Content of Care in 15,000 Sick Child Consultations in Nine Lower‐Income Countries

Kruk, Mary; Gage, Anna; Mbaruku, Godfrey; Leslie, Hannah H

doi:10.1111/1475-6773.12842

Cited by 20 publications

(27 citation statements)

References 27 publications

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“…Data were collected by trained observers, which could lead clinicians to behave differently (Hawthorne effect), and is subject to observer error. Other studies that removed the first observation from analysis found similar performance [36]. Hawthorne effect would bias our results upward, suggesting that actual practice may potentially be worse than observed here, thus strengthening the concern about pre-service education.…”

Section: Associate Clinicians Nurses/midwivessupporting

confidence: 60%

Clinical performance among recent graduates in nine low‐ and middle‐income countries

Lewis

Roder‐DeWan

Malata

et al. 2019

Tropical Med Int Health

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SummaryObjectivesRecent studies have identified large and systematic deficits in clinical care in low‐income countries that are likely to limit health gains. This has focused attention on effectiveness of pre‐service education. One approach to assessing this is observation of clinical performance among recent graduates providing care. However, no studies have assessed performance in a standard manner across countries. We analysed clinical performance among recently graduated providers in nine low‐ or middle‐income countries.MethodsService Provision Assessments from Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda were used. We constructed a Good Medical Practice Index that assesses completion of essential clinical actions using direct observations of care (range 0–1), calculated index scores by country and clinical cadre, and assessed the role of facility and clinical characteristics using regression analysis.ResultsOur sample consisted of 2223 clinicians with at least one observation of care. The Good Medical Practice score for the sample was 0.50 (SD = 0.20). Nurses and midwives had the highest score at 0.57 (SD = 0.20), followed by associate clinicians at 0.43 (SD = 0.18), and physicians at 0.42 (SD = 0.16). The average national performance varied from 0.63 (SD = 0.18) in Uganda to 0.39 (SD = 0.17) in Nepal, persisting after adjustment for facility and clinician characteristics.ConclusionsThese results show substantial gaps in clinical performance among recently graduated clinicians, raising concerns about models of clinical education. Competency‐based education should be considered to improve quality of care in LMICs. Observations of care offer important insight into the quality of clinical education.

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Section: Associate Clinicians Nurses/midwivessupporting

confidence: 60%

Clinical performance among recent graduates in nine low‐ and middle‐income countries

Lewis

Roder‐DeWan

Malata

et al. 2019

Tropical Med Int Health

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“…These findings are important because getting HCWs to perform focused history and physical examinations continues to be a challenge. [16][17][18][19][20][21] This is not surprising, given the large patient burden and lack of support staff in most countries, but it can contribute to misdiagnosis and poor patient management. Given the time constraints faced by the typical HCW, future work in this area should continue to focus on training HCWs to perform rapid and focused history and physical examinations designed to quickly assess for evidence of severe disease and important secondary, nonmalaria diagnoses (such as pneumonia, bacterial sepsis, or a catastrophic abdominal event).…”

Section: Discussionmentioning

confidence: 99%

Effect of Supportive Supervision on Competency of Febrile Clinical Case Management in Sub-Saharan Africa

Martin

Eliades

Wun

et al. 2019

The American Journal of Tropical Medicine and Hygiene

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Since 2010, the WHO has recommended that clinical decision-making for malaria case management be performed based on the results of a parasitological test result. Between 2015 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported the implementation of this practice in eight sub-Saharan African countries through 5,382 outreach training and supportive supervision visits to 3,563 health facilities. During these visits, trained government supervisors used a 25-point checklist to observe clinicians' performance in outpatient departments, and then provided structured mentoring and action planning. At baseline, more than 90% of facilities demonstrated a good understanding of WHO recommendations-when tests should be ordered, using test results to develop an accurate final diagnosis, severity assessment, and providing the correct prescription. However, significant deficits were found in history taking, conducting a physical examination, and communicating with patients and their caregivers. After three visits, worker performance demonstrated steady improvement-in particular, with checking for factors associated with increased morbidity and mortality: one sign of severe malaria (72.9-85.5%), pregnancy (81.1-87.4%), and anemia (77.2-86.4%). A regression analysis predicted an overall improvement in clinical performance of 6.3% (P < 0.001) by the third visit. These findings indicate that in most health facilities, there is good baseline knowledge on the processes of quality clinical management, but further training and on-site mentoring are needed to improve the clinical interaction that focuses on second-order decision-making, such as severity of illness, management of non-malarial fever, and completing the patient-provider communication loop.

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“…When there are fewer patients, pressure on health workers to perform quick consultations is less likely than in facilities with high caseloads [52]. However, some studies did not find any association between caseload and health workers' performance [52,53]. For instance, in Tanzania Maestad et al did not find an association between caseload and the level of effort providers invest per patient case (defined as all actions taken by the clinician to improve the quality of the diagnostic process).…”

Section: Discussionmentioning

confidence: 99%

“…When there are fewer patients, pressure on health workers to perform quick consultations is less likely than in facilities with high caseloads . However, some studies did not find any association between caseload and health workers’ performance . For instance, in Tanzania Mæstad et al .…”

Section: Discussionmentioning

confidence: 99%

Factors associated with effective coverage of child health services in Burkina Faso

Koulidiati

Allegri

Souares

et al. 2018

Tropical Med Int Health

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Our study found that crude coverage is associated with pre-disposing and enabling factors of health care access, while the availability of nurses is a strong predictor for both crude and effective coverage. This suggests that in the context of scarcity of resources, investing in human resources in health sector could be one of the priorities for decision-makers to ensure children in need not only access to healthcare but also good quality of care.

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Content of Care in 15,000 Sick Child Consultations in Nine Lower‐Income Countries

Abstract: Consultations for children in nine lower-income countries are brief and limited. A greater number of clinical actions was associated with caregiver knowledge and satisfaction.

Cited by 20 publications

References 27 publications

Clinical performance among recent graduates in nine low‐ and middle‐income countries

Clinical performance among recent graduates in nine low‐ and middle‐income countries

Effect of Supportive Supervision on Competency of Febrile Clinical Case Management in Sub-Saharan Africa

Factors associated with effective coverage of child health services in Burkina Faso

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