Improving paediatric epilepsy management at the first level of care: a pilot education intervention for clinical officers in Zambia

Abstract

ObjectiveEpilepsy affects approximately 50 million people globally, with approximately 80% living in low/middle-income countries (LMIC), where access to specialist care is limited. In LMIC, primary health workers provide the majority of epilepsy care, despite limited training in this field. Recognising this knowledge gap among these providers is an essential component for closing the epilepsy treatment gap in these regions.SettingIn Zambia, the vast majority of healthcare is provided by clinical officers (COs), primary health providers with 3 years post-secondary general medical education, who predominantly work in first-level health centres around the country.ParticipantsWith cooperation from the Ministry of Health, a total of 10 COs from 4 surrounding first-level health centres around the capital city of Lusaka participated, with 9 completing the entire course.InterventionCOs were trained in a 3-week structured course on paediatric seizures and epilepsy, based on adapted evidence-based guidelines.ResultsPreassessment and postassessment were conducted to assess the intervention. Following the course, there was improved overall knowledge about epilepsy (69% vs 81%, p<0.05), specifically knowledge regarding medication management and recognition of focal seizures (p<0.05), improved seizure history taking and appropriate medication titration (p<0.05). However, knowledge regarding provoked seizures, use of diagnostic studies and general aetiologies of epilepsy remained limited.ConclusionsThis pilot project demonstrated that a focused paediatric epilepsy training programme for COs can improve knowledge and confidence in management, and as such is a promising step for improving the large epilepsy treatment gap in children in Zambia. With feasibility demonstrated, future projects are needed to expand to more rural regions for more diverse and larger sample of primary health provider participants and encompass more case-based training and repetition of key concepts as well as methods to improve and assess long-term knowledge retention.

Development and Evaluation of a Pediatric Epilepsy Training Program for First Level Providers in Zambia

“…15 While this is an efficient model for general health care delivery, providing quality pediatric epilepsy management is only feasible with adequate training, which continues to be limited in the country, with this primary health workforce showing less than adequate knowledge on seizure management at baseline. 16,17 An effective way to improve knowledge in an efficient manner for task-shifting care is via use of algorithmic and module based trainings, which also can improve health seeking behaviors and awareness in communities. 5,[18][19][20] Beneficial impact in regards to recognition of epilepsy, reducing stigma, and improving health seeking behaviors and treatment adherence by people with epilepsy has been seen in both large and small programs targeting epilepsy at the community worker or primary provider level.…”

“…Additionally, the 1 day intense didactic workshop does not include the level of clinical skill building we have found required for rural community first level providers in our region based upon our prior work with clinical officers, wherein we found even multiple sessions of case-based lectures did not translate well into practical application of skills. 17 Experience from our prior educational intervention work in Zambia has highlighted the need for including strengthening knowledge at multiple provider levels, direct clinical skills training, and incorporating a evaluation mechanism to measure overall clinical practice change. 17 Overall, demonstrating consistent benefits of education programs is difficult to achieve, as is creating mechanisms for sustainability.…”

“…17 Experience from our prior educational intervention work in Zambia has highlighted the need for including strengthening knowledge at multiple provider levels, direct clinical skills training, and incorporating a evaluation mechanism to measure overall clinical practice change. 17 Overall, demonstrating consistent benefits of education programs is difficult to achieve, as is creating mechanisms for sustainability. While the presumption is that offering any training could only be beneficial, false confidence in knowledge may lead to more management error and referral delays.…”

“… 15 While this is an efficient model for general health care delivery, providing quality pediatric epilepsy management is only feasible with adequate training, which continues to be limited in the country, with this primary health workforce showing less than adequate knowledge on seizure management at baseline. 16 , 17 …”

“… 17 Experience from our prior educational intervention work in Zambia has highlighted the need for including strengthening knowledge at multiple provider levels, direct clinical skills training, and incorporating a evaluation mechanism to measure overall clinical practice change. 17 …”