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The care-giver must check the regularity of drug intake. Sex-dependent variations and timing of thyroid growth during puberty. Factors affecting the presence of adequately iodized salt at home in Wolaita, Southern Ethiopia: Community Based Study. Assessing heterogeneity in meta-analysis: Q statistic or I 2 index? Collaboration In research I collaborate with many national and international research groups.

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When the national holiday falls on a Saturday or Sunday, staff are given a day off which can be taken during any time of the year in agreement with their supervisor.


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Alana April 12, Thankful to you for giving to us, I additionally reliably increase some new helpful information from your post. Alana April 12, Thank you for some other informative website. Methods Studies reporting on knowledge, attitudes and practices of public and private practitioners with TB patients were selected through searching electronic databases and grey literature. Findings Of reports, 20 full-texts were assessed, of which 11 met the eligibility and quality criteria; all studies focused on private sector care.

Methods No review protocol exists for this study. Study eligibility Practitioners in any health setting in Pakistan were included, including general practitioners, specialist physicians, nurses and non-clinical personnel. Quality and bias assessment Bias was minimised in several ways.

Data extraction and analysis Information on study characteristics and data on TB diagnosis and treatment were extracted Table 1. Table 1 Summary of data extracted from literature. Open in a separate window. Table 2 National and international guidelines on TB care. When possible, at least one early morning specimen should be obtained. All adult patients suspected of having pulmonary TB should have at least two sputum specimens examined for AFB smear microscopy in a quality-assured laboratory ISTC Standard 8 : All patients including those with HIV infection who have not been treated previously should receive an internationally accepted first-line treatment regimen using drugs: The initial phase should consist of two months of isoniazid INH , rifampicin RIF , pyrazinamide PZA , and ethambutol EMB.

The continuation phase should consist of isoniazid and rifampicin given for four months. Fixed dose combinations of 2,3 or 4 drugs are highly recommended. During the continuation phase, isoniazid and rifampicin HR are administered daily for four months. Fixed dose combinations with proven bio-availability are preferred over individual drugs preparations.

ISTC Standard 10 : Response to therapy in patients with pulmonary tuberculosis should be monitored by follow-up sputum microscopy two specimens upon completion of the initial phase of treatment two months. If the sputum smear is positive, they should be examined again at 3 months and, if still positive, culture and drug susceptibility testing should be performed.

In patients with extrapulmonary TB and in children, the response to treatment is best assessed clinically. Sputum smear is done at the end of 2 months, if smear is negative, the continuation phase will start. However if sputum smear is positive, a repeat test will be carried out. ISTC Standard A written record of all medications given, bacteriologic response, and adverse reactions should be maintained for all patients. Records of treatment must be kept.

The care-giver must check the regularity of drug intake. Treatment outcomes must be assigned to every patient. Fig 1. Study characteristics One study was excluded for poor quality details in S1 Table. Outcome measures Data on knowledge and practices were extracted from eleven studies and compared to the national guidelines Table 2.

Fig 2. Forest plot on cough. Fig 3. Forest plots on diagnosis knowledge and practice. Fig 4. Forest plots on prescriptions for intensive and continuation phases. Fig 5. Forest plot on prescribing in fixed doses. ISTC Standard 10—knowledge of using sputum microscopy to assess clinical progress after the initial phase of treatment Data was extracted from eight studies.

Fig 6. Forest plot on assessing clinical progress. Fig 7. Forest plot on recording treatments. Comparison across study contexts A comparison of results was not possible between public and private contexts, owing to the fact that all included studies were found to be based solely on private practitioners in particular, medical doctors.

Discussion The private healthcare sector in Pakistan poses both challenges and opportunities for the control of TB in the country: for example, recent, innovative initiatives to engage with this sector have shown notable successes in promoting TB case detection [ 32 ].

Conclusion TB management in Pakistan requires improvement in all areas identified in this research, in relation to diagnosis, treatment, and monitoring. PDF Click here for additional data file. S1 Fig Full electronic database search input. S3 Fig Forest plot on range of symptoms. TIF Click here for additional data file. S4 Fig Forest plot on diagnosing and not referring. S5 Fig Forest plot on treating and not referring. S1 Table Quality assessment.

DOCX Click here for additional data file. Data Availability All relevant data are within the paper and its Supporting Information files. References 1. World Health Organisation. Pakistan: Stop Tuberculosis.

Khan M. Recent advances in the management of tuberculosis. Journal of Pakistan Association of Dermatologists. January; 15 — Tuberculosis in Pakistan: A decade of progress, a future of challenge. J Pak Med Assoc. April; 59 4 :1—8. J Ayub Med Coll Abbottabad. Knowledge, attitudes and practices of private sector providers of tuberculosis care: a scoping review.

August 1; 15 8 — Available from Quality of tuberculosis care in India: a systematic review. July 1; 19 7 — Directorate of Tuberculosis Control. National Guidelines for tuberculosis control in Pakistan. Herzog R. A systematic review. BMC public health. February 19; 13 1 :1 Available from National Tuberculosis Program—Pakistan. National Guidelines for the Control of Tuberculosis in Pakistan. Tuberculosis Coalition for Technical Assistance.

Latin American Journal of Pharmacy. June 1; 31 5 —6. Value in Health. Available from: Soomro M. Barriers in the management of tuberculosis in Rawalpindi, Pakistan: a qualitative study. Although not all interventions had this feature, positive attitudes of workers toward mCDSS was linked to their expectation of automatically generated monthly reports, therefore relieving them of this administrative task CommCare and Basics. The effect of the supervisory feedback component of the CommCare app was not reported.

Health workers believed that it met their needs for continuous professional development, therefore increasing competence and self-confidence and resulting in a decreased reliance on peers or referral facilities. Although it did not have a training component, similar perceptions were echoed in the DESIRE study where nurses found the app empowering and perceived it as being able to improve quality of care.

The mPneumonia study inferred that in addition to the level of experience of target users, availability of resources such as medical supplies and context of use also influenced disposition of health workers to the mCDSS.

Against the background of long waiting times and understaffed facilities, SMS interventions were appreciated for being easy and concise. The frequency, length, and timing of messages in the Kenyan study on Text Messaging of Malaria Guidelines were important considerations for health workers. Although three out of every four respondents found the frequency of messages one in the morning and another in the evening, five days a week adequate, a few considered it excessive and noted the risk of it becoming boring or repetitive.

Contrary to initial concerns, workflow assessments in QUALMAT showed that use of the mCDSS did not significantly increase overall time taken to deliver ANC compared with nonintervention sites, although certain tasks such as patient registration and physical examination were found to need twice as much time. This was expected since the standard preintervention paper formats had to be maintained during the intervention.

It could also mean that adherence behavior had improved due to the intervention. Studies that measured effects of mCDSS compared with paper systems, such as eIMCI, report that the former was faster and easier to use and improved adherence behavior.

The usability assessment of the DESIRE study found that whereas initial use of the system was challenging, given time and frequent use, users found it easier and faster about min compared with standard paper practice about min and eventually streamlined it into their workflow. Similar findings were reported in piloting the CommCare app. TBTech was interestingly designed such that both paper and electronic systems were integrated and aligned to existing workflow and organizational processes.

This meant that the intervention was not perceived as a big deviation from routine processes of health workers, and therefore easily accepted. This unease was especially prominent for workers with insufficient training, in which case their mind-lines ie, knowledge base were not reliable. In such situations, health workers were found to rely on patient reports client-lines. An improvement in the technical aspects of care such as physical examination—parts of which may be otherwise skipped—made clients feel attended to and more involved in the care process.

Two studies report that use of guidelines or decision algorithms created positive feedback loops whereby more clients were willing to see health workers whose confidence was in turn enhanced DESIRE, Text Messaging of Malaria Guidelines. A less positive effect was however reported by some nurses who felt that the tablet decreased effectiveness of patient consultation, such as missing nonverbal cues when concentrating on the tablet DESIRE.

Similar but yet unexplained low levels of use were reported in some study sites under the ALMANACH intervention despite high positive attitudes and enthusiasm for the support system. CommCare suspects that drop in reporting rates after the pilot period was due to technical issues or lack of effective monitoring and supervision.

Use of unique motivational messages suggests that such strategies could extend the novelty effect and increase chances of long-term adoption Text Messaging of Malaria Guidelines. According to eIMCI study, time efficiency of using the device was an indicator of its sustainability for routine use. For example, the Bacis study found that younger computer literate nurses were more enthusiastic and responsive to the intervention than older nurses.

These differences were explained by differing contexts, resources, and expenditures needed in each country. Programs such as TBTech built on the work process of existing systems such that decision support functions could be maintained even in situations where electricity or the Internet was unavailable.

One study found that by creating informal communities of practice involving peers with prior experience of mHealth, technical challenges were better managed by program managers DESIRE. Equally important is the role that perceived benefit of mCDSS use plays in facilitating its use. The need for technical training was higher in older workers Bacis with low computer literacy, compared with younger health workers or those who used the system on their personal mobile phones txt2MEDLINE. Contrarily, another study reported that initial technical difficulties encountered by health workers existed irrespective of sociodemographic and computer literacy levels ALMANACH.

Delays between training and program implementation could lead to decreased skill, motivation, and general disposition to the intervention.

The perception that decision support algorithms are based on updated best practices from a trusted source national or international body was also reported as a facilitator of use Text Messaging of Malaria Guidelines. Experiences of the QUALMAT team showed that poor ownership by local stakeholders could lead to suboptimal program outcomes despite including incentives.

Taking these into account, implementation of TBTech included supply chain management, provider training on clinical knowledge, hardware purchase, and maintenance and provision of mobile radiology units. This review synthesized evidence on the use of mobile technology as a clinical decision support system in Africa. Evidence indicates significant support for using mCDSS to improve health worker performance and service delivery specifically within sub-Saharan Africa. However, evidence is insufficient regarding their effects on the quality of care.

Key findings are highlighted in Textbox 1. Weak study designs, short intervention periods, and small sample sizes may explain this gap, although, even from more robust studies, the link to clinical outcomes is largely lacking [ 47 ]. Two studies, however, reported statistically significant m4Change and even sustained effects SMS for Malaria Guidelines on quality of care and provider behavior respectively, which is similar to reports on the ability of mCDSS to improve adherence to guidelines, evidence-based practice, and patient outcomes [ 48 , 49 ].

Other reviews have reported studies showing effects on guideline adherence or patient outcomes, which were either not statistically significant or suboptimal [ 47 ]. Specific features of computerized decision aids could enhance eg, content control or constrain eg, patient narratives the quality of decision-making [ 11 ], but we could not establish direct links between study outcomes and features of the mCDSS used.

Significant improvement in clinical practice has been shown in decision support systems focused on clinicians and associate clinicians physician assistants and nurses [ 48 ]; however, none of the interventions compared perceptions and outcomes across different health worker cadres. Unsustained enthusiasm regarding mCDSS use reflects the novelty effect, which in addition to perceived risk or reward can influence technological adoption [ 50 ].

High expectations or inaccurate perceptions of the capability of mobile devices may explain why some workers used the system more than others, as was the case in the ALMANACH study. It could also be due to short training or intervention periods, limiting ability of users to become familiar with the system, and to modify their expectations. Although the relatively short duration characterizing many mHealth pilots hinder the ability to evaluate rate and effect of adoption over time, a human-centered, multistakeholder approach to design and implement these technologies has been suggested as a way to mitigate resistance and encourage efficient integration into complex environments such as health systems [ 27 , 30 , 40 – 46 ].

Although some of the studies in this review used strategies such as training, supervision, and financial incentives to motivate the adoption and utilization of mCDSS, there were mixed reports about their effectiveness.

Direct or indirect supervisory support may additionally trigger the Hawthorne effect, influencing mCDSS adoption. Despite health worker concerns, evidence showed that consultation time was not significantly increased due to these innovations.

Future studies need to understand how mCDSS influences workflow patterns—the goal of which is to improve time efficiency while retaining quality services, and they should aim to identify how mHealth innovations can be designed and implemented to effectively become an integral part of the systems in which they are introduced.

The risk of overreliance on the recommendations of mCDSS e-lines above provider knowledge and experience, and the conflict that could result has been established in the discussions on limitations of decision support systems [ 49 ]. However, there is equal need to consider that mind-lines of health workers may be inaccurate and shaped by flawed perceptions, insufficient clinical training, and sociocultural norms [ 53 ].

The flexibility to override decision support recommendations may therefore need to be balanced with system accuracy and training or experience of users.

Findings that providers were more engaged in the care process during mCDSS use contradict anecdotal perceptions that interpersonal relationships are decreased with the use of electronic devices.

Although inconclusive, whereas these effects on improved patient-provider relationships could be due to improved adherence to standard evidence-based practice, they could also be purely psychological and inflated. Future before-after studies that assess attitudinal and interpersonal changes are therefore needed. Other studies in high-resource contexts have highlighted the beneficial role of incentives at a facility level [ 55 ]. Although these may have stimulated use of mCDSS, quality of care did not improve.

Further investigation is needed regarding the benefits of financial or nonfinancial incentives in implementing and sustaining mCDSS use, and at what level PBI are most effective. This also highlights the multiplicity of factors that need to be taken into account to achieve effective clinical decision-making support interventions. A major concern of policy makers regarding added benefits of adopting mHealth is related to its cost and cost-effectiveness. Although only 2 of the 11 studies reported cost implications, willingness of stakeholders to share costs is important for continuity and sustainability.

A Chinese study found that compared with standard paper formats, text messages were about times cheaper for stimulating guideline use [ 57 ]. Although there was agreement on the ease of its use, most respondents found that the messages, which were received once daily three times a week, were too short and infrequent. It is crucial to conduct additional studies that show how and when timing, frequency, and length of text message mCDSS interventions are most suitable.

Regular updates of decision support software could also minimize the risk of information being perceived as redundant. Clinical decision-making is only one aspect of the continuum of care. This may possibly explain suboptimal effects on quality of service delivery. The extent to which mCDSS increases competencies of lower cadre health workers needs to be investigated so that task-shifting strategies can better leverage technological innovation.

Rigorous evaluation methodology could shed more light on outcome and impact of the use of mHealth for clinical decision support especially taking into consideration different contexts, various cadres of health workers, and their levels of experience and training.

As health care systems are increasingly incorporating technological and ICT-based interventions into routine practice, training of all health professionals should be adapted to include this competence. Although the evidence in this review spans interventions executed within the last ten years, resources did not allow us to engage in translations of articles in other languages, which implies that we may have excluded some relevant articles from French-speaking countries.

Additionally, although we recognized that we may have gained more insight into the different interventions if we had included a consultation stage in the review process [ 20 ], due to time constraints, we did not contact study authors for additional information or further ongoing research. In contrast to systematic reviews, the absence of quality assessment of papers included in scoping reviews makes findings hard to generalize and the effectiveness of studies difficult to weigh [ 20 ].

Despite these limitations, we believe that the breadth and depth of evidence presented here is sufficiently relevant for the aims of this review. The volume of evidence presented on the use of mobile technology as a clinical decision support system in sub-Saharan Africa is an indication of growth in the domain and its potential for improving health service delivery in low-resource settings.

Several evidence gaps need to be addressed, including specific mechanisms underlying use, sustainability, and effects of mCDSS on quality of care and their ability to be fully integrated into routine practice.

In light of the effect that differences in health worker cadre, training, and intervention context could have on utilization and outcomes of mCDSS, future research should adopt comparative analyses in order to identify for whom these programs work best. It is also needful to understand in what contexts, why, how, and at what costs, mCDSS lead to changes in health worker performance.

Although quality of service delivered by these interventions on a clinical and individual level is yet to be fully explored, the evidence gathered is useful for informing future policy, practice, and research. The authors would like to thank Ralph de Vries, Vrije Universiteit Library, for his assistance and guidance in refining the search strategy and modifying it to fit the parameters of the various databases.

The funding agency had no role in study design, analysis, or preparation of the manuscript. All authors have approved the final manuscript. Edited by C Dias; submitted Skip to Main Content Skip to Footer.


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