Acceptability of Phone-Based Communication Intervention by Healthcare Workers as an Adjunct to Routine Referral Form: A Qualitative Study in South Western Uganda

Introduction: A functional maternal referral system should encompass a feasible communication system between health facilities. In Uganda, the current paper-based patient referral form is associated with inadequate patient-information and low feedback rates. A recent quasi-experimental study demonstrated that a phone-based communication intervention is feasible for iterative communication between health facilities, and there were improved maternal-fetal outcomes and high rates of feedback. However, the acceptability of the intervention was not assessed. Objective: The study assessed the acceptability of a phone-based communication intervention by the health care workers (HCWs) for iterative communication between the referring and receiving health facilities. Methods: This was a qualitative study conducted in South Western Uganda, in April 2021. The study employed a theoretical framework of acceptability of medical interventions. We conducted in-depth interviews with HCWs and used deductive-inductive analysis. Results: We enrolled a total of 23 HCWs, of whom 69.6% (n = 16) were females while 30.4% (n = 7) were males. Majority (65.2%, n = 15), were midwives and the rest were: doctors (30.4%, n = 7) and a nurse (4.3%). The HCWs were positive towards the intervention: they believed that the intervention reduced delays, promoted professional escort, encouraged sharing of supplies, enabled exchange of relatively more patient details, feedback and improved case management. They believed it was culturally acceptable and had enough skills and experience of operating phones. All participants recommended scale out of the intervention, but advised on the need for dedicated human-resource to coordinate phone calls, ensure availability of airtime and charged battery. Conclusion: This study demonstrates that the phone-based communication intervention was highly accepted by the healthcare workers, and that hospitals can successfully give feedback to lower health centres through iterative phone calls. This provides a possible solution to the long-standing challenge of poor feedback rates and a vicious cycle of poor maternal-fetal outcomes in resource limited settings.

Minor Gynecologic Surgery: A Review of the Training Experience and Skill Building Opportunities for Providers in Low and Middle Income Countries

Purpose: Minor gynecologic surgery is the cornerstone of gynecologic evaluation and intervention in countries with a well-established medical infrastructure. Surgical training and exposure to minor procedures are not available in low and middle-income countries due to the complex challenges of patient delay and lack of access to healthcare, physician shortages, and the lack of ancillary services such as pathology and radiology. This paper reviews current training statistics, the international literature on minor gynecologic surgery and training strategies. Methods: PubMed searches using MESH terms cone biopsy, dilation and curettage, and loop electrosurgical excision procedure were performed. Statistics of minor surgical procedures among US Obstetrics and Gynecology Residency programs were tabulated. We then searched for data of training programs and surgical statistics in low resource countries. Results:Dilation and curettage is the most common minor gynecologic procedure in the United States but is performed with significantly lower frequency in low and middle-income countries. The most common procedure for the treatment of preinvasive disease was cryotherapy followed by loop electrosurgical excision procedure. There was no information about minor surgical procedures performed in hospitals in low and middle-income countries. Statistics from four-year American training programs showed an average of 209 minor cervical procedures performed annually. Conclusion: Expertise in minor gynecologic procedures is vital and requires the development of both adequate training programs and local medical infrastructure. Strategies for training in minor surgery for providers in low and middle-income countries include online curriculums, mentored relationships with senior physicians, and simulation models.

Teaching by Teleconference: A Model for Distance Medical Education across Two Continents

Introduction: In Uganda, an estimated 120 obstetrician/gynecologists serve a population of 30 million people demonstrating the need to train additional skilled clinician leaders in reproductive health. In 2012, a partnership was formed with the Mbarara Regional Referral Hospital (MRRH) in southwest Uganda and the Massachusetts General Hospital (MGH) in Boston, USA, in part to increase access to specialist training. This report presents an update in the development of a teaching conference between the institutions. Methods: In June 2012, a didactic teleconference between the institutions was instituted. Various conferencing tools were tried: direct telephone connection, VentriloTM conferencing system and SkypeTM via personal computer or smart phone. In Mbarara, Internet was accessed via cellular data. In Boston, Internet was accessed via hospital network or cellular data. All lectures were HIPAA compliant. PowerPoint lectures were stored in a collective DropboxTM that could be accessed and downloaded prior to lecture dates. Results: Over 30 months, 30 lectures were given. Lecturers included faculty and fellows from maternal fetal medicine, gynecology oncology, urogynecology, family planning, psychiatry and obstetric anesthesia. A patient case pertinent to the teaching topic framed the discussion. About 20 participants attended each lecture. Internet connectivity was the biggest challenge. Ultimately audio Skype via cellular data proved the most successful modality and became the method of choice. Conclusion: A successful collaboration in medical education via teleconference is sustainable, low cost, and beneficial to both resource-rich and resource-poor institutions. Expertise can be shared bilaterally and internationally by individuals potentially unable travel.