BACKGROUND: More efficient methods to detect and treat precancerous lesions of the cervix at a single visit, such as low-cost confocal microscopy, could improve early diagnosis and hence outcomes. We piloted a prototype smartphone-compatible confocal micro-endoscope (SCME) among women presenting to a public cervical cancer screening clinic in Kampala, Uganda. We describe the piloting of the SCME device at an urban clinic used by lower cadre staff.
METHODS: We screened women aged 18 and 60 years, who presented for cervical cancer screening at the Kawempe National Referral Hospital Kampala, and evaluated the experience of their providers (nurses). Nurses received a 2-day training by the study doctors on how to use the SCME, which was added to the standard Visual Inspection with Acetic acid (VIA)-based cervical cancer screening. The SCME was used to take colposcopy images before and after VIA at positions 12 and 6 O\'clock if VIA negative, and on precancer-suspicious lesions if VIA positive. We used questionnaires to assess the women\'s experiences after screening, and the experience of the nurses who operated the SCME.
RESULTS: Between November 2021 and July 2022, we screened 291 women with a median age of 36 years and 65.7% were HIV positive. Of the women screened, 146 were eligible for VIA, 123 were screened with the SCME, and we obtained confocal images from 103 women. Of those screened with the SCME, 60% found it comfortable and 81% were willing to screen again with it. Confocal images from 79% of the women showed distinguishable cellular features, while images from the remaining 21% were challenging to analyze. Nurses reported a mean score of 85% regarding the SCME\'s usefulness to their work, 71% regarding their satisfaction and willingness to use it again, 63% in terms of ease of use, and 57% concerning the ease of learning how to operate the SCME.
CONCLUSIONS: Our findings demonstrate the feasibility of using the SCME by lower cadre staff in low-resource settings to aid diagnosis of precancerous lesions. However, more work is needed to make it easier for providers to learn how to operate the SCME and capture high-quality confocal images.

BACKGROUND: Task shifting is an approach where specific tasks are transferred, when convenient, from health workers with high qualifications to health workers with less training and lower qualifications. This approach is mainly used to utilize the available human resources for health. Tasks that are traditionally linked to the physician role have increasingly been transferred to registered nurses during the last decade. Knowledge regarding the experiences and reflections of physicians and their leaders related to giving up tasks or how such policies can best be implemented is limited. This study aimed to explore physicians\' and their leaders\' perspectives on task shifting, especially to registered nurses, in different Norwegian emergency departments.
METHODS: The study was carried out from June to October 2022. It had an explorative and descriptive qualitative design and an inductive approach, semi-structured interviews was used. The study involved ten physicians and leaders from three different regional hospitals in south-eastern Norway. Manifest and latent content analysis were used to analyse the data. The COREQ guidelines were applied in the study.
RESULTS: From the three categories 1) The rationale for task shifting, 2) Teambuilding and 3) Implementation of task shifting, with nine subcategories. One overall main theme emerged: It is not the task, it is the shifting - moving towards a person-centred culture.
CONCLUSIONS: The study indicates that developing a person-centred culture and fostering a team approach in emergency departments is more important than simply shifting tasks, as task shifting may lead to fragmented care and resistance from physicians. Hospital leaders must invest time and effort into organising teams and providing clear leadership to support the redesign of professional roles, recognising the cultural and traditional challenges involved. Policymakers should promote guideline development, team training programs, and cooperation methods to support a person-centred culture and effective task shifting in emergency departments.

This study explored the potential of telemedicine integration into the eye health ecosystem with an aim of scaling effective refractive error coverage in Kenya. This exploratory study was conducted telephonically and through online interviews with key opinion leaders, ophthalmologists, optometrists, ophthalmic clinical officers, optical technicians and beneficiaries of the optical technician\'s services in rural areas. A telemedicine workflow was developed and validated based on the comments from the key opinion leaders using the Delphi technique. Quantitative and qualitative data were analysed using SPSS and NVivo Software respectively. All of the key opinion leaders agreed that telemedicine is relevant in the eye health ecosystem and recognition of primary vision technicians is critical for effective telemedicine integration. The reasons for the need of telemedicine integration were categorized into; good relationship, organized refractive error service delivery, convenience and availability and cost reduction. The possible factors influencing integration of telemedicine identified were categorized into cost, unwillingness, dominance, perception, lack of technical team, policies and network coverage. The limited human resources in the eye health ecosystem in developing countries cannot effectively deliver refractive error services to the growing population. Hence, integration of telemedicine and establishment of policies recognizing telemedicine are desirable to strengthen task shifting and scale effective refractive error coverage.

UNASSIGNED: The implementation of task sharing and shifting (TSTS) policy as a way of addressing the shortage of physicians and reducing the burden of hypertension in Africa birthed the idea of the African School of Hypertension (ASH). The ASH is saddled with the responsibility of training non-physician health workers across Africa continent in the management of uncomplicated hypertension.
UNASSIGNED: To get feedback from some faculty members and students who participated in the first ASH programme.
UNASSIGNED: This was a cross-sectional exploratory qualitative study conducted among eight students and eight faculty members. Feedback from the program was obtained by conducting in-depth interviews centred on description of course content; expectations and knowledge acquired from ASH; level of interaction between students and faculty members; challenges faced during the ASH; level of implementation of acquired training; and suggestions to improve subsequent ASH programs.
UNASSIGNED: The course content of the ASH was described as simple, appropriate and adequate while interaction between students and faculty members were highly cordial and engaging. New knowledge about hypertension management was acquired by the students with different levels of implementation post-graduation. Some identified challenges with the ASH program were poor internet connectivity during lectures, non-uniformity of TSTS policies and hypertension management guidelines across Africa, technical problems with hypertension management app and low participation from other African countries apart from Nigeria. Some recommendations to improve ASH program were development of a uniform hypertension management guideline for Africans, wider publicity of the ASH, interpretation of lectures into French and Portuguese languages and improvement of internet connectivity.
UNASSIGNED: The ASH programme has largely achieved its objectives with the very encouraging feedback received from both faculty members and the students. Steps should be taken to address the identified challenges and implement the suggested recommendations in subsequent ASH program to sustain this success.

BACKGROUND: Physicians and associate (non-physician) clinicians conduct cesarean sections in Tanzania and Malawi. Urogenital fistulas may occur as complications of cesarean section. Location and circumstances can indicate iatrogenic origin as opposed to ischemic injury following prolonged, obstructed labor.
METHODS: This retrospective review assessed the frequency of iatrogenic urogenital fistulas following cesarean sections conducted by either associate clinicians or physicians in Tanzania and Malawi. It focuses on 325 women with iatrogenic fistulas among 1290 women who had fistulas after cesarean birth in Tanzania and Malawi between 1994 and 2017. An equivalence test compared the proportion of iatrogenic fistulas after cesarean sections performed by associate clinicians and physicians (equivalence margin = 0.135). Logistic regression was used to model the occurrence of iatrogenic fistula after cesarean section, controlling for cadre, date, maternal age, previous abdominal surgery and parity.
RESULTS: Associate clinicians attended 1119/1290 (86.7%) cesarean births leading to fistulas, while physicians attended 171/1290 (13.3%). Iatrogenic fistulas occurred in 275/1119 (24.6%) cesarean births by associate clinicians and in 50/171 (29.2%) cesarean births by physicians. The risk difference and 90% confidence interval were entirely contained within an equivalence margin of 13.5%, supporting a conclusion of equivalence between the two cadres. The odds of iatrogenic fistula after cesarean section were not statistically significantly different between associate clinicians and physicians (aOR 0.90; 95% CI 0.61-1.33).
CONCLUSIONS: Associate clinicians appear equivalent to physicians performing cesarean sections in terms of iatrogenic fistula risk. Lower iatrogenic proportions for associate clinicians could reflect different caseloads. The occurrence of iatrogenic fistulas illustrates the importance of appropriate labor management and cesarean section decision-making, irrespective of health provider cadre. Given the noninferior performance and lower costs of employing associate clinicians, other countries with insufficient and/or unequally distributed health workforces could consider task-shifting cesarean sections to associate clinicians.

UNASSIGNED: Medication prescribing by pharmacists is a task shifting approach to help ensure quality and accessibility of healthcare. In many countries, like the Netherlands, pharmacist prescribing is not legally ensured, and it is unknown what citizens think of its potential introduction.
UNASSIGNED: To investigate citizen perspectives on the potential role of pharmacists in prescribing in primary care.
UNASSIGNED: A Citizen Platform with citizens (>18 years) from the Netherlands was conducted in October 2022. This consisted of a one-day program in which the participants were engaged in interactive assignments and received expert presentations to foster the development of informed opinions. In the final assignment, 3 participant groups designed their ideal future scenario including preconditions regarding the role of the pharmacist in prescribing in primary care. All assignments were recorded, and notes were taken. The researchers then consolidated the 3 scenarios into one version and categorized the preconditions. The Citizen Platform results were summarized and subsequently discussed in 2 online focus groups with other citizens in February 2023 to investigate the perspectives of less informed citizens. Focus group discussions were audio-recorded, transcribed, and thematically analyzed.
UNASSIGNED: The Citizen Platform (n = 10) resulted in a shared scenario involving a primary care center where general practitioners (GPs) pharmacists and other healthcare professionals collaborate as a team. In this scenario, pharmacists can modify treatment in certain chronic diseases, manage minor ailments and support GPs with the care for patients with complex needs. Preconditions needed to realize this scenario include having shared medical records, the GP retaining the overview of the care for the patient and additional training for pharmacists. The focus groups (n = 6, in total) yielded 5 themes which acknowledge potential pharmacist prescribing but depict a more skeptical view towards pharmacist prescribing and include several concerns, for example pharmacists\' potential conflict of interest.
UNASSIGNED: Citizens that are informed about opportunities for pharmacy prescribing are capable of sketching potential scenarios for pharmacist prescribing in a collaborative primary care context. Less informed citizens seem more skeptical towards pharmacist prescribing.

BACKGROUND: Despite increasing morbidity and mortality from non-communicable diseases (NCD) globally, health systems in low- and middle-income countries (LMICs) have limited capacity to address these chronic conditions, particularly in sub-Saharan Africa (SSA). There is an urgent need, therefore, to respond to NCDs in SSA, beginning by applying lessons learned from the first global response to any chronic disease-HIV-to tackle the leading cardiometabolic killers of people living with HIV (PLHIV). We have developed a feasible and acceptable package of evidence-based interventions and a multi-faceted implementation strategy, known as \"TASKPEN,\" that has been adapted to the Zambian setting to address hypertension, diabetes, and dyslipidemia. The TASKPEN multifaceted implementation strategy focuses on reorganizing service delivery for integrated HIV-NCD care and features task-shifting, practice facilitation, and leveraging HIV platforms for NCD care. We propose a hybrid type II effectiveness-implementation stepped-wedge cluster randomized trial to evaluate the effects of TASKPEN on clinical and implementation outcomes, including dual control of HIV and cardiometabolic NCDs, as well as quality of life, intervention reach, and cost-effectiveness.
METHODS: The trial will be conducted in 12 urban health facilities in Lusaka, Zambia over a 30-month period. Clinical outcomes will be assessed via surveys with PLHIV accessing routine HIV services, and a prospective cohort of PLHIV with cardiometabolic comorbidities nested within the larger trial. We will also collect data using mixed methods, including in-depth interviews, questionnaires, focus group discussions, and structured observations, and estimate cost-effectiveness through time-and-motion studies and other costing methods, to understand implementation outcomes according to Proctor\'s Outcomes for Implementation Research, the Consolidated Framework for Implementation Research, and selected dimensions of RE-AIM.
CONCLUSIONS: Findings from this study will be used to make discrete, actionable, and context-specific recommendations in Zambia and the region for integrating cardiometabolic NCD care into national HIV treatment programs. While the TASKPEN study focuses on cardiometabolic NCDs in PLHIV, the multifaceted implementation strategy studied will be relevant to other NCDs and to people without HIV. It is expected that the trial will generate new insights that enable delivery of high-quality integrated HIV-NCD care, which may improve cardiovascular morbidity and viral suppression for PLHIV in SSA. This study was registered at ClinicalTrials.gov (NCT05950919).

UNASSIGNED: Primary healthcare is the first point of entry into the healthcare system. Scaling up primary mental healthcare is recommended in South African mental health policy. However, there is a paucity of data exploring the views of primary healthcare nurses (PHCNs) with regards to caring for people living with mental illness (PLWMI) in South Africa.
UNASSIGNED: To explore the views of PHCNs around caring for PLWMI and task shifting.
UNASSIGNED: A community health centre in Gauteng province, South Africa.
UNASSIGNED: A qualitative study design using the framework approach was employed. Semi-structured individual interviews were conducted among a convenient sample of PHCNs in a community health centre in Gauteng. Interviews were transcribed and data analysed thematically.
UNASSIGNED: Eight PHCNs were interviewed in June 2022. Five themes emerged: (1) participants highlighted their current practice which excludes mental healthcare; (2) participants described feeling fearful of caring for PLWMI; (3) participants ascribed their lack of confidence in caring for PLWMI largely due to insufficient under- and post-graduate mental healthcare training. (4) task shifting was not welcome due to inadequate mental healthcare training and preexisting challenges in the healthcare system; and (5) recommendations to prioritise mental healthcare training prior to implementing task shifting were made.
UNASSIGNED: Primary healthcare nurses, although empathic towards PLWMI, expressed discomfort with caring for them. This is influenced by multiple factors, some of which may be addressed by improved training and support.
UNASSIGNED: This study provides insight into how PHCNs feel about caring for PLWMI and task shifting.

Treating children with acute malnutrition can be challenging, particularly regarding access to healthcare facilities during treatment. Task shifting, a strategy of transferring specific tasks to health workers with shorter training and fewer qualifications, is being considered as an effective approach to enhancing health outcomes in primary healthcare. This study aimed to assess the effectiveness of integrating the treatment of acute malnutrition by community health volunteers into integrated community case management in two sub-counties in northern Kenya (Loima and Isiolo). We conducted a two-arm non-inferiority cluster-randomized controlled trial across 20 community health units. Participants were children aged 6-59 months with uncomplicated acute malnutrition. In the intervention group, community health volunteers used simplified tools and protocols to identify and treat eligible children at home and provided the usual integrated community case management package. In the control group, community health volunteers provided the usual integrated community case management package only (screening and referral of the malnourished children to the health facilities). The primary outcome was recovery (MUAC ≥12.5 cm for 2 consecutive weeks). Results show that children in the intervention group were more likely to recover than those in the control group [73 vs 50; risk difference (RD) = 26% (95% CI 12 to 40) and risk ratio (RR) = 2 (95% CI 1.2 to 1.9)]. The probability of defaulting was lower in the intervention group than in the control group: RD = -21% (95% CI -31 to -10) and RR = 0.3 (95% CI 0.2 to 0.5). The intervention reduced the length of stay by about 13 days, although this was not statistically significant and varied substantially by sub-county. Integrating the treatment of acute malnutrition by community health volunteers into the integrated community case management programme led to better malnutrition treatment outcomes. There is a need to integrate acute malnutrition treatment into integrated community case management and review policies to allow community health volunteers to treat uncomplicated acute malnutrition.

UNASSIGNED: Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC).
UNASSIGNED: To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC.
UNASSIGNED: Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary.
UNASSIGNED: The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive.
UNASSIGNED: The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.
Task shifting from general practitioners to other health professionals could increase treatment capacity in out-of-hours primary care.Task shifting occurs for care to patients with less urgent and less complex health issues.The long-term implications of task shifting in out-of-hours primary care should be investigated.