where they exist, community health programs run by community health workers play are key role to fill the existing gap between the public health system and households. This helps to foster benefits after missions and prevents erosion of coping skills. What do we know about scaling up and sustainability of CHW programs? A CHW performance tool was applied in an established CHW program located at the site of ongoing health mission. Enablers and Barriers were identified and discussed. Tenwek Community Development uses the local church institution to mobilize community for health through volunteers called CRPs (community resource persons). Enablers and barriers exist and these keep on changing with time. Programs need to maintain a dashboard for sustainability that stakeholders can benchmark during the life of a program

Uses of point-of-care ultrasound (POCUS) and its impact in a limited resource setting: Nicaragua

Background: Limited resources or logistics may hamper the delivery of health care on short-term medical missions (STMMs). Newer, smaller point-of-care ultrasound (POCUS) machines have become increasingly used in these remote areas. Hypothesis: The use of POCUS, as part of standard clinical practice, will alter management and allow for more tailored patient care. Materials and Methods: A prospective cohort study was conducted in Sébaco, Nicaragua over the course of one week in a series of small outreach clinics to determine how often POCUS changed patient management. Results: A total of 59 patients were enrolled and will be reported with the categories and frequency of indications for POCUS and how often the results altered physician management. Conclusion: POCUS can be of significant benefit to resource-limited countries where healthcare is limited by access to care, availability of medications and/or imaging, and the ability of the patient to adhere to treatment.

Using community health workers and a mobile health tool to improve diabetes care in rural Guatemala

We are in the midst of a global diabetes epidemic, which poses particular challenges to low and middle income countries - such as Guatemala - due to the lack of resources and healthcare infrastructure for chronic disease management. We partnered with a community health worker (CHW) program in San Lucas Tolimán, Guatemala, which serves ~200 patients with diabetes living in rural villages. We developed protocols for the titration of metformin and glyburide and management of diabetic complications. We then integrated these protocols into a smartphone application, which gives clinical recommendations to the CHWs. As of May 2017, we have trained 10 CHWs in the use of the application and have enrolled 16 patients in the program. More patients will be enrolled in the upcoming months. We are following patients with A1c and other biometric data and will present these preliminary outcomes, as well as discuss the logistics of program implementation.