Search

The COVID-19 pandemic plunged hospital systems into resource-deprived conditions unprecedented since the 1918 flu pandemic. It brought forward concerns around ethical management of scarcity, racism and distributive justice, cross-disciplinary collaboration, provider wellness, and other difficult themes. We, a group of medical educators and global health educators and clinicians, use the education literature to argue that experience gained through global health activities has greatly contributed to the effectiveness of the COVID-19 pandemic response in North American institutions. Support for global health educational activities is a valuable component of medical training, as they build skills and perspectives that are critical to responding to a pandemic or other health system cataclysm. We frame our argument as consideration of three questions that required rapid, effective responses in our home institutions during the pandemic: How can our health system function with new limitations on essential resources? How do we work at high intensity and volume, on a new disease, within new and evolving systems, while still providing high-quality, patient-centered care? And, how do we help personnel manage an unprecedented level of morbidity and mortality, disproportionately affecting the poor and marginalized, including moral difficulties of perceived care rationing?

ObjectiveTo explore how respondents with common chronic conditions—hypertension (HTN) and diabetes mellitus (DM)—make healthcare-seeking decisions.SettingThree health facilities in Nakaseke District, Uganda.DesignDiscrete choice experiment (DCE).Participants496 adults with HTN and/or DM.Main outcome measuresWillingness to pay for changes in DCE attributes: getting to the facility, interactions with healthcare providers, availability of medicines for condition, patient peer-support groups; and education at the facility.ResultsRespondents were willing to pay more to attend facilities that offer peer-support groups, friendly healthcare providers with low staff turnover and greater availabilities of medicines. Specifically, we found the average respondent was willing to pay an additional 77 121 Ugandan shillings (UGX) for facilities with peer-support groups over facilities with none; and 49 282 UGX for 1 month of medicine over none, all other things being equal. However, respondents would have to compensated to accept facilities that were further away or offered health education. Specifically, the average respondent would have to be paid 3929 UGX to be willing to accept each additional kilometre they would have to travel to the facilities, all other things being equal. Similarly, the average respondent would have to be paid 60 402 UGX to accept facilities with some health education, all other things being equal.ConclusionsOur findings revealed significant preferences for health facilities based on the availability of medicines, costs of treatment and interactions with healthcare providers. Understanding patient preferences can inform intervention design to optimise healthcare service delivery for patients with HTN and DM in rural Uganda and other low-resource settings.

Purpose Stakeholders have expressed concerns regarding the impact of visiting trainees and physicians from high-income countries (HICs) providing education and/or short-term clinical care in low- and middle-income countries (LMICs). This systematic review aimed to summarize LMIC host perceptions of visiting trainees and physicians from HICs during short-term experiences in global health (STEGH). Method In September 2018 then again in August 2020, the authors searched 7 databases (PubMed, Embase, Scopus, Web of Science, ERIC, Cochrane Library, Global Index Medicus) for peer-reviewed studies that described LMIC host perceptions of STEGH. They extracted information pertaining to study design, participant demographics, participant perceptions, representation of LMICs and HICs, and HIC visitors' roles and used thematic synthesis to code the text, develop descriptive themes, and generate analytical themes. Results Of the 4,020 studies identified, 17 met the inclusion criteria. In total, the studies included 448 participants, of which 395 (88%) represented LMICs. The authors identified and organized 42 codes under 8 descriptive themes. They further organized these descriptive themes into 4 analytical themes related to STEGH: (1) sociocultural and contextual differences, (2) institutional and programmatic components, (3) impact on host institutions and individuals, and (4) visitor characteristics and conduct. Conclusions STEGH can have both beneficial and detrimental effects on LMIC host institutions and individuals. The authors translated these findings into a set of evidence-based best practices for STEGH that provide specific guidance for LMIC and HIC stakeholders. Moving forward, LMIC and HIC institutions must work together to focus on the quality of their relationships and create conditions in which all stakeholders feel empowered to openly communicate to ensure equity and mutual benefit for all parties.

The COVID-19 pandemic has highlighted both that frontline workers face a new set of personal hazards in health care settings and that there are not well-established recommendations to address the broader risks to these workers and their families. Particularly vulnerable households include dual health care professional households, single-parent health care professional households, and households with health care professionals responsible for a high-risk family member (i.e., an older adult or immunocompromised person). While the demographics of these households are heterogeneous, it is expected that the professional and personal concerns specific to COVID-19 will be similar. These concerns include family safety, balancing full-time work with home-based schooling for children, the looming threat of illness to one or both partners, the potential of infecting high-risk family members, and the challenges of planning for the future during uncertain times. To elucidate these concerns in their department, the authors sought input from colleagues in dual health care professional households through an open-ended email communication. Respondents expressed a range of concerns centered on balancing professional and family responsibilities during the COVID-19 pandemic. In this commentary, the authors propose several recommendations in the areas of support networks, leadership and culture, and operations and logistics that health care institutions can adopt to minimize the burden on these vulnerable households during states of emergency. The successful implementation of these recommendations hinges on creating a work environment in which all health care providers feel comfortable voicing their concerns.

Professionalism standards encourage physicians to participate in public advocacy on behalf of societal health and well-being. While the number of publications of advocacy curricula for GME-level trainees has increased, there has been no formal effort to catalog them. To systematically review the existing literature on curricula for teaching advocacy to GME-level trainees and synthesize the results to provide a resource for programs interested in developing advocacy curricula. A systematic literature review was conducted to identify articles published in English that describe advocacy curricula for graduate medical education trainees in the USA and Canada current to September 2017. Two reviewers independently screened titles, abstracts, and full texts to identify articles meeting our inclusion and exclusion criteria, with disagreements resolved by a third reviewer. We abstracted information and themes on curriculum development, implementation, and sustainability. Learning objectives, educational content, teaching methods, and evaluations for each curriculum were also extracted. After reviewing 884 articles, we identified 38 articles meeting our inclusion and exclusion criteria. Curricula were offered across a variety of specialties, with 84% offered in primary care specialties. There was considerable heterogeneity in the educational content of included advocacy curriculum, ranging from community partnership to legislative advocacy. Common facilitators of curriculum implementation included the American Council for Graduate Medical Education requirements, institutional support, and preexisting faculty experience. Common barriers were competing curricular demands, time constraints, and turnover in volunteer faculty and community partners. Formal evaluation revealed that advocacy curricula were acceptable to trainees and improved knowledge, attitudes, and reported self-efficacy around advocacy. Our systematic review of the medical education literature identified several advocacy curricula for graduate medical education trainees. These curricula provide templates for integrating advocacy education into GME-level training programs across specialties, but more work needs to be done to define standards and expectations around GME training for this professional activity.

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.

Global health and its predecessors, tropical medicine and international health, have historically been driven by the agendas of institutions in high-income countries (HICs), with power dynamics that have disadvantaged partner institutions in low- and middle-income countries (LMICs). Since the 2000s, however, the academic global health community has been moving toward a focus on health equity and reexamining the dynamics of global health education (GHE) partnerships. Whereas GHE partnerships have largely focused on providing opportunities for learners from HIC institutions, LMIC institutions are now seeking more equitable experiences for their trainees. Additionally, lessons from the COVID-19 pandemic underscore already important lessons about the value of bidirectional educational exchange, as regions gain new insights from one another regarding strategies to impact health outcomes. Interruptions in experiential GHE programs due to COVID-19-related travel restrictions provide an opportunity to reflect on existing GHE systems, to consider the opportunities and dynamics of these partnerships, and to redesign these systems for the equitable benefit of the various partners. In this commentary, the authors offer recommendations for beginning this process of change, with an emphasis on restructuring GHE relationships and addressing supremacist attitudes at both the systemic and individual levels.

Background Non-communicable diseases (NCDs) are an increasing global concern, with morbidity and mortality largely occurring in low- and middle-income settings. We established the prospective Rural Uganda Non-Communicable Disease (RUNCD) cohort to longitudinally characterize the NCD prevalence, progression, and complications in rural Africa. Methods We conducted a population-based census for NCD research. We systematically enrolled adults in each household among three sub-counties of the larger Nakaseke Health district and collected baseline demographic, health status, and self-reported chronic disease information. We present our data on self-reported chronic disease, as stratified by age, sex, educational attainment, and sub-county. Results A total of 16,694 adults were surveyed with 10,563 (63%) respondents enrolled in the self-reported study. Average age was 37.8 years (SD = 16.5) and 45% (7481) were male. Among self-reported diseases, hypertension (HTN) was most prevalent (6.3%). 1.1% of participants reported a diagnosis of diabetes, 1.1% asthma, 0.7% COPD, and 0.4% kidney disease. 2.4% of the population described more than one NCD. Self-reported HTN was significantly higher in the peri-urban subcounty than in the other two rural sub-counties (p Conclusions The RUNCD will establish one of the largest NCD patient cohorts in rural Africa. First analysis highlights the feasibility of systematically enrolling large numbers of adults living in a rural Ugandan district. In addition, our study demonstrates low levels of self-reported NCDs compared to the nation-wide established levels, emphasizing the need to better educate, characterize, and care for the majority of rural communities.

A discrete choice experiment (DCE) is a method to quantify preferences for goods and services in a population. Participants are asked to choose between sets of 2 hypothetical scenarios that differ in terms of particular characteristics. Their selections reveal the relative importance of each “attribute”, or characteristic, and the extent to which people consider trade-offs between characteristics. DCEs are increasingly used in healthcare and public health settings as they can inform the design of health-related interventions to achieve maximum impact. Specific efforts must be made in the development process to ensure relevance of DCEs to the communities in which they are administered. Herein, we build upon gaps in the prior literature by offering researchers a step-by-step process to guide DCE development for resource-limited settings, including detailed methodological considerations for each step and a specific actionable approach that we hope will simplify the process for other researchers. We present the 6 steps we followed to develop a DCE to evaluate patient preferences for management of hypertension and diabetes in rural Uganda. These steps are: 1) formative work; 2) attribute selection; 3) attribute level selection; 4) DCE design selection; 5) determination of attribute level combinations; and 6) assessment and enhancement of tool comprehensibility. We describe each of these steps in detail to ease the development process for researchers looking to develop locally contextualized, end-user-centric health interventions.

BackgroundThe growing burden of non-communicable diseases (NCDs) threatens low-income countries. Self-care practices are crucial for successful management of NCDs to prevent complications. We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda.MethodsBetween April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted 19 in-depth interviews exploring treatment practices and response to symptoms. We used content analysis to identify emergent themes.ResultsThree themes emerged in patients’ descriptions of their self-care practices. First, patients preferred conventional medicines as their first line of resort, but often used traditional medicines. In particular, patients used traditional medicines to mitigate the negative impacts of inconsistent access to conventional medicines and to supplement those medicines. Second, patients adopted a wide range of vernacular practices to supplement treatments and unavailable diagnostic tests, including tasting their urine to gauge blood-sugar level. Finally, patients sought social support for self-care activities, relying on networks of family members and peers for instrumental and emotional support. Patients saw their children as the most reliable source of support, especially money for medicines, transport and home necessities.InterpretationPatients valued conventional medicines but also engaged in varied self-care practices. They depended upon networks of social support from family and peers to maintain self-care. Interventions to improve self-care may be more effective if they improve access to medicines and engage or enhance patients’ social support networks.

Quality problem Although widely utilized in resource-rich health care systems, the use of quality improvement (QI) techniques is less common in resource-limited environments. Uganda is a resource-limited country in Sub-Saharan Africa that faces many challenges with health care delivery. These challenges include understaffing, inconsistent drug availability and inefficient systems that limit the provision of clinical care. Initial assessment Poor adherence to prescribed inpatient medications was identified as a key shortcoming of clinical care on the internal medicine wards of Mulago National Referral Hospital, Kampala, Uganda. Baseline data collection revealed a pre-intervention median inpatient medication adherence rate of 46.5% on the study ward. Deficiencies were also identified in attendant (lay caretaker) education, and prescriber and pharmacy metrics. Choice of solution A QI team led by a resident doctor and consisting of a QI nurse, a pharmacist and a ward nurse supervisor used standard QI techniques to address this issue. Implementation Plan-Do-Study-Act cycle interventions focused on attendant involvement and education, physician prescription practices and improving pharmacy communication with clinicians and attendants. Evaluation Significant improvements were seen with an increase in overall medication adherence from a pre-intervention baseline median of 46.5% to a post-intervention median of 92%. Attendant education proved to be the most effective intervention, though resource and staffing limitations made institutionalization of these changes difficult. Lessons learned QI methods may be the way forward for optimizing health care delivery in resource-limited settings like Uganda. Institutionalization of these methods remains a challenge due to shortage of staff and other resource limitations.

Health care workforce development is a key pillar of global health systems strengthening that requires investment in health care worker training institutions. This can be achieved by developing partnerships between training institutions in resource-limited and resource-rich areas and leveraging the unique expertise and opportunities both have to offer. To realize their full potential, however, these relationships must be equitable. In this article, we use a previously described global health ethics framework and our ten-year experience with the Makerere University-Yale University (MUYU) Collaboration to provide an example of an equity-focused global health education partnership.

Background In 2020, non-communicable diseases (NCDs) currently account for 40% of deaths in east Africa and are expected to surpass communicable diseases as the leading causes of death in sub-Saharan Africa by 2030. However, there remain many gaps in the provision of high quality, patient-centred NCD service delivery in low-income countries such as Uganda, especially in rural settings. We developed a discrete choice experiment (DCE) to understand how patients with common NCDs, such as hypertension and diabetes, make health-care-seeking decisions. A DCE is a quantitative tool that measures the weight of different factors that affect a decision. Participants are presented with two hypothetical scenarios to choose between. Here we report on the formative, qualitative phase of DCE development. Methods For this DCE, choice sets consist of two health facilities described in terms of various attributes (factors) that affect decision-making. To develop a locally relevant DCE, we conducted formative qualitative research consisting of 18 in-depth interviews with patients seeking care for hypertension or diabetes, or both, at three health facilities in rural Nakaseke District, Uganda. We purposively selected participants so that each disease and facility were represented. Interviews explored how participants choose which facility to visit and challenges that she or he faces in accessing care or medicines, or both. A team of three researchers coded the interviews using a directed approach to reveal 11 potential attributes on which patients make decisions. After review of the data and analysis with local and international content experts, we narrowed this list to six attributes to be included in the DCE. Findings The six selected attributes included: provision of education; availability of medicines; transport to the facility; costs associated with treatment; interactions with health-care providers; and presence of peer support groups. Attribute levels encompassed the range of experiences for each attribute as emerged from qualitative analysis. We then developed a full profile, fractional factorial DCE with three surveys. Interpretation The process of developing this NCD-focused DCE relied on reference to the literature, primary qualitative data collection, and expert consensus to create a tool that would yield actionable data to improve NCD health service delivery in rural Uganda. Little is known about how rural patients in low-income and middle-income countries navigate the health-care system, nor is there much description of how to develop DCEs to investigate patient preferences in these countries. This work will guide public health officials in developing NCD service delivery options and inform investigators on DCE development. Funding Yale Institute of Global Health Hecht Global Health Faculty Network Award Downs International Health Student Travel Fellowship

Background The prevalence of non-communicable diseases (NCDs) is increasing in rural sub-Saharan Africa. Implementation and adaptation of recommended self-care practices is crucial for successful management of NCDs to prevent complications. However, little is known about self-care practices in patients living in rural sub-Saharan Africa. In this study, we aimed to understand patients' adherence to self-care practices for hypertension, diabetes, or both, in rural Uganda and their reasons for non-adherence. Methods We conducted a mixed-methods study in adult patients previously diagnosed with diabetes or hypertension, or both, who attended outpatient NCD clinics at three health facilities in Nakaseke district. We concurrently collected quantitative data from a random sample of patients using pretested, structured questionnaires and held focus group discussions and in-depth interviews with a purposive sample of patients. Descriptive statistics were calculated for the quantitative data. Qualitative analysis was conducted using a thematic approach. Findings Between April and August, 2019, we administered questionnaires and carried out six focus group discussions and 19 in-depth interviews with 385 participants. Mean age was 54·0 years (SD 14·57) and most respondents, 257 (66·8%), were female. Of the 385 participants, 39·2% (151) had diabetes; 36·9% (142) had hypertension, and 23·9% (92) had both conditions. Most respondents reported daily adherence to medication for hypertension (79·5% [186/234]) and diabetes (84·8% [206/243]). Few participants (15·6% [60/385]) reported daily vigorous physical activity, but 63·1% (243/385) reported moderate physical activity at least once per week. Most respondents reported adherence to recommendations for dietary changes (75·6% [291/385]), non-smoking (98·7% [380/385]), alcohol abstinence (90·1% [347/385]), and weight management (75·6% [291/385]). From the interviews and discussions, patients reported that they tried to adhere to recommended medications but were limited by the inability to obtain them. Most patients reported irregular self-monitoring and many reported confusion about recommended practices due to mixed messages, mainly from their peers. Respondents also reported use of herbal remedies, soaking swollen feet in salt water, and coping with stress through prolonged sleep, social isolation, and alcohol use. Interpretation Varied self-care practices exist among rural Ugandan NCD patients. Patients inconsistently engage in recommended practices because of uncertain access to medicines, structural barriers, and inconsistent messaging. Locally adapted educational self-care programmes and consistent access to medicines could help improve self-care in these patients. As low-income countries like Uganda continue to advance their NCD policies, specific attention should be focused on strategies to ensure equitable access to essential NCD medicines. Additionally, the unique circumstances of people living in rural settings should be taken into account when developing programmes for management of NCDs. Funding Yale Institute of Global Health Hecht Global Health Faculty Network Award

BackgroundSub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda.Methods and resultsThe medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of pConclusionAdmissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.

Insulin is an essential medicine for people with diabetes (DM), but increasing prices have threatened its affordability. We examined the prevalence of and factors associated with cost-related insulin underuse. We administered a cross-sectional survey to patients with DM prescribed insulin at Yale Diabetes Center (YDC). Our primary outcome was cost-related underuse in the past 12 months, defined by a positive response to any 1 of 6 questions: Did you ⋯ 1) Use less insulin than prescribed 2) Try to stretch out your insulin 3) Take smaller doses of insulin than prescribed 4) Stop insulin 5) Not fill an insulin prescription 6) Not start insulin ⋯ because of cost? We examined the association of cost-related underuse with HbA1c >9% using logistic regression controlling for age, sex, age, DM duration, and income. Out of 354 patients prescribed insulin who had YDC visit in July 2017, 199 (56.2%) completed the survey (50.8% female, 60.8% white, 41.7% type 1). Of these patients, 51 (25.5%) reported cost-related insulin underuse. Patients with cost-related underuse had lower income levels, variable drug coverage and employment (Figure), and 3-fold higher odds of HbA1c >9% (p = 0.03) than patients who did not report underuse. One in four patients at our urban diabetes center reported cost-related insulin underuse, and this was associated with poor glycemic control. These results highlight an urgent need to address high insulin prices in the U.S. Disclosure D.M. Herkert: None. P. Vijayakumar: None. J. Luo: Consultant; Self; Alosa Health, Inc.. J. Schwartz: None. T.L. Rabin: None. E.M. DeFilippo: None. K.J. Lipska: Other Relationship; Self; Centers for Medicare and Medicaid Services. Research Support; Self; National Institutes of Health.

The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health.

Background : The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development. Methods : Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs. Results : In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs. Discussion : Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda. Keywords : Non-communicable diseases; Health system strengthening; Integration; Multi-sectoral collaboration (Published: 5 January 2015) Citation : Glob Health Action 2015, 8 : 26537 - http://dx.doi.org/10.3402/gha.v8.26537

PURPOSE This study describes the impact of an open-access, case-based global health ethics workshop and describes the breadth of dilemmas faced by students to inform future interventions. METHODS Eighty-two medical students who undertook electives at 16 international sites between 2012 and 2015 received web-based surveys at three time points, incorporating quantitative and free-text probes of knowledge, skills, and attitudes related to global health clinical ethics dilemmas. Sixty students (73%) completed the pre-workshop survey, 38 (46%) completed the post-workshop survey, and 43 (52%) completed the post-trip survey. RESULTS Analysis demonstrated improvement following the workshop in self-rated preparedness to manage ethical dilemmas abroad, identify ways to prepare for dilemmas, engage support persons, and manage related emotions (all comparisons, p

Students planning to travel abroad to study or participate in health-related activities are in distinct need of high quality pre-departure training. Health and medical systems vary tremendously throughout the world and, many of the students, both pre-health and health professions students, will be working in a clinical environment and may be actively engaging in healthcare delivery. The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) and the Forum on Education Abroad have both identified content areas that should be included in pre-departure training. Undergraduate students, health profession students, postgraduate trainees and even practising health professionals all require pre-departure training. The primary driver in any pre-departure training is to provide the students the information they need to be safe and behave professionally and appropriately while also ensuring the safety and welfare of the host community, including patients. The pre-departure tools highlighted in this chapter all share the goals.

To meet the demand by residents and to provide knowledge and skills important to the developing physician, global health (GH) training opportunities are increasingly being developed by United States (U.S.) residency training programs. However, many residency programs face common challenges of developing GH curricula, offering safe and mentored international rotations, and creating GH experiences that are of service to resource-limiting settings. Academic GH partnerships allow for the opportunity to collaborate on education and research and improve health care and health systems, but must ensure mutual benefit to U.S. and international partners. This article provides guidance for incorporating GH education into U.S. residency programs in an ethically sound and sustainable manner, and gives examples and solutions for common challenges encountered when developing GH education programs.

This survey study examines the association of higher insulin costs with nonadherence in patients with diabetes.

Background The majority of non-communicable disease related deaths occur in low- and middle-income countries. Patient-centered care is an essential component of chronic disease management in high income settings. Objective To examine feasibility of implementation of a validated patient-centered education tool among patients with heart failure in Uganda. Design Mixed-methods, prospective cohort. Settings A private and public cardiology clinic in Mulago National Referral and Teaching Hospital, Kampala, Uganda. Participants Adults with a primary diagnosis of heart failure. Interventions PocketDoktor Educational Booklets with patient-centered health education. Main Measures The primary outcomes were the change in Patient Activation Measure (PAM-13), as well as the acceptability of the PocketDoktor intervention, and feasibility of implementing patient-centered education in outpatient clinical settings. Secondary outcomes included the change in satisfaction with overall clinical care and doctor-patient communication. Key Results A total of 105 participants were enrolled at two different clinics: the Mulago Outpatient Department (public) and the Uganda Heart Institute (private). 93 participants completed follow up at 3 months and were included in analysis. The primary analysis showed improved patient activation measure scores regarding disease-specific knowledge, treatment options and prevention of exacerbations among both groups (mean change 0.94 [SD = 1.01], 1.02 [SD = 1.15], and 0.92 [SD = 0.89] among private paying patients and 1.98 [SD = 0.98], 1.93 [SD = 1.02], and 1.45 [SD = 1.02] among public paying patients, p

In recent years, increasing numbers of United States—based health professions students have traveled to low-resource settings for short-term clinical electives. The content of predeparture training can be highly variable, leaving students unprepared for the ethical challenges posed by these experiences. This is magnified by the lack of attention paid to the burdens and benefits for local staff, institutions, and patient well-being in the setting of disproportionate poverty and disease. Adequate predeparture training is necessary to help trainees recognize and navigate these ethical issues, avoid harm both to themselves and to others, and promote equitable global health partnerships. The case studies presented here, all of which are based on real student experiences, form the basis of this tool for predeparture training of health professions students preparing for international electives. The curriculum is designed to be implemented in a 90-minute session, in groups of up to 25 students. Student leaders, ideally a group of students who have had experience doing clinical rotations abroad, may serve as facilitators with faculty guidance. This module also includes evaluation tools to encourage continued curricular improvements. Analysis of the preworkshop, postworkshop, and posttrip questionnaires indicates that the students who engaged in these predeparture workshops demonstrated improved awareness of the range of ethical dilemmas that they might encounter while engaged in clinical work abroad, as well as increasing their self-rated ability to identify and negotiate these situations. Importantly, those students who participated in this workshop prior to travel felt more prepared to manage the ethical dilemmas that they encountered during their clinical rotations compared to those who did not participate.

development of a differential diagnosis, and integration of epidemiologic and clinical data in estimating the disease probabilities that guide cost-effective, empiric therapy. Laboratory reports are few, restricted to those available in resource-poor settings in the developing world. Outcomes & Evaluation: The cases have been the clinical focus of a global health course taught at Montefiore/Einstein in the Bronx for the past 8 years: 50 cases, edited for the classroom, are dissected during 15 interactive workshops by 20 senior Medicine residents divided into 4 discussion teams. Evaluations (with 100% response rates) reflect their success in this setting: 5.7 mean, 6.0 median on a scale with 61⁄4outstanding. Voluntary (and therefore very selected) feedback about Cases posted on the CUGH website has been very positive. Going Forward: The cases may too closely reflect the clinical reality of district hospitals in rural Africa where “gold standards” are rare and diagnoses often uncertain. (Hopefully such presumed diagnoses do not detract from the pedagogical value of the discussions.) Funding: None. Abstract #: CUGH005

Providing quality health care for refugees requires cross-cultural competence and unique medical knowledge.1,2 While the Society of General Internal Medicine called for the development of longitudinal training for residents in refugee care in 2004,3 most residents do not feel prepared to care for new immigrants.4 We describe the experience of the Yale Combined Internal Medicine-Pediatrics Residency Program in providing integrated care for a population of Burmese refugees. This model presented numerous challenges but we believe it represents a viable, rewarding alternative to one in which refugees are cared for in a distinct clinic. In 2007, our patient-centered medical home practice serving a multiethnic, largely poor and underserved community began caring for 66 newly resettled Burmese refugees, most of whom were members of the Karen ethnic minority. We developed 3 distinct interventions that helped us provide quality care to this group. We first organized an introductory community meeting that brought together faculty, residents, and office staff with representatives of the community. We held home visits during which we led health education discussions, reviewed common health concerns, and held pediatric acute care and catch-up immunization clinics. Connecticut, like many states, lacked comprehensive guidelines for refugee health care. Since our Karen patients were randomly distributed between physicians, we devised a standardized instrument to provide guidance during the initial visit. It prompted the clinician to gather information relevant to refugees and provide recommendations regarding infectious disease screening. The provision of efficient, quality care was limited by a vast cultural divide and by unreliable telephone interpretation. Taking medical histories, eliciting symptoms, and comprehending and following through on management plans were challenging. The extended time taken by visits with our Burmese patients affected patient flow and clinic efficiency. An integrated care model offers several advantages. Serving as a medical home to this population created a sense of trust between patients and providers. We focused on refugee-specific matters and general health issues concurrently and could effectively coordinate care with the resettlement agency and community. However, this model of care also presented distinct challenges. Varying degrees of cultural competence meant different levels of comfort in caring for this population. Our screening protocol was developed in parallel with home visits and ongoing primary care, limiting its effective, widespread implementation. We were faced with the question of when and how to shift the focus from fulfilling the needs of the newly arrived refugee to those of the primary care patient. Finally, though this vulnerable population merited special attention, we struggled with how to balance their needs with those of our other patients. With tens of thousands of refugees being resettled annually in the United States,5 exposure to their medical care needs is a vital component of residency training and one that fosters cultural competency. Our interventions provided structure and built trust as we cared for this population. Though rife with challenges, we believe a residency clinic can provide effective, comprehensive care to refugees.

In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners' knowledge of appropriate care and the actual care delivered (the know-do gap).To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India.We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs).For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners' characteristics. We also examined correct treatment recommended by practitioners with both methods.Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia.Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.

Objectives : To test the range of beliefs regarding the ethics of testing, in resource poor settings, new therapies that are less efficacious but more affordable and feasible than the best current therapeutic standard. Design : Using a web-based survey, we presented a hypothetical scenario proposing to test a therapy for HIV disease ("therapeutic inoculation") known to be less efficacious than highly active antiretroviral therapy (HAART). Respondents evaluated various trial designs as ethical or unethical. Participants : 604 subscribers to two listservs for individuals interested in international health research ethics. Main outcome measures : Proportion of respondents endorsing trials testing this "substandard" therapy, and proportion endorsing placebo-controlled trials. Results : There were 215 respondents from 47 countries. Forty-five percent of respondents were from low or middle income countries; 96% devoted at least some time to research activities; and 75% had "some" or "considerable" research expe...

What problems were addressed? The growing desire among medical trainees for structured exposure to global health issues has increased the demand for short-term field experiences in health care centres abroad. Establishing collaborations to provide these opportunities involves maintaining a balance between sponsoring and host institution interests. Trainees encounter a number of challenges in the course of these experiences, including personal and medical cultural differences, and ethical concerns relating to professionalism and patient care. The job of chief resident encompasses a host of administrative, educational and clinical activities that are well suited to addressing the needs that emerge as a result of these experiences. What was tried? In the 2010–2011 academic year, the Yale Primary Care Residency Programme created two new leadership positions: global health chief residents. These chiefs split their time between Yale and the established Makerere University–Yale University (MUYU) medical education collaboration based at Mulago National Referral Hospital, in Kampala, Uganda, the country’s national referral and teaching hospital. These two individuals are committed to careers in global health and had previously spent a total of 15 months working at Mulago Hospital in various capacities; thus they were familiar with the institution, faculty staff and leadership. Although they fulfilled typical clinical and educational responsibilities when in the USA, their goals during the time they spent in Uganda included providing educational supervision to visiting and local trainees, participating in direct patient care as members of the local faculty, and providing administrative support to the Kampalaand New Haven-based staff of the collaboration. Clinically, the chief residents served as attending physicians and held both bedside and classroom teaching sessions for Ugandan trainees. Administratively, they facilitated cross-cultural communications regarding finances, procedures and educational content, assisted the local staff and visiting trainees in understanding one another’s needs, standardised the on-site orientation process, and involved staff and faculty members from both universities in completing a summary report of the first 5 years of the collaboration. Importantly, their cumulative experiences with both institutions enabled them to provide emotional support and gave them the insight they needed to assist visiting trainees in processing their clinical and personal experiences. What lessons were learned? A tense political situation, arising from the presidential election that occurred during their stay, intermittent public demonstrations and a terrorist attack in Kampala a few months prior to their arrival, reduced the number of trainees who visited Uganda as part of the MUYU collaboration during the chief residents’ tenure. The chiefs took appropriate safety precautions and followed US State Department recommendations. Instead of negatively impacting the experience, this provided a greater opportunity for involvement in Ugandan medical education and in the administrative structure of the collaboration than had been anticipated. Recently proposed guidelines for global health training experiences emphasise the responsibilities of sponsoring institutions regarding the mentorship of visiting trainees, with a view towards meeting local needs and the priorities of host institutions. We successfully modified a well-established educational role, that of the chief resident, to improve the experience of our trainees while on rotation abroad and also demonstrated a commitment between international collaborators. We believe this role is reproducible and would strongly encourage all international collaborations that involve undergraduate or postgraduate medical education to consider placing a chief resident on site.