Improving hand hygiene measures in low-resourced intensive care units: experience at the Kigali University Teaching Hospital in Rwanda

Background: Proper hand hygiene (HH) practices have been shown to reduce healthcare-acquired infections. Several potential challenges in low-income countries might limit the feasibility of effective HH, including preexisting knowledge gaps and staffing.

Aim: We sought to evaluate the feasibility of the implementation of effective HH practice at a teaching hospital in Rwanda.

Methods: We conducted a prospective quality improvement project in the intensive care unit (ICU) at the Kigali University Teaching Hospital. We collected data before and after an intervention focused on HH adherence as defined by the World Health Organization ‘5 Moments for Hand Hygiene’ and assuring availability of HH supplies. Pre-intervention data were collected throughout July 2019, and HH measures were implemented in August 2019. Post-implementation data were collected following a 3-month wash-in.

Results: In total, 902 HH observations were performed to assess pre-intervention adherence and 903 observations post-intervention adherence. Overall, HH adherence increased from 25% (222 of 902 moments) before intervention to 75% (677 of 903 moments) after intervention (P < 0.001). Improvement was seen among all health professionals (nurses: 19–74%, residents: 23–74%, consultants: 29–76%). Conclusions: Effective HH measures are feasible in an ICU in a low-income country. Ensuring availability of supplies and training appears key to effective HH practices.

Needs-led human resource planning for Sierra Leone in support of oral health

Background
In Sierra Leone (SL), a low-income country in West Africa, dental care is very limited, largely private, and with services focused in the capital Freetown. There is no formal dental education. Ten dentists supported by a similar number of dental care professionals (DCPs) serve a population of over 7.5 million people. The objective of this research was to estimate needs-led requirements for dental care and human resources for oral health to inform capacity building, based on a national survey of oral health in SL.

Methods
A dedicated operational research (OR) decision tool was constructed in Microsoft Excel to support this project. First, total treatment needs were estimated from our national epidemiological survey data for three key ages (6, 12 and 15 years), collected using the ‘International Caries Classification and Management System (ICCMS)’ tool. Second, oral health needs were extrapolated to whole population levels for each year-group, based on census demographic data. Third, full time equivalent (FTE) workforce capacity needs were estimated for mid-level providers in the form of Dental Therapists (DTs) and non-dental personnel based on current oral disease management approaches and clinical timings for treatment procedures. Fourth, informed by an expert panel, three oral disease management scenarios were explored for the national population: (1) Conventional care (CC): comprising oral health promotion (including prevention), restorations and tooth extraction; (2) Surgical and Preventive care (S5&6P and S6P): comprising oral health promotion (inc. prevention) and tooth extraction (D5 and D6 together, & at D6 level only); and (3) Prevention only (P): consisting of oral health promotion (inc. prevention). Fifth, the findings were extrapolated to the whole population based on demography, assuming similar levels of treatment need.

Results
To meet the needs of a single year-group of childrens’ needs, an average of 163 DTs (range: 133–188) would be required to deliver Conventional care (CC); 39 DTs (range: 30–45) to deliver basic Surgical and Preventive care (S6P); 54 DTs for more extended Surgical and Preventive care (S5&6P) (range 38–68); and 27 DTs (range: 25–32) to deliver Prevention only (P). When scaled up to the total population, an estimated 6,147 DTs (range: 5,565–6,870) would be required to deliver Conventional care (CC); 1,413 DTs (range: 1255–1438 DTs) to deliver basic Surgical and Preventive care (S6P); 2,000 DTs (range 1590–2236) for more extended Surgical and Preventive care (S5&6P) (range 1590–2236); and 1,028 DTs to deliver Prevention only (P) (range: 1016–1046). Furthermore, if oral health promotion activities, including individualised prevention, could be delivered by non-dental personnel, then the remaining surgical care could be delivered by 385 DTs (range: 251–488) for the S6P scenario which was deemed as the minimum basic baseline service involving extracting all teeth with extensive caries into dentine. More realistically, 972 DTs (range: 586–1179) would be needed for the S5&6P scenario in which all teeth with distinctive and extensive caries into dentine are extracted.

Conclusion
The study demonstrates the huge dental workforce needs required to deliver even minimal oral health care to the Sierra Leone population. The gap between the current workforce and the oral health needs of the population is stark and requires urgent action. The study also demonstrates the potential for contemporary epidemiological tools to predict dental treatment needs and inform workforce capacity building in a low-income country, exploring a range of solutions involving mid-level providers and non-dental personnel.

Procedural fairness for radiotherapy priority setting in a low resource context

Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve their populations. This mismatch between demand and supply creates the need for priority setting. There is no widely accepted system to guide patient prioritization for radiotherapy in a low resource context. In the absence of consensus on allocation principles, fair procedures for priority setting should be established. Research is needed to understand what elements of procedural fairness are important to decision makers in diverse settings, assess the feasibility of implementing fair procedures for priority setting in low resource contexts, and improve these processes. This study presents the views of decision makers engaged in everyday radiotherapy priority setting at a cancer center in Rwanda. Semi-structured interviews with 22 oncology physicians, nurses, program leaders, and advisors were conducted. Participants evaluated actual radiotherapy priority setting procedures at the program (meso) and patient (micro) levels, reporting facilitators, barriers, and recommendations. We discuss our findings in relation to the leading Accountability for Reasonableness (AFR) framework. Participants emphasized procedural elements that facilitate adherence to normative principles, such as objective criteria that maximize lives saved. They ascribed fairness to AFR’s substantive requirement of relevance more than transparency, appeals, and enforcement. They identified several challenges unresolved by AFR, such as conflicting relevant rationales and unintended consequences of publicity and appeals. Implementing fair procedure itself is resource intensive, a paradox that calls for innovative, context-appropriate solutions. Finally, socioeconomic and structural barriers to care that undermine procedural fairness must be addressed.

The revival of telemedicine in the age of COVID-19: Benefits and impediments for Pakistan

Dear Editor

Defined as “the use of information and telecommunication technologies (ICT) in medicine, telemedicine intends to provide appropriate healthcare at a distance, hence eliminating the need for direct contact between a patient and physician [1]. It can be classified according to the type of interaction (pre-recorded or real-time) and type of format in which information is conveyed (videos, pictures, audio, etc.) [2]. Particularly in the setting of a natural or man-made disaster, telemedicine is known to function as a key component in the emergency response, enabling people to access routine care and health support despite widespread disruptions in health services [3].

The relevance of telemedicine to our health systems is more evident than ever today as we continue to battle the COVID- 19 pandemic that has modified our lifestyle and approach to medical care. In the face of lockdowns and social distancing protocols, telemedicine technologies are being employed for online consultations, monitoring and evaluating symptoms, tracking and circumventing COVID-19 hotspots, and addressing individual concerns through chat bots [4].

Although the age of COVID-19 has significantly propelled the adoption of telemedicine services globally, its market was booming even prior to the onset of the COVID-19 pandemic, with a market size estimated around US$50 billion as of 2019, projected to increase over 9-fold in the coming decade [5]. A growing body of literature supports the role of telemedicine in providing timely, affordable, and premium quality healthcare services surpassing geographical barriers, which is especially advantageous for resource limited countries. However, while it is being integrated in the health infrastructure in USA, Europe and South East Asia with increasing momentum, its future in the developing world remains obscure [6].

Although the rate is considerably slower than developed countries, developing countries are gradually adapting to the changing times with efforts to make high-quality healthcare accessible to the masses from the comfort of their residence via digital interventions. Sub-Saharan Africa, for example, has reported a significant increase in mobile health technology [7]. The implementation of telemedicine amid a concomitant burden of communicable and non-communicable diseases in low and middle income countries (LMICs) can have consequential impacts in addressing the basic health needs of the population. By reducing travel costs and time, telemedicine enables rural and marginalized communities to access the same quality of medical resources and care as urban dwellers, and promotes health equity [6].

The Status of Medical Devices and their Utilization in 9 Tertiary Hospitals and 5 Research institutions in Uganda

Introduction
Advancements in technology have led to great strides in research and innovation that has resulted in an improvement of healthcare provision around the world. However, it has been shown that majority of the technology is underutilized in Sub-Saharan Africa. The ever-increasing sophistication and cost of medical equipment means that access and proper use is limited in Low- and Middle-Income countries. There is however a general paucity of well documented evidence for utilization of medical equipment in LMICs. The aim of this study is therefore to evaluate the current availability and utilization of medical equipment in tertiary hospitals and research facilitates in Uganda. This will provide baseline information to clinical/biomedical engineers, innovators, managers as well as policy makers.

Methodology
The study evaluated the equipment currently used in 9 purposively selected public tertiary hospitals and 5 research laboratories representing different regions of Uganda. Data was collected by personnel specialized in the field of Biomedical Engineering utilizing a mixed method approach that involved inventory taking and surveys directed to the health workers in the designated health facilities.

Results
The hospitals contributed 1995 (85%) pieces of medical equipment while the research laboratories contributed 343 (15%) pieces amounting to 2338 pieces of equipment involved in the study. On average, 34% of the medical equipment in the health facilities were faulty and 85.6% lacked manuals.

Discussion and Conclusion
Although innovative solutions and donated equipment address the immediate and long-term goals of resource constrained settings, our study demonstrated that there are a number of issues around existing medical devices and these need immediate attention.

Strengthening Antimicrobial Resistance Diagnostic Capacity in Rural Rwanda: A Feasibility Assessment

Introduction: Antimicrobial resistance (AMR) is a global public health threat. Worse still, there is a paucity of data from low- and middle-income countries to inform rational antibiotic use.

Objective: Assess the feasibility of setting up microbiology capacity for AMR testing and estimate the cost of setting up microbiology testing capacity at rural district hospitals in Rwanda.

Methods: Laboratory needs assessments were conducted, and based on identified equipment gaps, appropriate requisitions were processed. Laboratory technicians were trained on microbiology testing processes and open wound samples were collected and cultured at the district hospital (DH) laboratories before being transported to the National Reference Laboratory (NRL) for bacterial identification and antibiotic susceptibility testing. Quality control (QC) assessments were performed at the DHs and NRL. We then estimated the cost of three scenarios for implementing a decentralized microbiology diagnostic testing system.

Results:There was an eight-month delay from the completion of the laboratory needs assessments to the initiation of sample collection due to the regional unavailability of appropriate supplies and equipment. When comparing study samples processed by study laboratory technicians and QC samples processed by other laboratory staff, there was 85.0% test result concordance for samples testing at the DHs and 90.0% concordance at the NRL. The cost for essential equipment and supplies for the three DHs was $245,871. The estimated costs for processing 600 samples ranged from $29,500 to $92,590.

Conclusion: There are major gaps in equipment and supply availability needed to conduct basic microbiology assays at rural DHs. Despite these challenges, we demonstrated that it is feasible to establish microbiological testing capacity in Rwandan DHs. Building microbiological testing capacity is essential for improving clinical care, informing rational antibiotics use, and ultimately, contributing to the establishment of robust national antimicrobial stewardship programs in rural Rwanda and comparable settings

Mobile Ecological Momentary Assessment and Intervention and Health Behavior Change Among Adults in Rakai, Uganda: Pilot Randomized Controlled Trial

Background:
An extraordinary increase in mobile phone ownership has revolutionized the opportunities to use mobile health approaches in lower- and middle-income countries (LMICs). Ecological momentary assessment and intervention (EMAI) uses mobile technology to gather data and deliver timely, personalized behavior change interventions in an individual’s natural setting. To our knowledge, there have been no previous trials of EMAI in sub-Saharan Africa.

Objective:
To advance the evidence base for mobile health (mHealth) interventions in LMICs, we conduct a pilot randomized trial to assess the feasibility of EMAI and establish estimates of the potential effect of EMAI on a range of health-related behaviors in Rakai, Uganda.

Methods:
This prospective, parallel-group, randomized pilot trial compared health behaviors between adult participants submitting ecological momentary assessment (EMA) data and receiving behaviorally responsive interventional health messaging (EMAI) with those submitting EMA data alone. Using a fully automated mobile phone app, participants submitted daily reports on 5 different health behaviors (fruit consumption, vegetable consumption, alcohol intake, cigarette smoking, and condomless sex with a non–long-term partner) during a 30-day period before randomization (P1). Participants were then block randomized to the control arm, continuing EMA reporting through exit, or the intervention arm, EMA reporting and behavioral health messaging receipt. Participants exited after 90 days of follow-up, divided into study periods 2 (P2: randomization + 29 days) and 3 (P3: 30 days postrandomization to exit). We used descriptive statistics to assess the feasibility of EMAI through the completeness of data and differences in reported behaviors between periods and study arms.

Results:
The study included 48 participants (24 per arm; 23/48, 48% women; median age 31 years). EMA data collection was feasible, with 85.5% (3777/4418) of the combined days reporting behavioral data. There was a decrease in the mean proportion of days when alcohol was consumed in both arms over time (control: P1, 9.6% of days to P2, 4.3% of days; intervention: P1, 7.2% of days to P3, 2.4% of days). Decreases in sex with a non–long-term partner without a condom were also reported in both arms (P1 to P3 control: 1.9% of days to 1% of days; intervention: 6.6% of days to 1.3% of days). An increase in vegetable consumption was found in the intervention (vegetable: 65.6% of days to 76.6% of days) but not in the control arm. Between arms, there was a significant difference in the change in reported vegetable consumption between P1 and P3 (control: 8% decrease in the mean proportion of days vegetables consumed; intervention: 11.1% increase; P=.01).

Conclusions:
Preliminary estimates suggest that EMAI may be a promising strategy for promoting behavior change across a range of behaviors. Larger trials examining the effectiveness of EMAI in LMICs are warranted.

Trial Registration:
ClinicalTrials.gov NCT04375423; https://www.clinicaltrials.gov/ct2/show/NCT04375423

Healthcare-associated infections and antimicrobial use in surgical wards of a large urban central hospital in Blantyre, Malawi: a point prevalence survey

Background
There are limited data on healthcare-associated infections (HAI) from African countries like Malawi.

Aim
We undertook a point prevalence survey of HAI and antimicrobial use in the surgery department of Queen Elizabeth Central Hospital (QECH) in Malawi and ascertained the associated risk factors for HAI.

Methods
A cross-sectional point prevalence survey (PPS) was carried out in the surgery department of QECH. The European Centre for Disease Prevention and Control PPS protocol version 5.3 was adapted to our setting and used as a data collection tool.

Findings
105 patients were included in the analysis; median age was 34 (IQR: 24–47) years and 55.2% patients were male. Point prevalence of HAI was 11.4% (n=12/105) (95% CI: 6.0%–19.1%), including four surgical site infections, four urinary tract infections, three bloodstream infections and one bone/joint infection. We identified the following risk factors for HAI; length-of-stay between 8 and 14 days (OR=14.4, 95% CI: 1.65–124.7, p=0.0143), presence of indwelling urinary catheter (OR=8.3, 95% CI: 2.24–30.70, p=0.003) and history of surgery in the past 30 days (OR=5.11, 95% CI: 1.46–17.83, p=0.011). 29/105 patients (27.6%) were prescribed antimicrobials, most commonly the 3rd-generation cephalosporin, ceftriaxone (n=15).

Conclusion
The prevalence rates of HAI and antimicrobial use in surgery wards at QECH are relatively high. Hospital infection prevention and control measures need to be strengthened to reduce the burden of HAI at QECH.

How to improve access to medical imaging in low- and middle-income countries ?

Imaging has become key in the care pathway of communicable and non-communicable diseases. Yet, there are major shortages of imaging equipment and workforce in low- and middle-income countries (LMICs). The International Society of Radiology outlines a plan to upscale the role of imaging in the global health agenda and proposes a holistic approach for LMICs. A generic model for organising imaging services in LMICs via regional Centres of Reference is presented. The need to better exploit IT and the potential of artificial intelligence for imaging, also in the LMIC setting, is highlighted.

To implement the proposed plan, involvement of professional and international organisations is considered crucial. The establishment of an International Commission on Medical Imaging under the umbrella of international organisations is suggested and collaboration with other diagnostic disciplines is encouraged to raise awareness of the importance to upscale diagnostics at large and to foster its integration into the care pathway globally.

The Future of Immersive Technology in Global Surgery Education

The second wave of immersive reality technology is required that enhances and exploits current applications, empirical evidence and worldwide interest. If this is successful, low- and middle-income countries will have improved access, less costs and reduced practical limitations. Affordability, availability, accessibility and appropriateness are determinates, and help from several innovative areas can achieve these targets. Artificial intelligence will allow autonomous support of trainees to accelerate their skills when interacting on mobile applications, as deep learning algorithms will generate models that identify data and patterns within them and provide feedback much like a human educator. Future immersive content needs to be high quality, tailored to the learners’ needs and created with minimal time and expenses. The co-creation process involves the integration of learners into the entire development process and a single learning goal can be identified that will have high reusability to surgical students. Sustainability of the material is ensured in the design stage leading to increased cost-effectiveness benefits. One framework has a proven high impact on the co-design of healthcare resources and is discussed. The connectivity of future immersive technology resources has been a major obstacle between regions in their uptake. A handful of collaboration platforms have been created that can deliver immersive content and experiences; the spearhead in this area will be from augmented reality and telesurgery. Opportunity for powerful, large-scale data culture via blockchain collaboration will be an emerging theme that will also drive towards affordability, availability, accessibility and appropriateness in the future global landscape of immersive technology in surgical education.