Interventional study to improve diabetic guidelines adherence using mobile health (m-Health) technology in Lahore, Pakistan.

OBJECTIVE: To check if mobile health (m-Health) short message service (SMS) can improve the knowledge and practice of the American Diabetic Association preventive care guidelines (ADA guidelines) recommendations among physicians. METHODOLOGY: Quasi-experimental pre-post study design with a control group. PARTICIPANTS: The participants of the study were 62 medical officers/medical postgraduate trainees from two hospitals in Lahore, Pakistan. Pretested questionnaire was used to collect baseline information about physicians' knowledge and adherence according to the ADA guidelines. All the respondents attended 1-day workshop about the guidelines. The intervention group received regular reminders by SMS about the ADA guidelines for the next 5 months. Postintervention knowledge and practice scores of 13 variables were checked again using the same questionnaire. Statistical analysis included χ2 and McNemar's tests for categorical variables and t-test for continuous variables. Pearson's correlation analysis was done to check correlation between knowledge and practice scores in the intervention group. P values of <0.05 were considered statistically significant. RESULTS: The total number of participating physicians was 62. Fifty-three (85.5%) respondents completed the study. Composite scores within the intervention group showed statistically significant improvement in knowledge (p<0.001) and practice (p<0.001) postintervention. The overall composite scores preintervention and postintervention also showed statistically significant difference of improvement in knowledge (p=0.002) and practice (p=0.001) between non-intervention and intervention groups. Adherence to individual 13 ADA preventive care guidelines level was noted to be suboptimal at baseline. Statistically significant improvement in the intervention group was seen in the following individual variables: review of symptoms of hypoglycaemia and hyperglycaemia, eye examination, neurological examination, lipid examination, referral to ophthalmologist, and counselling about non-smoking. CONCLUSION: m-Health technology can be a useful educational tool to help with improving knowledge and practice of diabetic guidelines. Future multicentre trials will help to scale this intervention for wider use in resource-limited countries.

Adherence To Diabetes Mellitus Treatment Guidelines From Theory To Practice: The Missing Link.

Diabetes mellitus is a complex multisystem disease that requires high quality care. Clinical practice guidelines help physicians and patients make the best possible health care decisions and improve health care management of diabetic patients. These guidelines provide the norms for clinical management as well as monitoring of diabetes care. They are not simple algorithms but are based on structured evidence based diabetic management protocols developed from randomized controlled trials. Despite the widespread availability of this diabetic guideline, their use is suboptimal at best. There are several factors blamed for contributing to this missing link from available theoretical guideline recommendations to practical applications of these guidelines. We present a brief review based on available literature review for an ongoing interventional study being done by authors in two tertiary care hospital in Lahore Pakistan for improving adherence to diabetes guidelines. We will discuss guideline implementation cycle and also present a framework encompassing various factors involved in adherence to guidelines. Until recently the emphasis to improve the guideline adherence targeted the factors relating to individual health care professionals in reference to their knowledge, attitude practice of the guidelines. However, we will discuss that broader range of health care systems, organizational factors, and factors relating to patients which may also significantly impact the adherence to the guidelines. The framework emphasises that it is important to understand the factors that act as barriers and contribute to the missing link between theory and practice of diabetic guidelines. This will help plan appropriate strategies in the pre-implementation stage for effective and improved diabetes guidelines adherence and management.

Team Based Learning (TBL) in undergraduate medical education.

OBJECTIVE: To determine if modified Team Based Learning (TBL) was more effective than Traditional Didactic Lecture (TDL) in improving knowledge outcomes about Diabetes management in fourth year medical students and to check the students' view about the TBL method in comparison with their earlier experience with TDL. STUDY DESIGN: A comparative study. PLACE AND DURATION OF STUDY: Lahore Medical and Dental College, Lahore, from January to February 2011 in 4 weeks. METHODOLOGY: Modification of the original TBL method as described by Michaelsen was done to accommodate the educational system. A total of 7 sessions were allotted to teach non-communicable diseases to fourth year MBBS students. Session which was scheduled for teaching Diabetes mellitus was conducted first by TDL and three weeks later with the TBL session. MCQ based tests were administered to self paired groups of students first after the TDL session and then after the TBL session. Wilcoxon signed-rank test was used to compare post-TDL and post-TBL test scores of the students. Students' views about the TBL session compared to the TDL session were checked by using pre-tested questionnaire. RESULTS: Seventy two, fourth year MBBS students participated in this TBL session. Majority were females 49 (68.1%). There was improvement of test scores of students after the TBL session when compared to the test scores after TDL session (p < 0.001). Majority of the respondents noted that TBL session was a better learning strategy compared to TDL. CONCLUSION: The 72 students included in the study achieved higher mean test scores on test questions that assessed their knowledge of Diabetes mellitus content learned using the TBL strategy compared with TDL method (p < 0.001). TBL learning method was favoured by a majority of medical students compared to the TDL session.

Medical students' perspective about role-plays as a teaching strategy in community medicine.

OBJECTIVE: To assess the students' perspective about role-plays conducted as a teaching methodology in community medicine. STUDY DESIGN: A quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Community Medicine at Fatima Memorial College of Medicine and Dentistry from July to November 2010. METHODOLOGY: A probability technique of simple random sampling was used to collect 63 students from the third and fourth year MBBS who were randomly distributed in five sub-groups. They were variously ascribed the roles of obsceners, participants and helpers. A questionnaire was distributed to collect student's responses. The data was analyzed on SPSS version 17 to compare the responses. Chi-square test was applied and p-value was fixed at < 0.05 as significant. RESULTS: Sixty-three students were selected as participants of this study in which 46 belonged to the fourth year MBBS class (73%) and 17 were third year MBBS students (27%). There were 13 male (20.6%) and 50 female (79.4%) students. Role-plays were identified as most effective method of teaching (n = 25, 37.9%) followed by lectures (n = 17, 25.8%, p = 0.054). Fifty-two students (78.5%) admitted that role-plays improved their knowledge of the subject, 55 (84.6%) said that it will help them in their clinical performance. Fifty-nine participants (89.4%) found role-plays interesting and 49 (74.2%) wanted to incorporate role-plays as a part of curriculum. Fifty-six of the participants (88.9%) agreed that role-plays improved their communication skills. Twenty-one participants (31.8%) believed that it helped them in making acquaintance with the local situation. Forty-six students (76.7%) identified role-plays as a feasible way of andragogy (p = 0.005) and 48 (76.2%) said that it provoked critical thinking about the subject (p = 0.038). Fifty-four students (85.7%) admitted that their attention span was better in role-plays as compared to lectures (p = 0.047). CONCLUSION: Role-plays were well accepted by the students as an effective teaching methodology and can be incorporated as a part of teaching strategies in Community Medicine.

Preferences for antimuscarinic therapy for overactive bladder.

OBJECTIVE • To examine patient preferences and strength of preferences for treatment for the various symptoms of overactive bladder and adverse events associated with the use of antimuscarinic treatments. PATIENTS AND METHODS • A discrete choice experiment (DCE) survey was developed that detailed treatment choices in terms of attributes relating to their efficacy in reducing symptoms and the likelihood of experiencing typical adverse events. Levels for each attribute were based on a literature review, qualitative interviews and a meta-analysis of clinical trial data. • Attributes were combined into choice sets using a fractional orthogonal design that had been folded over. Pairs of choice sets were presented to overactive bladder (OAB) patients (n= 332), who indicated which treatment alternative they preferred. Data were analysed using the conditional logit model. RESULTS • Participants expressed the strongest preference for the avoidance of urgency incontinence episodes, followed by preference for a reduction in the experience of urinary urgency and the number of micturition episodes. The influence of the likelihood of experiencing an adverse event on treatment preference was also estimated. • Finally, marginal rates of substitution were calculated to demonstrate the relative value of trade-offs between the various attributes. • Treatment preferences were found to be broadly similar across two patient age groups (i.e. under 45 s and 45 and over). CONCLUSION • The study demonstrates that individuals with OAB place significant emphasis on the prospect of reduction in symptoms. Avoidance of incontinence episodes is particularly valued and equivalent to a much greater reduction in the frequency of micturition or experience of urgency. However, even a modest increase in the likelihood of experiencing an adverse event could easily motivate a change in treatment preference.

Medical education: views and recommendations by final year MBBS students of a private medical college in Lahore.

OBJECTIVE: To obtain the views and recommendations of final year MBBS medical students of Lahore Medical and Dental College, Lahore about various aspects of the current medical education. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Lahore Medical and Dental College, Lahore in October and November 2007. METHODOLOGY: Preformed close ended structured questionnaire regarding medical teaching and evaluation methods and recommendations was used to collect the data from students of final year MBBS (n=120) at Lahore Medical and Dental College. SPSS 15 program was used for analysis. Data was presented as frequency percentages. RESULTS: A majority of the students (79%) thought that multimedia was the most effective teaching tool, (54%) students viewed 45 minutes as ideal lecture duration. Measures suggested to improve the examination results were regular tests (54%), improved lecture content (32%) and regular tutorials (10%). MCQ's were the mode of examination questions preferred by 62% of students. Recommendations given by students for improving the current medical education were better teaching (26%) followed by increased motivation in students 54 (16%) and more hands-on training/practical field work (12%). CONCLUSION: Medical students in this study preferred multimedia, lecture duration less than 45 minutes and MCQ's as their preferred mode of evaluation. Students recommended increased emphasis on better lectures, increasing learning motivation in students and more hands on training/practical field work to improve current medical teaching.

Medico-legal aspects of alleged rape victims in Lahore.

OBJECTIVE: To describe the socio-demographic along with the medico-legal characteristics of rape victims reporting to a female police station of Lahore. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Female Police Station in Shadman, Lahore, from, June 1995 to January 2009. METHODOLOGY: A total of 74 cases of alleged rape victims were identified while reviewing all available police files concerning reported rapes and attempted rapes from 1995 to 2008. The data was gathered on preformed questionnaires after conducting the pilot study. All information about victims and alleged offenders were extracted from the police files including socio-demographic profile of the accused and victim both. Use of weapon, evidence of physical and genital trauma, assailant identification and his relationship with the victim, number of accused persons and location of rape was noted in each case. Examination by doctor and obtaining the specimens were also identified and was related to the outcome of the court case. Chi-square test was applied to determine the association of rape with age and educational status of the victim and the accused. RESULTS: A total of 74 cases of alleged rape were reported in the study period at Shadman Female Police Station. Maximum number of victims was reported in the age group 10-19 years (n=46, 62.2%). Majority of the accused belonged to 20-39 years' age group constituting 64.8% of the total. Regarding educational status 45 (60.8%) of the victims and 51 (68.9%) of the accused were illiterate. Significant association was found between the educational status of rape victims and accused (p = 0.016) but not between their ages (p = 0.862). The maximum incidence of rape was reported in unmarried (n = 55, 74.3%) and unemployed (n =61, 82.4%) women. In 14 cases (19%) use of weapon was reported. Physical trauma was reported in 29 (39%) and genital trauma in 14 (19%) cases. The accused were identified as family friends (25%) and neighbours (23%) respectively. Only 21% of the victims were examined by doctor and specimens were obtained in only 14.9% of the cases. Acquittal of the accused was observed in 43% of the cases while 34% cases were still pending; conviction of the accused was observed in only 5% of the cases. CONCLUSION: Rape victims usually belong to young age group between 10-19 years majority of being unmarried and unemployed. Only a smaller fraction of the victims were examined by doctor and specimens were obtained in only few of the cases.

Determinants and pattern of health care services utilisation in post graduate students.

BACKGROUND: The health care utilisation of a population is dependent on their health seeking behaviour which is determined by their physical, political, socio-economic and socio-cultural aspects. OBJECTIVES: This particular study is conducted to identify the determinants and the patterns of health services utilisation by the postgraduate students of Allama Iqbal Open University in Pakistan. It was a cross-sectional study and conducted from December 2008 to April 2009 in Allama Iqbal Open University Islamabad. METHODS: A non-probability convenience sampling was done in post graduate students who were enrolled for Masters Degree at Allama Iqbal Open University Islamabad. Data was collected on a self administered, pre-tested questionnaire to identify the pattern of utilisation of health care services by this educated class. Data was labelled and entered in SPSS version 16. Chi-square test is applied as a test of significance with fixing the p value at 0.05 as significant. RESULTS: Only 129 students 32 males, 97 females) out of 250 responded to the questionnaire with the response rate of only 51.6%. The sociodemographic profile of the participants shows that 71 (55%) belong to age group 20-29 years, followed by 43 (33.3%) in age group 30-39 years. The marital status of the participants had a significant association with selection of health care services (p = 0.04). Twenty-four (75%) of the males and 67 (65%) of the females were using private sector facilities. Age, marital status and income of the study subjects had significant association with selection of the provider with p values of 0.000, 0.047 and 0.051 respectively. CONCLUSION: The health care system in Pakistan comprises the public as well as private health facilities. In Pakistan vast majority of doctors resides in urban area and attracts the educated class towards private sector. Utilisation of public health care facility is not the main priority of the educated class of the country. Government officials should pay attention to make it more convenient for general public.