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Healthcare workers must ensure effective infection prevention and control (IPC) to prevent nosocomial spread of SARS-CoV-2, the virus that causes COVID-19. This questionnaire study aims to evaluate Canadian critical care and emergency department nurses' readiness to follow IPC guidelines in their workplace, and to understand their perceptions of trust in organizational preparedness, communication, and infection risk.We adapted an internationally distributed survey for the Canadian context. This cross-sectional questionnaire, incorporating validated scales for items including institutional trust, was distributed by email to nurses via the Canadian Association of Critical Care Nurses and the Canadian Association of Emergency Physicians networks between 16 March and 25 May 2020. We evaluated intensive care unit and emergency department nurses' adherence to IPC protocols, barriers and facilitators to IPC guideline adherence, and their level of institutitonal trust.Three hundred and nineteen nurses responded to the survey. There was higher trust in organizational preparedness among nurses who were older (B = 0.31, P0.001) and more experienced (F = 18.09, P0.001), and particularly among those with previous experience working in outbreak settings (F = 7.87, P = 0.005). Compared with those without experience working in outbreak settings, respondents with this experience reported higher levels of fear of becoming ill and fear of providing care for COVID-19 patients (χCanadian nurses had strong self-reported adherence to IPC measures and personal protective equipment use. There were high levels of trust in health system leadership to ensure protective measures are present and reliable. Trust was particularly high among older and more experienced nurses despite these populations reporting higher levels of fear of personal illness.RéSUMé: OBJECTIF: Les travailleurs de la santé doivent assurer l’efficacité de la prévention et du contrôle des infections (PCI) pour prévenir la propagation nosocomiale du SRAS-CoV-2, le virus qui cause la COVID-19. Cette étude sous forme de questionnaire vise à évaluer le degré de préparation des infirmières et infirmiers des services d’urgence et de soins intensifs canadiens à suivre les lignes directrices de la PCI sur leur lieu de travail, ainsi qu’à comprendre leur degré de confiance dans la préparation, la communication et le risque d’infection au niveau de l’organisation. MéTHODE: Nous avons adapté un sondage distribué à l’échelle internationale au contexte canadien. Ce questionnaire sectoriel, incorporant des échelles validées pour des éléments tels que la confiance institutionnelle, a été distribué par courriel aux infirmières et infirmiers par l’entremise de l’Association canadienne des infirmiers/infirmières en soins intensifs et des réseaux de l’Association canadienne des médecins d’urgence entre le 16 mars et le 25 mai 2020. Nous avons évalué l’adhésion du personnel infirmier des unités de soins intensifs et des services d’urgence aux protocoles de la PCI, les obstacles et les facilitateurs à l’observance des lignes directrices de la PCI, ainsi que leur niveau de confiance institutionnelle. RéSULTATS: Trois cent dix-neuf infirmières et infirmiers ont répondu au questionnaire. Il y avait une plus grande confiance dans la préparation organisationnelle chez les infirmières et infirmiers plus âgés (B = 0,31, P0,001) et plus expérimentés (F = 18,09, P0,001), et en particulier parmi celles et ceux qui avaient déjà travaillé dans des contextes d’éclosion (F = 7,87, P = 0,005). Comparativement à celles et ceux qui n’ont pas d’expérience dans des contextes d’éclosion, les répondant(e)s avec expérience ont signalé des niveaux plus élevés de peur de tomber malade et de peur de fournir des soins aux patients atteints de la COVID-19 (χ

ObjectiveTo assess implementation and to identify barriers and facilitators to implementation, sustainability and scalability of an implementation strategy to provide lay health workers (LHWs) with the knowledge, skills and tools needed to implement an intervention to support patient tuberculosis (TB) treatment adherence.DesignMixed-methods design including a cluster randomised controlled trial and process evaluation informed by the RE-AIM framework.SettingForty-five health centres (HCs) in four districts in the south east zone of Malawi, who had an opportunity to receive cascade training.ParticipantsForty-five peer-trainers (PTs), 23 patients and 20 LHWs.InterventionImplementation strategy employing peer-led educational outreach, a clinical support tool and peer support network to implement a TB treatment adherence intervention.Outcome measuresProcess data were collected from study initiation to the end-of-study PT meeting, and included: LHW and patient interviews, quarterly PT meeting notes, training logs and study team observations and meeting notes. Data sources were first analysed in isolation, followed by method, data source and analyst triangulation. Analyses were conducted independently by two study team members, and themes revised through discussion and involvement of additional study team members as needed.ResultsForty-one HCs (91%) trained at least one LHW. Of 256 LHWs eligible to participate at study start 152 (59%) completed training, with the proportion trained per HC ranging from 0% to 100% at the end of initial cascade training. Lack of training incentives was the primary barrier to implementation, with intrinsic motivation to improve knowledge and skills, and to improve patient care and outcomes the primary facilitators of participation.ConclusionWe identified important challenges to and potential facilitators of implementation, scalability and sustainability, of the TB treatment adherence intervention. Findings provide guidance to scale-up, and use of the implementation strategies employed, to address LHW training and supervision in other areas.Trial registration numberNCT02533089.

Background With the global shortage of skilled health workers estimated at 7.2 million, outpatient tuberculosis (TB) care is commonly task-shifted to lay health workers (LHWs) in many low- and middle-income countries where the shortages are greatest. While shown to improve access to care and some health outcomes including TB treatment outcomes, lack of training and supervision limit the effectiveness of LHW programs. Our objective was to refine and evaluate an intervention designed to address common causes of non-adherence to TB treatment and LHW knowledge and skills training needs. Methods We employed a pragmatic cluster randomized controlled trial. Participants included 103 health centres (HCs) providing TB care in four districts in Malawi, randomized 1:1 stratified by district and HC funding (Ministry of Health, non-Ministry funded). At intervention HCs, a TB treatment adherence intervention was implemented using educational outreach, a point-of-care reminder tool, and a peer support network. Clusters in the control arm provided usual care. The primary outcome was the proportion of patients with successful TB treatment (i.e., cure or treatment completion). We used a generalized linear mixed model, with district as a fixed effect and HC as a random effect, to compare proportions of patients with treatment success, among the trial arms, with adjustment for baseline differences. Results We randomized 51 HCs to the intervention group and 52 HCs to the control group. Four intervention and six control HCs accrued no eligible patients, and 371 of 1169 patients had missing outcome, HC, or demographic data, which left 74 HCs and 798 patients for analysis. Randomization group was not related to missing outcome, however, district, age, and TB type were significantly related and included in the primary analysis model. Among the 1153 patients with HC and demographic data, 297/605 (49%) and 348/548 (64%) in the intervention and control arms, respectively, had treatment success. The intervention had no significant effect on treatment success (adjusted odds ratio 1.35 [95% confidence interval 0.93–1.98]). Conclusion We found no significant effect of the intervention on TB treatment outcomes with high variability in implementation quality, highlighting important challenges to both scale-up and sustainability. Trial registration ClinicalTrials.gov NCT02533089. Registered August 20, 2015.

ObjectiveThis review was conducted to identify interventions effective in improving uptake and retention of HIV-positive mothers and their infants in prevention of mother to child transmission (PMTCT) services in low-income and middle-income countries (LMICs) in order to inform programme planning.MethodsWe conducted a systematic review of studies comparing usual care with any intervention to improve uptake and retention of HIV-positive pregnant or breastfeeding women and their children from birth to 2 years of age in PMTCT services in LMICs. Twenty-two electronic databases were searched from inception to 15 January 2018, for randomised, quasi-randomised and non-randomised controlled trials, and interrupted time series studies; reference lists of included articles were searched for relevant articles. Risk of bias was assessed using the Cochrane Effective Practice and Organisation of Care group criteria. Random-effects meta-analysis was conducted for studies reporting similar interventions and outcomes.ResultsWe identified 29 837 articles, of which 18 studies were included in our review. Because of heterogeneity in interventions and outcome measures, only one meta-analysis of two studies and one outcome was conducted; we found a statistically significant increase in antiretroviral therapy (ART) use during pregnancy for integration of HIV and antenatal care relative to standard non-integrated care (pooled AOR=2.69; 95% CI 1.25 to 5.78, p=0.0113). The remaining studies assessing other patient, provider or health system interventions were synthesised narratively, with small effects seen across intervention categories for both maternal and infant PMTCT outcomes based predominately on evidence with moderate to high risk of bias.ConclusionsEvidence on the effectiveness of interventions to improve uptake and retention of mothers and infants in PMTCT care is lacking. Our findings suggest that integration of HIV and antenatal care may improve ART use during pregnancy. Future studies to replicate promising approaches are needed. Improved reporting of key methodological criteria will facilitate interpretation of findings and improve the utility of evidence to PMTCT programme planners.PROSPERO registration numberCRD42015020829.

Objectives The outcome of well-performed clinical research is essential for evidence-based patient management during pandemics. However, conducting clinical research amidst a pandemic requires researchers to balance clinical and research demands. We seek to understand the values, experiences, and beliefs of physicians working at the onset of the COVID-19 pandemic in order to inform clinical research planning. We aim to understand whether pandemic settings affect physician comfort with research practices, and how physician experiences shape their understanding of research in a pandemic setting. Methods A survey tool was adapted to evaluate familiarity and comfort with research during a pandemic. A cross-sectional, online questionnaire was distributed across Canadian research networks early in the COVID-19 outbreak. The survey was administered between March 11th and 17th, 2020, during a time of local transmission but prior to the surge of cases. We aimed to recruit into the survey physicians in infectious disease and critical care research networks across Canada. Results Of the 133 physician respondents, 131 (98%) considered it important to conduct clinical research during the COVID-19 pandemic. Respondents were more accepting of adaptations to the research process in during a pandemic compared to in a non-pandemic setting, including conducting research with deferred consent (χ2 = 8.941, 95% CI: -0.264, -0.085, p = 0.003), using non-identifiable observational data with a waiver of consent with a median score of 97 out of 100 (IQR: 79.25–100) vs median 87 out of 100 (IQR: 63–79) (95% CI: -12.43, 0.054, p = 0.052). The majority felt that research quality is not compromised during pandemics. Conclusions Physicians consider it important to conduct research during a pandemic, highlighting the need to expedite research activities in pandemic settings. Respondents were more accepting of adaptations to the research process for research conducted during a pandemic, compared to that conducted in its absence of a pandemic.

Background Evidence-based clinical algorithms (EBCA) are knowledge tools to promote evidence use by codifying evidence into action plans to facilitate appropriate care. However, their impact on process and outcomes of care varies considerably across practice settings and providers, highlighting the need for tailoring of both these knowledge tools and their implementation strategies to target end users and the setting in which EBCAs are to be employed. Leadership at the Tikur Anbessa Specialized Hospital emergency department (TASH-ED) in Addis Ababa, Ethiopia identified a need for context-appropriate EBCAs to improve evidence uptake to mitigate care gaps in this high volume, high acuity setting. We aimed to identify barriers and facilitators to utilization of EBCAs in the TASH-ED, to identify priority targets for development of EBCAs tailored for the TASH-ED context and to understand the process of care in the TASH-ED to inform implementation planning. Methods We employed a multi-component qualitative design including: semi-structured interviews with TASH-ED clinical, administrative and support services staff, and Toronto EM physicians who had worked in the TASH-ED; direct observation of the process of care in TASH-ED; document review. Results Although most TASH-ED participants reported an awareness of EBCAs, they noted little or no experience using them, primarily due to the poor fit of many EBCAs to their practice setting. All participants felt that context-appropriate EBCAs were needed to ensure standardized and evidence-based care and improve patient outcomes for common ED presentations. Trauma, sepsis, acute cardiac conditions, hypertensive emergencies, and diabetic keto-acidosis were most commonly identified as priorities for EBCA development. Lack of medication, equipment and human resources were identified as the primary barriers to use of EBCAs in the TASH-ED. Support from leadership and engagement of stakeholders outside the ED where EBCAs were believed to be less well accepted were identified as essential facilitators to implementation of EBCAs in the TASH-ED. Conclusions This study found a perceived need for EBCAs tailored to the TASH-ED setting to support uptake of evidence-based care into routine practice for common clinical presentations. Barriers and facilitators provide information essential to development of both context-appropriate EBCAs and plans for their implementation in the TASH-ED. Electronic supplementary material The online version of this article (10.1186/s12913-019-4008-2) contains supplementary material, which is available to authorized users.

Background Despite availability of effective treatment, tuberculosis (TB) remains an important cause of morbidity and mortality globally, with low- and middle-income countries most affected. In many such settings, including Malawi, the high burden of disease and severe shortage of skilled healthcare workers has led to task-shifting of outpatient TB care to lay health workers (LHWs). LHWs improve access to healthcare and some outcomes, including TB completion rates, but lack of training and supervision limit their impact. The goals of this study are to improve TB care provided by LHWs in Malawi by refining, implementing, and evaluating a knowledge translation strategy designed to address a recognized gap in LHWs’ TB and job-specific knowledge and, through this, to improve patient outcomes. Methods/design We are employing a mixed-methods design that includes a pragmatic cluster randomized controlled trial and a process evaluation using qualitative methods. Trial participants will include all health centers providing TB care in four districts in the South East Zone of Malawi. The intervention employs educational outreach, a point-of-care reminder tool, and a peer support network. The primary outcome is proportion of treatment successes, defined as the total of TB patients cured or completing treatment, with outcomes taken from Ministry of Health treatment records. With an alpha of 0.05, power of 0.80, a baseline treatment success of 0.80, intraclass correlation coefficient of 0.1 based on our pilot study, and an estimated 100 clusters (health centers providing TB care), a minimum of 6 patients per cluster is required to detect a clinically significant 0.10 increase in the proportion of treatment successes. Our process evaluation will include interviews with LHWs and patients, and a document analysis of LHW training logs, quarterly peer trainer meetings, and mentorship meeting notes. An estimated 10–15 LHWs and 10–15 patients will be required to reach saturation in each of 2 planned interview periods, for a total of 40–60 interview participants. Discussion This study will directly inform the efforts of knowledge users within TB care and, through extension of the approach, other areas of care provided by LHWs in Malawi and other low- and middle-income countries. Trial registration ClinicalTrials.gov NCT02533089. Registered 20 August 2015. Protocol Date/Version 29 May 2016/Version 2. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1563-2) contains supplementary material, which is available to authorized users.

Summary Purpose Due to differences in epilepsy types and surgery, economic evaluations of epilepsy treatment in adults cannot be extrapolated to children. We evaluated the cost-effectiveness of epilepsy surgery compared to medical treatment in children with intractable epilepsy. Method Decision tree analysis was used to evaluate the cost-effectiveness of surgery relative to medical management. Fifteen patients had surgery and 15 had medical treatment. Cost data included inpatient and outpatient costs for the period April 2007 to September 2009, physician fee, and medication costs. Outcome measure was percentage seizure reduction at one-year follow-up. Incremental cost-effectiveness ratio (ICER) was assessed. Sensitivity analysis was performed for different probabilities of surgical and medical treatment outcomes and costs, and surgical mortality or morbidity. Results More patients managed surgically experienced Engel class I and II outcomes compared to medical treatment at one-year follow-up. Base-case analysis yielded an ICER of $369 per patient for each percentage reduction in seizures for the surgery group relative to medical group. Sensitivity analysis showed robustness for the different probabilities tested. Conclusion Surgical treatment resulted in greater reduction in seizure frequency compared to medical therapy and was a cost-effective treatment option in children with intractable epilepsy who were evaluated for epilepsy surgery and subsequently underwent surgery compared to continuing medical therapy. However, larger sample size and long-term follow-up are needed to validate these findings.

Background Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO’s Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael’s Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these. Methods We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers). Results Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators. Conclusion This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.

Background Despite recent improvements, uptake and retention of mothers and infants in prevention of mother-to-child transmission (PMTCT) services remain well below target levels in many low- and middle-income countries (LMICs). Identification of effective interventions to support uptake and retention is the first step towards improvement. We aim to complete a systematic review and meta-analysis to evaluate the effectiveness of interventions at the patient, provider or health system level in improving uptake and retention of HIV-infected mothers and their infants in PMTCT services in LMICs. Methods/Design We will include studies comparing usual care or no intervention to any type of intervention to improve uptake and retention of HIV-infected pregnant or breastfeeding women and their children from birth to 2 years of age attending PMTCT services in LMICs. We will include randomized controlled trials (RCTs), cluster RCTs, non-randomized controlled trials, and interrupted time series. The primary outcomes of interest are percentage of HIV-infected women receiving/initiated on anti-retroviral prophylaxis or treatment, percentage of infants receiving/initiated on anti-retroviral prophylaxis, and percentage of women and infants completing the anti-retroviral regimen/retained in PMTCT care. The following databases will be searched from inception: Ovid MEDLINE and EMBASE, The WHO Global Health Library, CAB abstracts, EBM Reviews, CINAHL, HealthSTAR and Web of Science databases, Scopus, PsychINFO, POPLINE, Sociological Abstracts, ERIC, AIDS Education Global Information System, NLM Gateway, LILACS, Google Scholar, British Library Catalogue, DARE, ProQuest Dissertation & Theses, the New York Academy of Grey Literature, Open Grey, The Cochrane Library, WHO International Clinical Trials Registry, Controlled Clinical Trials, and clinicaltrials.gov. Reference lists of included articles will be hand searched and study authors and content experts contacted to inquire about eligible unpublished or in progress studies. Screening, data abstraction, and risk of bias appraisal using the Cochrane Effective Practice and Organization of Care criteria will be conducted independently by two team members. Results will be synthesized narratively and a meta-analysis conducted using the DerSimonian Laird random effects method if appropriate based on assessment of clinical and statistical heterogeneity. Discussion Our findings will be useful to PMTCT implementers, policy makers, and implementation researchers working in LMICs. Systematic review registration PROSPERO CRD42015020829 Electronic supplementary material The online version of this article (doi:10.1186/s13643-015-0136-x) contains supplementary material, which is available to authorized users.

Background Ethiopian emergency department (ED) patients have a considerable burden of illness and injury for which all-cause mortality rates have not previously been published. This study sought to characterize the burden of and to identify predictors for early all-cause mortality among patients presenting to the Tikur Anbessa Specialized Hospital ED (TASH-ED) in Ethiopia. Methods Data was prospectively collected from the records of all patients who died within 72 h of ED presentation. Pearson’s Chi square and Fisher’s exact tests were used to investigate associations between two outcome variables: (a) time to death and (b) immediate cause of death in relation to specific demographic and clinical factors. Time from ED presentation to death was dichotomized as ‘very early’ mortality within ≤6 h and death >6–72 h and logistic regression was used to assess the adjusted impact of these demographic and clinical variables on the probability of dying within 6 h of ED presentation. Results Between October 2012 and May 2013, 9956 patients visited the ED and 220 patients died within 72 h of admission. After excluding patients dead on arrival (n = 34), the average age of death was 43.1 years and the overall mortality rate was 1.9 %. Head injury (21.5 %) and sepsis (18.8 %) were the most common causes of death. Relative to medical patients, trauma patients were more likely to be male (p 48 h vs.

Objectives To explore similarities and differences in challenges to maternal health and evidence implementation in general across several low- and middle-income countries (LMICs) and to identify common and unique themes representing barriers to and facilitators of evidence implementation in LMIC health care settings. Study Design Secondary analysis of qualitative data. Setting Meeting reports and articles describing projects undertaken by the authors in five LMICs on three continents were analyzed. Projects focused on identifying barriers to and facilitators of implementation of evidence products: five World Health Organization maternal health guidelines, and a knowledge translation strategy to improve adherence to tuberculosis treatment. Data were analyzed using thematic content analysis. Results Among identified barriers to evidence implementation, a high degree of commonality was found across countries and clinical areas, with lack of financial, material, and human resources most prominent. In contrast, few facilitators were identified varied substantially across countries and evidence implementation products. Conclusion By identifying common barriers and areas requiring additional attention to ensure capture of unique barriers and facilitators, these findings provide a starting point for development of a framework to guide the assessment of barriers to and facilitators of maternal health and potentially to evidence implementation more generally in LMICs.

With the support of the World Health Organization’s Evidence-Informed Policy Network, knowledge translation platforms have been developed throughout Africa, the Americas, Eastern Europe, and Asia to further evidence-informed national health policy. In this commentary, we discuss the approaches, activities and early lessons learned from the development of a Knowledge Translation Platform in Malawi (KTPMalawi). Through ongoing leadership, as well as financial and administrative support, the Malawi Ministry of Health has strongly signalled its intention to utilize a knowledge translation platform methodology to support evidence-informed national health policy. A unique partnership between Dignitas International, a medical and research non-governmental organization, and the Malawi Ministry of Health, has established KTPMalawi to engage national-level policymakers, researchers and implementers in a coordinated approach to the generation and utilization of health-sector research. Utilizing a methodology developed and tested by knowledge translation platforms across Africa, a stakeholder mapping exercise and initial capacity building workshops were undertaken and a multidisciplinary Steering Committee was formed. This Steering Committee prioritized the development of two initial Communities of Practice to (1) improve data utilization in the pharmaceutical supply chain and (2) improve the screening and treatment of hypertension within HIV-infected populations. Each Community of Practice’s mandate is to gather and synthesize the best available global and local evidence and produce evidence briefs for policy that have been used as the primary input into structured deliberative dialogues. While a lack of sustained initial funding slowed its early development, KTPMalawi has greatly benefited from extensive technical support and mentorship by an existing network of global knowledge translation platforms. With the continued support of the Malawi Ministry of Health and the Evidence-Informed Policy Network, KTPMalawi can continue to build on its role in facilitating the use of evidence in the development and refinement of health policy in Malawi.

Objective:We conducted a needs assessment to identify knowledge gaps in the management of tropical diseases by Canadian emergency physicians and identify available, related continuing medical education (CME) resources.Methods:A literature review was conducted to summarize challenges in the management of commonly encountered tropical diseases. An anonymous online survey was administered to Canadian emergency physicians using the Canadian Association of Emergency Physicians survey deployment service in July and August 2012. The survey identified self-reported gaps in knowledge and assessed knowledge using case-based vignettes. A list of CME resources was generated from a review of major academic emergency medicine journals, online cases, and conference topics from emergency medicine associations during 2010– 2011. Two independent reviewers assessed the relevance of the resources; differences were resolved by consensus.Results:From 635 citations, 47 articles were selected for full review; the majority (66%) were retrospective chart reviews, few (10.6%) had an emergency medicine focus, and fewer still were Canadian (8.5%). In total, 1,128 surveys were distributed, and 296 (27%) participants were included in the study. Most respondents reported ‘‘no’’ (52.4%) or ‘‘some’’ (45.9%) training in tropical medicine. Most (69.9%) rated their comfort in managing patients with tropical diseases as ‘‘low.’’ Few (11.1%) respondents reported a tropical disease being misdiagnosed or mismanaged; 44.1% indicated malaria. The perceived need for further training was high (76.7%). Conference workshops were the most highly requested CME modality, followed by case studies and podcasts. Correct answers to case vignettes ranged from 30.7 to 58.4%. Although 2,038 CME titles were extracted from extensive searches, only 6 were deemed relevant.Conclusions:Most Canadian emergency physicians have had minimal training in tropical diseases, reported a low comfort level in their management, and identified a high need for CME opportunities, which are lacking.

Background: As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to assume a growing role in strengthening health systems. A growing list of tasks, some of them complex, is being shifted to community health workers’ job descriptions. Health Surveillance Assistants (HSAs) - as the community health worker cadre in Malawi is known - play a vital role in providing essential health services and connecting the community with the formal health care sector. The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs’ perspectives on their roles and responsibilities. Methods: A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre’s role and to triangulate collected data. Results: HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs. Conclusion: This study provides insights into HSAs’ perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre’s effectiveness in addressing the country’s health priorities.

Background The objective of this review is to identify and critically evaluate the published literature on emergency medicine (EM) training programs in resource-limited health-care settings in order to provide insight for developing EM training programs in such health systems. Methods A literature search was conducted up to the end of April 2011 using MEDLINE, EMBASE, The Cochrane Library, EBM Reviews, Healthstar and Web of Science databases, using the following search terms: Emergency Medicine, Emergency Medicine Services, Education Training Residency Programs, Emergency Medical Systems and Medical Education, without limitation to income countries as outlined in the World Bank World Trade Indicators classification 2009-2010 (World Trade Indicators Country Classification by Region and Income, July 2009-July 2010). As the intent of the review was to identify and critically evaluate the literature readily available (published) to LMICs developing EM programs, the gray literature was not searched. Results The search yielded 16 articles that met the final inclusion criteria. As the majority of articles provide a narrative description of the processes and building blocks used in developing the residency programs reported, we present our results in narrative format. By providing a summary of the lessons learned to date, we hope to provide a useful starting point for other resource-limited settings interested in establishing emergency medicine specialty training programs and hope to encourage further information exchange on this matter. Conclusions The results of the review indicate that EM training is in its infancy in resource-constrained health-care systems. There are few detailed reports of these programs successes and limitations, including efforts to optimize graduate retention. Despite the paucity of currently published data on the development of EM residency training programs in these settings, this review demonstrates the need for encouraging further information exchange to aid in such efforts, and the authors make specific recommendations to help guide future authors on reporting on such efforts.

Despite recent advances in our understanding of paediatric pain and its management, pain continues to be undertreated globally, particularly in children and in low income countries. This article describes the development of a paediatric analgesia and sedation protocol, tailored to the specific setting of the Medical Research Council (MRC) paediatric ward in the Gambia, West Africa. An iterative process was used throughout development, with inputs from the medical literature, local providers, and pain experts, incorporated to ensure a safe, effective, and locally appropriate protocol. We demonstrate that evidence-based published guidelines, can and should be adapted to allow for optimal pain management given the resources and capabilities of specific health care settings. It is hoped that the process and protocol described here, will not only help to improve care on the MRC ward, but serve as an example to others working toward improving pain management in similar health care settings.

Lay health workers (LHWs) play a pivotal role in addressing the high TB burden in Malawi. LHWs report lack of training to be a key barrier to their role as TB care providers. Given the cost of traditional off-site training, an alternative approach is needed. Our objective was to evaluate the effectiveness of a KT intervention tailored to LHWs needs. The study design is a pragmatic cluster randomized trial. The study was embedded within a larger trial, PALMPLUS, and compared three arms which included 28 health centers in Zomba district, Malawi. The control arm included 14 health centers randomized as controls in the larger trial and maintained as control sites. Seven of 14 PALMPLUS intervention sites were randomized to the LHW intervention (PALM/LHW intervention arm), and the remaining 7 PALMPLUS sites maintained as a PALM only arm. PALMPLUS intervention sites received an educational outreach program targeting mid-level health workers. LHW intervention sites received both the PALMPLUS intervention and the LHW intervention employing on-site peer-led educational outreach and a point-of-care tool tailored to LHWs identified needs. Control sites received no intervention. The main outcome measure is the proportion of treatment successes. Among the 28 sites, there were 178 incident TB cases with 46/80 (0.58) successes in the control group, 44/68 (0.65) successes in the PALMPLUS group, and 21/30 (0.70) successes in the PALM/LHW intervention group. There was no significant effect of the intervention on treatment success in the univariate analysis adjusted for cluster randomization (p = 0.578) or multivariate analysis controlling for covariates with significant model effects (p = 0.760). The overall test of the intervention-arm by TB-type interaction approached but did not achieve significance (p = 0.056), with the interaction significant only in the control arm [RR of treatment success for pulmonary TB relative to non-pulmonary TB, 1.18, 95% CI 1.05–1.31]. We found no significant treatment effect of our intervention. Given the identified trend for effectiveness and urgent need for low-cost approaches to LHW training, further evaluation of tailored KT strategies as a means of LHW training in Malawi and other LMICs is warranted. ClinicalTrials.gov NCT01356095 .

Background Like many sub-Saharan African countries, Malawi is facing a critical shortage of skilled healthcare workers. In response to this crisis, a formal cadre of lay health workers (LHW) has been established and now carries out several basic health care services, including outpatient TB care and adherence support. While ongoing training and supervision are recognized as essential to the effectiveness of LHW programs, information is lacking as to how these needs are best addressed. The objective of this qualitative study was to explore LHWs responses to a tailored knowledge translation intervention they received, designed to address a previously identified training and knowledge gap. Methods Forty-five interviews were conducted with 36 healthcare workers. Fourteen to sixteen interviews were done at each of 3 evenly spaced time blocks over a one year period, with 6 individuals interviewed more than once to assess for change both within and across individuals overtime. Results Reported benefits of the intervention included: increased TB, HIV, and job-specific knowledge; improved clinical skills; and increased confidence and satisfaction with their work. Suggestions for improvement were less consistent across participants, but included: increasing the duration of the training, changing to an off-site venue, providing stipends or refreshments as incentives, and adding HIV and drug dosing content. Conclusions Despite the significant departure of the study intervention from the traditional approach to training employed in Malawi, the intervention was well received and highly valued by LHW participants. Given the relative low-cost and flexibility of the methods employed, this appears a promising approach to addressing the training needs of LHW programs, particularly in Low- and Middle-income countries where resources are most constrained. Electronic supplementary material The online version of this article (doi:10.1186/s12909-016-0580-x) contains supplementary material, which is available to authorized users.