Effectiveness of Shared Decision-making Training Programs for Health Care Professionals Using Reflexivity Strategies: Secondary Analysis of a Systematic Review.

BACKGROUND: Shared decision-making (SDM) leads to better health care processes through collaboration between health care professionals and patients. Training is recognized as a promising intervention to foster SDM by health care professionals. However, the most effective training type is still unclear. Reflexivity is an exercise that leads health care professionals to question their own values to better consider patient values and support patients while least influencing their decisions. Training that uses reflexivity strategies could motivate them to engage in SDM and be more open to diversity. OBJECTIVE: In this secondary analysis of a 2018 Cochrane review of interventions for improving SDM by health care professionals, we aimed to identify SDM training programs that included reflexivity strategies and were assessed as effective. In addition, we aimed to explore whether further factors can be associated with or enhance their effectiveness. METHODS: From the Cochrane review, we first extracted training programs targeting health care professionals. Second, we developed a grid to help identify training programs that used reflexivity strategies. Third, those identified were further categorized according to the type of strategy used. At each step, we identified the proportion of programs that were classified as effective by the Cochrane review (2018) so that we could compare their effectiveness. In addition, we wanted to see whether effectiveness was similar between programs using peer-to-peer group learning and those with an interprofessional orientation. Finally, the Cochrane review selected programs that were evaluated using patient-reported or observer-reported outcome measurements. We examined which of these measurements was most often used in effective training programs. RESULTS: Of the 31 training programs extracted, 24 (77%) were interactive, among which 10 (42%) were considered effective. Of these 31 programs, 7 (23%) were unidirectional, among which 1 (14%) was considered effective. Of the 24 interactive programs, 7 (29%) included reflexivity strategies. Of the 7 training programs with reflexivity strategies, 5 (71%) used a peer-to-peer group learning strategy, among which 3 (60%) were effective; the other 2 (29%) used a self-appraisal individual learning strategy, neither of which was effective. Of the 31 training programs extracted, 5 (16%) programs had an interprofessional orientation, among which 3 (60%) were effective; the remaining 26 (84%) of the 31 programs were without interprofessional orientation, among which 8 (31%) were effective. Finally, 12 (39%) of 31 programs used observer-based measurements, among which more than half (7/12, 58%) were effective. CONCLUSIONS: Our study is the first to evaluate the effectiveness of SDM training programs that include reflexivity strategies. Its conclusions open avenues for enriching future SDM training programs with reflexivity strategies. The grid developed to identify training programs that used reflexivity strategies, when further tested and validated, can guide future assessments of reflexivity components in SDM training.

Experience and Perception of Patients and Healthcare Professionals on Acute Leukemia in Rwanda: A Qualitative Study.

Purpose: To explore challenges associated with the timely diagnosis, therapy, and prognosis of acute leukemia in Rwanda. Methods: This is a qualitative study using a phenomenological approach that involved patients, patients' guardians, and healthcare professionals such as physicians from district hospitals and specialists from referral hospitals, as well as healthcare administrators. The primary data were collected from district and referral hospitals and central healthcare administration in Rwanda. The data were collected between July and October 2019. In-depth interviews were conducted, and thematic analysis was employed to interpret the results. Results: We identified barriers to seeking healthcare such as (i) insufficient knowledge within the population may lead patients and their guardians to consult traditional healers before seeking qualified medical care, and (ii) financial constraints that preclude payment of healthcare fees or other out-of-pocket cost related to diagnosis and treatment. We also observed that the referral system is tedious and primary healthcare facilities lack the competence and resources for the necessary diagnostic practices. Both may further delay diagnosis and therapy. Accordingly, healthcare professionals at the referral hospitals stated that most patients were seen at an advanced stage of the disease. For the treatment of acute lymphoblastic leukemia (ALL), only chemotherapy is utilized in Rwanda, while bone marrow (BM) transplantation is not available. Palliation is the only available treatment for the vast majority of Rwandan acute myeloid leukemia (AML) patients. Conclusion: ALL and AML are likely under-reported in Rwanda and diagnosis may be delayed, which may be explained by patient-related factors (lack of knowledge, financial constraints), a tedious referral system, and suboptimal diagnostic resources.

Shared decision-making and person-centred care approaches in three African regions.

Five years ago, we published a 'wake-up' paper on shared decision-making (SDM) in West Africa. In the current paper, our overview has been expanded to more African regions (central and north, in addition to the west) as well as to person-centred care (PCC) approaches. While these concepts are known in all regions to varying degrees, results indicate that most known SDM and PCC efforts originate from West Africa. In general, the focus seems to be predominantly on partnership-driven healthcare programs, such as COVID-19 infection; HIV/AIDS and maternal/neonatal care; and patient-provider communication and patient participation instead of comprehensive SDM approaches. The findings also indicate the absence of SDM training for African health professionals beyond specific healthcare programs, but some education on decision-making or critical appraisal of health information in primary or undergraduate health schools is carried out in certain African countries. Building on these sectoral initiatives, future directions include developing research and training programs in the perspective of scaling effective approaches.

Model fidelity of group antenatal and postnatal care: a process analysis of the first implementation of this innovative service model by the Preterm Birth Initiative-Rwanda.

Background: For a large trial of the effect of group antenatal care on perinatal outcomes in Rwanda, a Technical Working Group customized the group care model for implementation in this context. This process analysis aimed to understand the degree of fidelity with which the group antenatal care model was implemented during the trial period. Methods: We used two discreet questionnaires to collect data from two groups about the fidelity with which the group antenatal care model was implemented during this trial period. Group care facilitators recorded descriptive data about each visit and self-assessed process fidelity with a series of yes/no checkboxes. Master Trainers assessed process fidelity with an 11-item tool using a 5-point scale of 0 (worst) to 4 (best). Results: We analyzed 2763 questionnaires completed by group care facilitators that documented discreet group visits among pregnant and postnatal women and 140 questionnaires completed by Master Trainers during supervision visits. Data recorded by both groups was available for 84 group care visits, and we compared these assessments by visit. Approximately 80% of all group visits were provided as intended, with respect to both objective measures (e.g. group size) and process fidelity. We did not find reliable correlations between conceptually-related items scored by Master Trainers and self-assessment data reported by group visit facilitators. Conclusions: We recommend both the continued participation of expert observers at new and existing group care sites and ongoing self-assessment by group care facilitators. Finally, we present two abbreviated assessment tools developed by a Rwanda-specific Technical Working Group that reviewed these research results.

Before and after implementation of group antenatal care in Rwanda: a qualitative study of women's experiences.

BACKGROUND: The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women's experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements. METHODS: We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation. RESULTS: Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout. DISCUSSION: These results are consistent with other published reports of women's perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women's experiences of care. CONCLUSION: Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov as NCT03154177 .

Postnatal care in Rwanda: facilitators and barriers to postnatal care attendance and recommendations to improve participation.

BACKGROUND: Sub-Saharan Africa has the highest rates of neonatal mortality in the world with an estimated 1.2 million deaths within the first 28 days of life. Postnatal care (PNC) can contribute to reductions in morbidity and mortality in mothers and newborns through vital support that identifies danger signs and establishes valuable practices and referral processes. METHODS: This qualitative data was collected as a part the East Africa Preterm Birth Initiative (PTBi-EA) to guide development of a group antenatal (ANC) and PNC model in Rwanda. Key-informant in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in four districts. Sixteen FGDs with 180 participants and 22 IDIs were completed at the time of thematic saturation. RESULTS: Four themes highlighted facilitators and barriers to PNC attendance and recommendations to improve participation: 1) There is little awareness in the community of what the PNC package is; PNC 4 in particular is not well understood; 2) PNC visits by community health workers (CHWs) are well accepted and valued; 3) Providers perceive PNC 4 as an added burden to an already high workload; 4) Community structures exist to better disseminate key messages about PNC, but have not yet been effectively utilized. CONCLUSIONS: This qualitative work provides evidence that the PNC package was not initially well understood. Regardless, PNC service delivery performed by CHWs in Rwanda is well accepted and appreciated by the population, providing assurance that the full package has potential to be well utilized and valued by the population.

The impact of an mHealth monitoring system on health care utilization by mothers and children: an evaluation using routine health information in Rwanda.

Maternal and child mortality rates remain unacceptably high globally, particularly in sub-Saharan Africa. A popular approach to counter these high rates is interventions delivered using mobile phones (mHealth). However, few mHealth interventions have been implemented nationwide and there has been little evaluation of their effectiveness, particularly at scale. Therefore, we evaluated the Rwanda RapidSMS programme-one of the few mHealth programmes in Africa that is currently operating nationwide. Using interrupted time series analysis and monthly data routinely reported by public health centres (n = 461) between 2012 and 2016, we studied the impact of RapidSMS on four indicators: completion of four antenatal care visits, deliveries in a health facility, postnatal care visits and malnutrition screening. We stratified all analyses based on whether the district received concurrent additional supports, including staff and equipment (10 out of 30 Districts). We found that community health workers in Rwanda sent more than 9.3 million messages using RapidSMS, suggesting the programme was successfully implemented. We found that the implementation of the RapidSMS system combined with additional support including training, supervision and equipment provision increased the use of maternal and child health services. In contrast, implementing the RapidSMS system alone was ineffective. This suggests that mHealth programmes alone may be insufficient to improve the use of health services. Instead, they should be considered as a part of more comprehensive interventions that provide the necessary equipment and health system capacity to support them.

Assessing the perspectives of users and beneficiaries of a community health worker mHealth tracking system for mothers and children in Rwanda.

INTRODUCTION: Mobile Health (mHealth) programs have increasingly been used to tackle maternal and child health problems in low and middle income countries. However, few studies have evaluated how these programs have been perceived by intended users and beneficiaries. Therefore, we explored perceptions of healthcare officials and beneficiaries regarding RapidSMS Rwanda, an mHealth system used by Community Health Workers (CHWs) that was scaled up nationwide in 2013. METHODS: We conducted key informant interviews and focus group discussions with key stakeholders, providers, and beneficiaries of maternal and child health services at both the national and community levels. Semi-structured interviews were used to assess perceptions about the impact of and challenges facing the RapidSMS system. Interviews and focus group discussions were recorded (with the exception of one), transcribed verbatim, and analyzed. RESULTS: We conducted a total of 28 in-depth interviews and 10 focus group discussions (93 total participants). A majority of respondents believed that RapidSMS contributed to reducing maternal and child mortality rates. RapidSMS was generally accepted by both CHWs and parents. Participants identified insufficient training, a lack of equipment, and low CHW motivation as the main challenges facing RapidSMS. CONCLUSION: Our findings suggest that an mHealth program can be well accepted by both policymakers, health providers, and the community. We also found significant technical challenges that have likely reduced its impact. Addressing these challenges will serve to strengthen future mHealth programs.

Women's knowledge and attitudes towards cervical cancer prevention: a cross sectional study in Eastern Uganda.

BACKGROUND: Cervical cancer is a leading cause of morbidity and mortality among women in Uganda, often due to late disease diagnosis. Early screening for the cancer has been shown to be the most effective measure against the disease. Studies conducted elsewhere have reported the lack of awareness and negative attitudes towards cervical cancer as barriers to early screening. This study assessed the knowledge and attitudes of Ugandan women about cervical cancer prevention with the aim of informing prevention and control interventions. METHODS: This study was conducted in Bugiri and Mayuge districts in eastern Uganda. It was a cross-sectional community based survey and collected data by means of a questionnaire. A total of 900 women aged 25-49 years participated in the study. Women's knowledge and attitudes towards cervical cancer prevention were assessed and scored. Data were analysed using STATA 12.0 software. Bivariate and multivariate analyses were carried out to establish the relationship between knowledge levels and demographic characteristics. RESULTS: Most (794; 88.2%) of the respondents had heard about cervical cancer, the majority (557; 70.2%) having received information from radio and 120 (15.1%) from health facilities. Most women (562; 62.4%) knew at least one preventive measure and (743; 82.6%) at least one symptom or sign of the disease. The majority (684; 76.0%) of respondents perceived themselves to be at risk of cervical cancer, a disease most (852; 94.6%) thought to be very severe. Living in peri-urban areas (AOR = 1.62, 95% CI: 1.15 - 2.28), urban areas (AOR = 3.64, 95% CI: 2.14 - 6.19), having a higher monthly income (AOR = 0.50, 95% CI: 0.37 - 0.68) and having had an HIV test (AOR = 1.99, 95% CI: 1.34-2.96) were associated with level of knowledge about cervical cancer prevention. CONCLUSION: Although general knowledge about cervical cancer prevention was relatively high among women, and attitudes mostly encouraging, specific knowledge about screening was low. There were also undesirable perceptions and beliefs regarding cervical cancer among respondents. There is therefore need for more education campaigns to bridge identified knowledge gaps, and scale up of cervical cancer screening services to all women to increase service uptake.

Uptake of Cervical Cancer Screening and Associated Factors among Women in Rural Uganda: A Cross Sectional Study.

BACKGROUND: In developing countries, inadequate access to effective screening for cervical cancer often contributes to the high morbidity and mortality caused by the disease. The largest burden of this falls mostly on underserved populations in rural areas, where health care access is characterized by transport challenges, ill equipped health facilities, and lack of information access. This study assessed uptake of cervical cancer screening and associated factors among women in rural Uganda. METHODS: This descriptive cross sectional study was carried out in Bugiri and Mayuge districts in eastern Uganda and utilised quantitative data collection methods. Data were collected using a semi-structured questionnaire on cervical cancer screening among females aged between 25 and 49 years who had spent six or more months in the area. Data were entered in Epidata 3.02 and analysed in STATA 12.0 statistical software. Univariate, bivariate and multivariate analyses were performed. RESULTS: Of the 900 women, only 43 (4.8%) had ever been screened for cervical cancer. Among respondents who were screened, 21 (48.8%) did so because they had been requested by a health worker, 17 (39.5%) had certain signs and symptoms they associated with cervical cancer while 16 (37.2%) did it voluntarily to know their status. Barriers to cervical cancer screening were negative individual perceptions 553 (64.5%) and health facility related challenges 142 (16.6%). Other respondents said they were not aware of the screening service 416 (48.5%). The independent predictors of cervical cancer screening were: being recommended by a health worker [AOR = 87.85, p<0.001], knowing where screening services were offered [AOR = 6.24, p = 0.004], and knowing someone who had ever been screened [AOR = 9.48, p = 0.001]. CONCLUSION: The prevalence of cervical cancer screening is very low in rural Uganda. Interventions to increase uptake of cervical cancer screening should be implemented so as to improve access to the service in rural areas.