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1.  Assessment of neonatal care in clinical training facilities in Kenya 
Archives of Disease in Childhood  2014;100(1):42-47.
Objective
An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya.
Design
Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data.
Setting
Neonatal units of 22 public hospitals.
Patients
Neonates aged <7 days.
Main outcome measures
Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission.
Results
All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0–3) and a median score of 6 out of 8 for signs of severe illness (IQR 4–7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively.
Conclusions
Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.
doi:10.1136/archdischild-2014-306423
PMCID: PMC4283661  PMID: 25138104
Neonatology; Health services research; Measurement; Evidence Based Medicine; Data Collection
2.  Knowledge and skills retention following Emergency Triage, Assessment and Treatment plus Admission course for final year medical students in Rwanda: a longitudinal cohort study 
Archives of disease in childhood  2014;99(11):993-997.
Aim
To determine whether, after the Emergency Triage, Assessment and Treatment plus Admission (ETAT+) course, a comprehensive paediatric life support course, final year medical undergraduates in Rwanda would achieve a high level of knowledge and practical skills and if these were retained. To guide further course development, student feedback was obtained.
Methods
Longitudinal cohort study of knowledge and skills of all final year medical undergraduates at the University of Rwanda in academic year 2011–2012 who attended a 5-day ETAT+ course. Students completed a precourse knowledge test. Knowledge and clinical skills assessments, using standardised marking, were performed immediately postcourse and 3–9 months later. Feedback was obtained using printed questionnaires.
Results
84 students attended the course and re-evaluation. Knowledge test showed a significant improvement, from median 47% to 71% correct answers (p<0.001). For two clinical skills scenarios, 98% passed both scenarios, 37% after a retake, 2% failed both scenarios. Three to nine months later, students were re-evaluated, median score for knowledge test 67%, not significantly different from postcourse (p>0.1). For clinical skills, 74% passed, with 32% requiring a retake, 8% failed after retake, 18% failed both scenarios, a significant deterioration (p<0.0001).
Conclusions
Students performed well on knowledge and skills immediately after a comprehensive ETAT+ course. Knowledge was maintained 3–9 months later. Clinical skills, which require detailed sequential steps, declined, but most were able to perform them satisfactorily after feedback. The course was highly valued, but several short courses and more practical teaching were advocated.
doi:10.1136/archdischild-2014-306078
PMCID: PMC4198299  PMID: 24925893
3.  Knowledge and skills retention following Emergency Triage, Assessment and Treatment plus Admission course for final year medical students in Rwanda: a longitudinal cohort study 
Archives of Disease in Childhood  2014;99(11):993-997.
Aim
To determine whether, after the Emergency Triage, Assessment and Treatment plus Admission (ETAT+) course, a comprehensive paediatric life support course, final year medical undergraduates in Rwanda would achieve a high level of knowledge and practical skills and if these were retained. To guide further course development, student feedback was obtained.
Methods
Longitudinal cohort study of knowledge and skills of all final year medical undergraduates at the University of Rwanda in academic year 2011–2012 who attended a 5-day ETAT+ course. Students completed a precourse knowledge test. Knowledge and clinical skills assessments, using standardised marking, were performed immediately postcourse and 3–9 months later. Feedback was obtained using printed questionnaires.
Results
84 students attended the course and re-evaluation. Knowledge test showed a significant improvement, from median 47% to 71% correct answers (p<0.001). For two clinical skills scenarios, 98% passed both scenarios, 37% after a retake, 2% failed both scenarios. Three to nine months later, students were re-evaluated, median score for knowledge test 67%, not significantly different from postcourse (p>0.1). For clinical skills, 74% passed, with 32% requiring a retake, 8% failed after retake, 18% failed both scenarios, a significant deterioration (p<0.0001).
Conclusions
Students performed well on knowledge and skills immediately after a comprehensive ETAT+ course. Knowledge was maintained 3–9 months later. Clinical skills, which require detailed sequential steps, declined, but most were able to perform them satisfactorily after feedback. The course was highly valued, but several short courses and more practical teaching were advocated.
doi:10.1136/archdischild-2014-306078
PMCID: PMC4198299  PMID: 24925893
Medical Education; Accident & Emergency; Resuscitation; Low income populations; Rwanda
4.  What clinical signs best identify severe illness in young infants aged 0–59 days in developing countries? A systematic review 
Archives of disease in childhood  2011;96(11):1052-1059.
Despite recent overall improvement in the survival of under-five children worldwide, mortality among young infants remains high, and accounts for an increasing proportion of child deaths in resource-poor settings. In such settings, clinical decisions for appropriate management of severely ill infants have to be made on the basis of presenting clinical signs, and with limited or no laboratory facilities. This review summarises the evidence from observational studies of clinical signs of severe illnesses in young infants aged 0–59 days, with a particular focus on defining a minimum set of best predictors of the need for hospital-level care. Available moderate to high quality evidence suggests that, among sick infants aged 0–59 days brought to a health facility, the following clinical signs—alone or in combination—are likely to be the most valuable in identifying infants at risk of severe illness warranting hospital-level care: history of feeding difficulty, history of convulsions, temperature (axillary) ≥37.5°C or <35.5°C, change in level of activity, fast breathing/respiratory rate ≥60 breaths per minute, severe chest indrawing, grunting and cyanosis.
doi:10.1136/adc.2010.186049
PMCID: PMC3081806  PMID: 21220263
6.  Developing and Introducing Evidence Based Clinical Practice Guidelines for Serious Illness in Kenya 
Archives of disease in childhood  2008;93(9):799-804.
The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.
doi:10.1136/adc.2007.126508
PMCID: PMC2654066  PMID: 18719161
7.  Health systems research in a low income country - easier said than done 
Archives of disease in childhood  2008;93(6):540-544.
Summary
Small hospitals sit at the apex of the pyramid of primary care in many low-income country health systems. If the Millennium Development Goal for child survival is to be achieved hospital care for severely ill, referred children will need to be improved considerably in parallel with primary care in many countries. Yet we know little about how to achieve this. We describe the evolution and final design of an intervention study attempting to improve hospital care for children in Kenyan district hospitals. We believe our experience illustrates many of the difficulties involved in reconciling epidemiological rigour and feasibility in studies at a health system rather than an individual level and the importance of the depth and breadth of analysis when trying to provide a plausible answer to the question - does it work? While there are increasing calls for more health systems research in low-income countries the importance of strong, broadly-based local partnerships and long term commitment even to initiate projects are not always appreciated.
doi:10.1136/adc.2007.126466
PMCID: PMC2654065  PMID: 18495913
8.  Evidence review of hydroxyurea for the prevention of sickle cell complications in low-income countries 
Archives of Disease in Childhood  2013;98(11):908-914.
Hydroxyurea is widely used in high-income countries for the management of sickle cell disease (SCD) in children. In Kenyan clinical guidelines, hydroxyurea is only recommended for adults with SCD. Yet many deaths from SCD occur in early childhood, deaths that might be prevented by an effective, disease modifying intervention. The aim of this review was to summarise the available evidence on the efficacy, effectiveness and safety of hydroxyurea in the management of SCD in children below 5 years of age to support guideline development in Kenya. We undertook a systematic review and used the Grading of Recommendations Assessment, Development and Evaluation system to appraise the quality of identified evidence. Overall, available evidence from 1 systematic review (n=26 studies), 2 randomised controlled trials (n=354 children), 14 observational studies and 2 National Institute of Health reports suggest that hydroxyurea may be associated with improved fetal haemoglobin levels, reduced rates of hospitalisation, reduced episodes of acute chest syndrome and decreased frequency of pain events in children with SCD. However, it is associated with adverse events (eg, neutropenia) when high to maximum tolerated doses are used. Evidence is lacking on whether hydroxyurea improves survival if given to young children. Majority of the included studies were of low quality and mainly from high-income countries. Overall, available limited evidence suggests that hydroxyurea may improve morbidity and haematological outcomes in SCD in children aged below 5 years and appears safe in settings able to provide consistent haematological monitoring.
doi:10.1136/archdischild-2012-302387
PMCID: PMC3812872  PMID: 23995076
Genetics; Haematology
9.  Adoption of recommended practices and basic technologies in a low-income setting 
Archives of Disease in Childhood  2014;99(5):452-456.
Objective
In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent.
Design and setting
We used data collected on a consistent panel of indicators during four separate cross-sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002–2012).
Main outcome measures
Basic resource availability, use of diagnostics and uptake of recommended practices.
Results
There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines.
Conclusions
Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low-income settings and to those developing novel therapeutic or diagnostic interventions.
doi:10.1136/archdischild-2013-305561
PMCID: PMC3995214  PMID: 24482351
Health services research; Tropical Paediatrics
10.  Millennium Development Goals progress: a perspective from sub-Saharan Africa 
Archives of Disease in Childhood  2015;100(Suppl 1):S57-S58.
Sub-Saharan Africa is a highly diverse geo-political region. Any brief discussion of the progress made over the last 15 years towards the Millennium Development Goals (MDGs) will therefore not do justice to the true complexity of context and events. Our focus will be MDG4—to reduce child mortality by 66% from 1990 levels. We will touch briefly on MDG1, to eradicate extreme poverty and hunger, MDG2, to achieve universal primary education, and MDG5, to improve maternal health, which are inextricably linked with child well-being. We will also draw on an eclectic mix of additional global indicators. Acknowledging the limitations of this approach, we first offer a summary of expected progress and then point to debates on future goals.
doi:10.1136/archdischild-2013-305747
PMCID: PMC4316853  PMID: 25613971
Tropical Paediatrics; Comm Child Health; Epidemiology; General Paediatrics
11.  What clinical signs best identify severe illness in young infants aged 0–59 days in developing countries? A systematic review 
Archives of Disease in Childhood  2011;96(11):1052-1059.
Despite recent overall improvement in the survival of under-five children worldwide, mortality among young infants remains high, and accounts for an increasing proportion of child deaths in resource-poor settings. In such settings, clinical decisions for appropriate management of severely ill infants have to be made on the basis of presenting clinical signs, and with limited or no laboratory facilities. This review summarises the evidence from observational studies of clinical signs of severe illnesses in young infants aged 0–59 days, with a particular focus on defining a minimum set of best predictors of the need for hospital-level care. Available moderate to high quality evidence suggests that, among sick infants aged 0–59 days brought to a health facility, the following clinical signs—alone or in combination—are likely to be the most valuable in identifying infants at risk of severe illness warranting hospital-level care: history of feeding difficulty, history of convulsions, temperature (axillary) ≥37.5°C or <35.5°C, change in level of activity, fast breathing/respiratory rate ≥60 breaths per minute, severe chest indrawing, grunting and cyanosis.
doi:10.1136/adc.2010.186049
PMCID: PMC3081806  PMID: 21220263

Results 1-11 (11)