Original Contribution
Assessment of Point-of-Care Ultrasound Training for Clinical Educators in Malawi, Tanzania and Uganda

https://doi.org/10.1016/j.ultrasmedbio.2019.01.019Get rights and content

Abstract

Integrating point-of-care ultrasound (POCUS) to enhance diagnostic availability in resource-limited regions in Africa has become a main initiative for global health services in recent years. In this article, we present lessons learned from introducing POCUS as part of the Global Health Service Partnership (GHSP), a collaboration started in 2012 between the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide health care work force education and training in resource-limited countries. A cross-sectional survey of GHSP clinical educators trained to use POCUS and provided with hand-held ultrasound during their 1-y deployment during the period 2013–2017. The survey consisted of 35 questions on the adequacy of the training program and how useful POCUS was to their overall clinical and educational mission. Clinical educators engaged in a series of ultrasound educational initiatives including pre-departure training, bedside training in the host institutions, online educational modules, educational feedback on transmitted images and training of local counterparts. In this study 63 GHSP clinical educators who participated in the POCUS trainings were identified, and 49 were included at the study (78% response rate). They were assigned to academic institutions in Tanzania (n = 24), Malawi (n = 21) and Uganda (n = 18). More than 75% reported use of POCUS in clinical diagnoses and 50% in determining treatment, and 18% reported procedural application of ultrasound in their practice. The top indications for POCUS were cardiac exams, second- and third-trimester obstetric exams, lung and pleura, liver and spleen and gynecology/first-trimester obstetrics. The largest perceived barriers were lack of ultrasound knowledge by the clinical educators, lack of time, equipment security, difficulty accessing the Internet and equipment problems. We concluded that our multiphase POCUS training program has increased the utility, acceptability and usage of POCUS in resource-limited settings.

Introduction

Point-of-care ultrasound (POCUS) refers to the use of ultrasound at the bedside of patients to aid diagnosis, guide procedures and monitor response to therapy. POCUS is becoming standard of care for diagnostic and therapeutic interventions in a variety of clinical settings in highly developed medical systems (Bellamkonda et al., 2015, Dietrich et al., 2017, McLario and Sivitz, 2015, Moore and Copel, 2011). In recent years there has been an increasing effort to integrate POCUS into clinical care provided in resource-limited settings (Becker et al., 2017, Bélard et al., 2018, Epstein et al., 2018, Henwood et al., 2017, Stanley et al., 2017, Vinayak, 2017, Vinayak and Brownie, 2018, Zaver et al., 2018). These efforts include initiatives to improve the relevance of ultrasound training programs enabling clinicians with a point-of care imaging modality.

Launched in early 2012, the Global Health Service Partnership (GHSP) is a collaboration between the President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide medical and nursing education and training in collaboration with host institutions in Malawi, Tanzania and Uganda (Kerry and Mullan, 2014, Stuart-Shor et al., 2017).

In 2013, the ultrasound training was included as part of GHSP clinical educators’ training with the hope of improving the quality of and transforming learning for the very diverse clinical environment with a wide variability in accessing imaging and diagnostic capabilities (Boniface et al. 2018). The GHSP POCUS program for clinical educators has four major components: (i) a pre-departure training during orientation in Washington, DC; (ii) on-site hands-on training in the host institutions; (iii) self-study online modules and educational materials; and (iv) online feedback on transmitted images (Boniface et al. 2018).

The GHSP has therefore presented us with the unique opportunity to train and monitor clinicians in the use of POCUS over an extended period in resource-limited settings. We report our experience of training, deploying and guiding GHSP clinical educators in the use of bedside ultrasound techniques and POCUS in their educational and clinical activities at several sites in Malawi, Uganda and Tanzania. We describe our model for training practitioners in the use of POCUS in low-resource settings and how we provided them with continuing oversight and practice-based improvement programs. We report on how and why POCUS was used at GHSP sites and outline barriers to use and acceptance. We hope that our process and findings will shed light on how POCUS can be used to improve delivery of care in resource-limited settings. The conclusions of this study will also guide educational activities supporting POCUS in resource-challenged settings.

Section snippets

Study setting

We conducted a qualitative and quantitative cross-sectional survey among 63 GHSP clinical educators trained to use POCUS and provided with handheld ultrasound during their 1-y period of deployment during the period 2013–2017. Data were collected and managed from self-administered questionnaires using Research Electronic Data Capture (REDCap) (Harris et al. 2009). REDCap is a secure, web-based application designed to support data capture for research studies, providing (i) an intuitive interface

Survey population

Seventy-eight percent of GHSP clinical educators (49/63) responded to the survey. The clinical educators’ specialties include family medicine (n = 11), internal medicine and subspecialties (n = 11), pediatrics (n = 9), midwifery (n = 8), obstetrics and gynecology (n = 7), emergency medicine (n = 2), anesthesiology (n = 1) and critical care (n = 1). Twenty-three clinical educators were serving in-country at the time of the survey. The time between ultrasound training and completion of the survey

Discussion

A survey of GHSP clinical educators who underwent a multiphase ultrasound training and had served as clinical educators in sub-Saharan Africa suggest that an innovative POCUS educational activity focusing on capacity building among GHSP clinical educators and local POCUS “champions”—clinicians who dedicated extra time to learning to use ultrasound as well as teach others—resulted in a successful program implementation. Survey responses indicate that the program increased US knowledge and skills

Conclusions

A survey of GHSP clinical educators who underwent a multiphase POCUS training suggests that the educational program increased POCUS knowledge and skills among clinical educators, increased diagnostic utility of POCUS, provided an opportunity to enhance clinical teaching and has led to a sustainable partnership between the United States and institutions in the host countries. This educational program, and the materials developed to support it, can serve as a resource for academic institutions

Acknowledgments

The authors thank the Global Health Service Partnership clinical educators and their counterpart clinicians in the host countries. We could not have carried out this research without their dedication, participation and support. We gratefully acknowledge the GE Foundation for donating portable handheld ultrasounds and assisting educational training sessions for the Global Health Service Partnership program.

Conflict of interest disclosure

The authors declare that they have no competing interests.

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