The Center for Global Health (CGH) offers clinical rotations at international partner institutions to FSM students during the summer between their first and second-year of medical school as well as at various points during phase II and phase III of the curriculum. After first year, FSM students pursue independent research projects, mentored by a Northwestern faculty member, that meet the Area of Scholarly Concentration requirement.
The mission of the Area of Scholarly Concentration (AOSC) is to train students to perform a highly mentored project which culminates with the writing of a thesis. The goals of this program include the performance – in a highly individualized area of independent study – of a hypothesis-driven investigation or formal project in biomedical research or a medically related fields. Areas of investigation include clinical investigation, translational medicine, global health, community and family health, medical humanities and the medical social sciences. These investigations will enhance the student’s ability to identify and solve problems, encourage critical thinking and develop mentored relationships with Northwestern University and Feinberg faculty members. Learn more about the AOSC program here.
Funding is available to FSM students who wish to pursue a global health AOSC project via the Global Health Initiative.
There are generally two paths to participate in a global health program during the summer between first and second year of medical school. The first path involves identifying an independent AOSC project during four weeks of the nine-week summer break and conducting research at Feinberg’s campus in Chicago. Pending approval by both your AOSC mentor and advisor, a student may apply to participate in a four-week clinical rotation at one of FSM’s global partners generally after the AOSC requirement is met. It is important to note that AOSC is a graduation requirement while a global health rotation is an elective.
The second path involves identifying a global health research project at an international site. This requires getting an early start on the AOSC project and identifying a mentor who can assist the student to identify a feasible study at an international site. A second mentor must be identified at the host-institution and the study protocol needs to be reviewed by both Northwestern and the host-university’s Institutional Review Board.
Other requirements for a global health AOSC project include:
- The student identifies a Feinberg School of Medicine mentor and a hypothesis-driven investigation by early December
- The mentor and the student’s AOSC Thesis Advisor approve the AOSC project
- Student meets regularly with their mentor (at least once per month) over the winter and spring of the current academic year to develop the AOSC project
- The project is reviewed by IRB and approved or determined to be exempt
- Data collection, analysis, and synthesis into a thesis will be performed in June or July for a minimum of four weeks
- Student presents a poster at the Feinberg School of Medicine’s global health day, evaluate their global health rotation upon their return to Chicago, and complete all pre-departure requirements and attend required preparatory meetings at CGH
- Student completes all other AOSC requirements prior to graduation
Meeting with a Mentor
- Students are encouraged to review faculty profiles and their research interests via recent publications and contact faculty to learn more. An excellent place to start is the roster of affiliated CGH faculty
- Another resources is the Global Health Portal faculty directory, which includes NU faculty across all Northwestern schools with research interests
Global Health Area of Scholarly Contentration Past Projects
Investigator: Hayley Sparks
Mentor: Lucy Linley (MD) and Daniel Robinson (MD)
Research Site: Mowbray Maternity Hospital, Cape Town, South Africa
Background: For mothers unable to provide their own milk for infant feedings, alternative feeding options include formula and donor expressed breast milk (DEBM). Research suggests that DEBM may be associated with better outcomes than formula, particularly for preterm infants.1 At the Mowbray Maternity Hospital (MMH) neonatal intensive care unit, specific criteria exist for the use of DEBM, including positive maternal HIV status. MMH provides care for a resource limited population in Cape Town, South Africa with a high burden of HIV. To date, there has been no evaluation of adherence to the clinical criteria for use of DEBM or an evaluation of resources utilized to sustain DEBM use at MMH. The objective of this study was to define the use of DEBM at MMH. Our research aims were to 1) measure infant outcomes associated with use of DEBM, including infants born to HIV+ women and all infants using DEBM, 2) define compliance with the defined criteria for use of DEBM in the MMH neonatal intensive care unit, and 3) define total use of DEBM so as to inform Milk Matters (the DEBM bank) of expected resources needed annually, e.g. volume of milk, to sustain provisions of DEBM to MMH.
Methods: We used a retrospective cohort analysis to measure DEBM use in infants cared for at MMH. Screening for eligible infants involved a retrospective medical record review to include all infant charts that contained consent for DEBM use in the medical record for infants admitted January 1, 2015- January 1, 2016. Data variables collected from the chart for each patient included: 1. Demographic characteristics: maternal age at delivery, maternal medical problems during pregnancy, gestational age at delivery, infant growth characteristics at birth, and mode of delivery and 2. Outcome data: nutritional intake during hospitalization (volume of milk, duration of DEBM use, other forms of nutrition used during hospitalization (formula, mother’s own milk), infant growth through discharge, prevalence of morbidities acquired during hospitalization (e.g. sepsis, chronic lung disease), and length of stay.
Results: Medical records for 106 infants contained signed consent for DEBM. Of those infants who survived to discharge, 39% were born to HIV positive mothers. Women with a mean (± standard deviation) age of 27.7 ± 6.2 years delivered at 31.2 ± 3.3 weeks of gestation. Infant birth weight was 1415 ± 690 grams. Analysis of feeding and growth outcomes for these infants is ongoing.
Conclusions:DEBM is used for preterm infant feedings in a resource limited setting with a high burden of HIV positive mothers. Further analysis will define clinical and growth outcomes associated with DEBM feedings as well as the predominance of DEBM feedings as related to mother’s own milk and/or infant formula.
1. Arslanoglu, S., Moro, G. E., & Ziegler, E. E. (2006). Adjustable fortification of human milk fed to preterm infants: does it make a difference?. Journal of Perinatology, 26(10), 614-621.
Investigator: Matthew Doerfler
Mentor: Dr. Sally McFall, PhD
Research Site: Cape Town, South Africa
Background: Rapid and accurate tuberculosis (TB) screening is critical to public health in South Africa, as the country bears high prevalences of TB infection, drug-resistant TB, and TB/HIV co-infection. To address this, the Center for Innovation in Global Health Technologies (CIGHT) at Northwestern University, Quidel Corporation, and other academic institutions are developing an improved molecular platform for PCR-based TB diagnostics. The platform uses a unique device for both collecting and processing sputum. In this study, feedback on two collection jar prototypes and the current design was gathered from focused interviews with laboratory users and hospital transport staff around Cape Town, South Africa.
Methods: Focused interviews were performed with laboratory users involved in the processing of patient sputum as well as professional drivers transporting collected sputum. A “rocket” prototype, a “squeeze” prototype, and the current jar were analyzed. In each case, the participant was presented with the standard cup designs and asked five questions regarding his or her workflow, opinions, and ideas for improvement. The prototypes were then introduced in alternating order between interviews, and five questions were asked regarding each. The prototypes were compared to the standard cup designs. Lastly, the participants quantified both the usability and safety of all three jars on a scale of 1 to 10.
Results: Interviews were collected from ten laboratory users. Nine said that the squeeze prototype would negatively impact their workflow, with all nine pointing to its inability to stand. Six stated that the rocket model would positively impact their workflow, with seven favoring the maximum/minimum lines. The current jar was perceived to be significantly easier to use than the squeeze model (p-value: 0.009), while no difference was observed between the current jar and the rocket model (p-value: 0.4). The squeeze model was viewed as significantly less safe than the rocket model (p-value: 0.0007). Three transportation staff also participated in interviews. Two were concerned about the jars cracking and emphasized that the containers undergo stress during transport. Otherwise, all drivers thought the design would not affect transport.
Conclusions: The most successful design for a sputum collection jar in this setting would be self-supporting and sturdy, with lines demarcating volume between 1 ml and 5 ml. It is essential that the lid makes a tight seal with the container. Furthermore, a flat surface should exist on the outside to which labels may be attached. When designing this device, more attention should be given to laboratory users than transportation staff. Based on the results of this study, one recommendation would be an inner, conical shape surrounded by a cylindrical container.
Investigator: Jordan Rook
Mentor: Mamta Swaroop, MD
Research Site: Bolivia
Background: More than 5 million people die each year as a result of injuries accounting for 9% of the world’s deaths. Low-income and middle-income countries (LMICs) are disproportionately affected, accounting for more than 90% of theses fatalities (1).
Bolivia, a land-locked country in South-America, ranks low among Latin American countries in several areas of health and development including: poverty, education, mortality, and life expectancy (2). Currently 13% of deaths in Bolivia are attributed to injuries with that figure only expected to rise in the coming years. Currently, Bolivia lacks a universal and organized EMS system. Improvement is imperative as it is estimated that 34-48% of all injury deaths in LMICs could be prevented if the quality of trauma care were elevated to the standards of high-income countries (3).
Methods: 17 semi-structured interviews were collected with trauma patients in 4 hospitals throughout Santa Cruz de la Sierra, Bolivia’s second most populous city. Hospitals included two large public healthcare facilities-equivalent to level-1 trauma centers, a second level public hospital, as well as Santa Cruz’s preeminent private hospital. Participant injuries ranged in severity from Achilles tendon ruptures to open fractures, and intracranial hemorrhages. Patients were asked about pre-hospital experiences as well as the quality of their care and any improvements they believed necessary of the EMS and trauma system. Interviews are in the process of being transcribed, de-identified, and translated, and will eventually be coded and analyzed.
Results: (Results are preliminary. Coding and analysis has not yet begun). Throughout the 16 interviews obtained at public hospitals, a few themes stood out. Patients were often transported to multiple hospitals with transit times as extensive as 24 hours before arrival at a tertiary hospital center capable of treating their injuries. Patients distrust public ambulances with the majority choosing to take taxis in the case of emergencies. In addition they often do not know the number to call an ambulance, relying on the Internet. Patients would like training in basic first aid, and they largely believe that Bolivian’s would assist one another in emergency situations. Patients often believe that the word trauma describes either broken bones or emotional trauma. This is inconsistent with the definition of emergent injury that is common in English speaking countries. As for the 1 interview conducted at the private hospital, the patient received prompt care at the hospital, and had no complaints about the quality of her care. An unrelated theme that became clear during the project is a crippling delay in orthopedic operations due to the expectation that patients buy their hardware and medical supplies prior to operations.
Conclusion: Although the results are preliminary, the findings seems promising and may be helpful in designing and implementing culturally specific EMS improvements and interventions in Santa Cruz de la Sierra as well as Bolivia as a whole. This data will complement the quantitative data collected via trauma registry at the 4 participating hospitals.
1) Injuries and Violence, The Facts 2014. World Health Organization. Geneva Switzerland. 2015
2) CIA Factbook, Bolivia.https://www.cia.gov/library/publications/the-world-factbook/geos/bl.html. Accessed 1/19/16
3) Mock, C. N., M. Joshipura, C. Arreola-Risa, and R. Quansah. 2012. “An Estimate of the Number of Lives That Could Be Saved through Improvements in Trauma Care Globally.” World Journal of Surgery 36 (5): 959–63.
Investigator: Katie Truitt
Mentor: Mark Fisher, PhD
Research Site: Cape Town, South Africa
Background: Northwestern University’s Center for Innovation in Global Health Technology (CIGHT), along with Quidel Corporation and multiple other academic institutions, is developing a new PCR-based tuberculosis (TB) screening test that promises to be both significantly faster and more sensitive than current models. The system requires the use of a new sputum collection cup. Two prototypes of potential collection cup options were designed by CIGHT. These cups were brought to Cape Town, South Africa to gain user feedback. South Africa has an incredibly high burden of TB, with 80% of the population infected with the bacterium and 1% of the population developing active TB each year. In South Africa, TB is the leading cause of death.
Methods: Two cup options were designed by CIGHT for use within the Savanna PCR-based TB diagnostics platform. These cups allow collection and decontamination of a sputum sample to be done within the same cup and also can be placed straight into a heating and mixing device. Field observation was done in TB screening and treatment clinics in Cape Town to better understand existing workflow in gathering and processing sputum in the current collection cups. Following this, interviews to gain user feedback on the cups were performed on nurses and other health care workers in Cape Town using a mix of open ended and scale 1-10 questions. To qualify for this study, interviewees had to be directly involved in gathering a sputum sample from patients. Ten interviews were done at five different care facilities.
Results: In comparing their current sputum collection cup to the two new models designed by CIGHT, 70% of interviewees would prefer to keep using their current cup. Of those who would use on of CIGHT’s options, all picked Option 1, a cup with a funnel shape made of a harder plastic. No interviewees wanted to use Option 2, an elliptical shaped cup made of malleable plastic. Both of CIGHT’s options have minimum and maximum markings and all interviewees responded that they liked these markings. Positive feedback of Option 1 noted its hard plastic base, nicely screwing cap, and its ability to fit into containers already used for storing current cups. Negative elements include the lack of space to place a label and the need for patients to hold the cup near the top, potentially causing them to cough on their hands. Positive feedback for Option 2 again noted the nicely screwing cap. Negative feedback included concerns that it would need to be stored upside down in order to rest on a flat surface and that the edges seem like a potential place for tearing and leakage, creating worry for increased TB exposure.
Conclusion: This study demonstrates the impact research and scientific advances can have in the front lines of caring for patients. Feedback from those using sputum collection cups every day should continue to be gathered in order to design the most user friendly and effective diagnostic testing system.
1. Kanabus, Annabel "Information about Tuberculosis", GHE, 2016, www.tbfacts.org
Investigator: Chintan Pathak
Mentor: Mamta Swaroop, MD
Research Site: New Delhi, India
Background: Helmet usage has long been a cornerstone in preventing and minimizing injuries in MTW accidents; however, helmet usage laws have been slow to be implemented in India. In 1988, India passed the Motor Vehicle Act which made it mandatory for MTW riders to wear helmets. This law was adapted and implemented in New Delhi in 1997. However, two years later, women pillions and Sikhs were exempted from wearing helmets when the law was challenged as undermining religious expression in the New Delhi High Court. These exemptions made the law difficult to enforce. In a study conducted in 2011, of those observed, 58.7% were helmeted and 41.3% were unhelmeted. In 2014, the New Delhi government revised the law requiring all motorized two wheeler riders to wear helmets exempting only Sikh women. The purpose of this study is to determine the prevalence of helmet usage in motorized two-wheeled (MTW) vehicle riders in New Delhi, India.
Methods: In order to quantify helmet usage in New Delhi, at least twenty-five minutes of video was taken each in the morning rush hour, mid-day, and evening rush hour from June 15-June 25th, 2016 at four representative intersections in the city. (Rajiv Chawk Circle and Barakhambha Road, intersection, AIIMS Trauma Center road and Mahatma Ghandi Road intersection, India Gate C Hexagon, Safdarjung Hospital Road and Mahatma Gandhi Road intersection) These intersections are comprised of a mix of residential, business, and mixed-use locations.
Results: Results from this study are not yet available as the videos recorded have not yet been reviewed. The video recordings will be analyzed for the number of MTW riders, their gender, approximate age (adult or child), and helmet usage by two reviewers who are versed in Indian culture.
Conclusion: While the results are not yet available, the key factor in this study will be determining if helmet usage in MTW riders has increased following the helmet law change in New Delhi. If this is the case, future studies could look at changes in patterns of injury in MTW collisions. Potential limitations of this study are that construction projects have changed the roads that were analyzed in the 2011 study. As such, results from this study may not be directly comparable to the previous study. Additionally, factors such as weather and seasonal variations could also limit the generalizability of the data given the short data collection window of this study.
Investigator: Jonathon Judkins
Mentor: Priya Kumthekar, MD & Judith Paice, PhD/RN
Research Site: Mary Potter Palliative Care Clinic, Korçe, Albania
Background: Palliative care services in Albania have been developing slowly over the past two decades, but when compared with these services in more highly developed healthcare systems, the palliative care options available in Albania is ruefully inadequate. Even with the progress seen in the field in the last twenty years, there is little-to-no support for the family members of terminally ill patients. This goal of this study was to assess the wellbeing of family-member caregivers of terminal cancer patients in four key areas: physical wellbeing, social wellbeing, psychological wellbeing, and spiritual wellbeing. The aim was to identify which of these areas would be most beneficial to target in newly developed programs aimed at these family-member caregivers.
Methods: This study took place between May and July 2016 in Korçe, Albania and the surrounding villages. A convenience sample of 40 family-member caregivers who had a family member receiving palliative care at the Mary Potter Palliative Care Clinic were recruited either in the Clinic, or during a home-visit if the patient was unable to leave the home. We defined a caregiver (an eligibility criterion for the study) as anybody in the household who contributed to the patient’s care, although 35 of 40 respondents self-identified as the primary caregiver. We collected demographic information about both the individual participant, as well as information about the household as a whole.
A 37-item ordinal survey, developed at the City of Hope Beckman Research Center to assess caregiver wellbeing, was translated into Albanian and administered by Albanian staff members of the clinic. The family member caregivers responded to each question with a numerical answer from 0-10, with 0 meaning “worst outcome” and 10 meaning “best outcome.”
Preliminary Results: The analysis completed thus far has compared the responses to individual questions, as well as the cumulative responses for each of the four categories: physical, psychological, social, and spiritual wellbeing.
The two questions with the most negative responses were: “How distressing has your family member’s illness been for your family?” (1.55, 95% CI: 0.65 – 2.45) and “How distressing was your family member’s initial diagnosis for you?” (1.53, 95% CI: 0.72 – 2.34).
The two questions with the most positive responses were: “How useful do you feel?” (8.38, 95% CI: 7.77 – 8.99) and “Is the amount of support you receive from others sufficient to meet your needs?” (6.90, 95% CI: 5.88 – 7.92).
Physical wellbeing had a mean of 4.38 (95% CI: 3.92 – 5.14). Psychological wellbeing had a mean of 4.37 (95% CI: 4.09 – 4.65). Social wellbeing had a mean of 4.02 (95% CI: 3.60 – 4.44). Spiritual wellbeing has a mean of 4.43 (95% CI: 3.99 – 4.87).
Analysis will continue with a multivariate analysis comparing several demographic factors with survey responses.
Conclusions: The responses to individual questions will be used to determine the best approach to pursue in the creation of support programs for the caregivers, both before and after the death of the ill family member. Although there were no significant differences between the four categories analyzed, the fact that the averages are all incredibly low illuminates the need for these caregiver-centered programs.
Limitations for this study include the cultural and religious bias due to geographical constraints. Additionally, the variety of education levels attained by participants was significant. The survey has been validated in English but was not validated in Albanian or in the population studied. Finally, there was no pathological staging information available, and this variable normally correlates highly with caregiver wellbeing, so it will remain a confounder throughout analysis.
Investigator: Varshini Cherukupalli
Mentor: Mamta Swaroop, MD & Marissa Boeck, MD
Research Site: Nanakpur, Haryana, India
Background: Global estimates show an astounding five billion people lack access to safe, quality and timely surgical care. Community level surveys are useful for characterizing unmet surgical need in low- and middle-income countries. Health facility surgical and trauma capacity evaluations aid in the identification and subsequent correction of deficiencies at each level of care. This study aimed to assess the local burden of surgical disease in a rural Indian region through the Surgeons OverSeas Assessment of Surgical need (SOSAS) tool. Government health facility surgical and trauma care capacities were estimated using a modified Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool, which incorporated questions from the International Assessment of Capacity for Trauma (INTACT) and Tool for Situational Analysis to Assess Emergency and Essential Trauma Care (TSAAEESC) instruments.
Methods: This study took place between June and July 2015 in Nanakpur, Haryana. SOSAS sampling divided the region into three sectors of eight clusters each, with two clusters randomly selected per sector resulting in 50 households designated for survey. The head of household provided demographic data, while two household members shared surgical histories in six anatomical regions. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem for which the respondent did not access care. Categorical and continuous variables were analyzed using Pearson’s chi-squared and Kruskal Wallis tests, respectively.
The modified PIPES survey was administered to the eight government health facilities with at least one operating room in Nanakpur. This included two primary health centers, one secondary-level community health center, four tertiary hospitals and one tertiary subspecialty hospital. At each location a physician, hospital administrator or scrub nurse completed the survey. Overall PIPES and INTACT indices were calculated. Median scores were compared via Wilcoxon rank sum tests.
Results: One hundred percent of households selected for the SOSAS survey participated, totaling 93 individuals with a median age of 35 years (IQR 26-50). The twenty-eight respondents (30.1%; 95% CI: 21.0-40.5) who indicated they had a current surgical need were older (median age 46.5 vs. 33 years, p=0.034) and more likely to lack travel funds to a tertiary center (64.3% vs. 32.4%, p=0.041) compared to those without a current surgical need. Six individuals had an unmet surgical need (6.5%; 95% CI: 2.45-13.5).
The modified PIPES showed the eight evaluated facilities had a median of 250 beds (IQR 6.0-784.0), three general surgeons (IQR 0-15.0), and 2.5 anesthesiologists (IQR 0.5-22.5). Median index scores were significantly higher for tertiary versus primary and community health centers: PIPES (10.667 vs. 4.19, p=0.03) and INTACT (9.25 vs. 3.75, p=0.03).
Conclusions: This study highlights the significant burden of surgical disease and stark contrasts between surgical service availability at primary/community and tertiary health care facilities in the remote area of Nanakpur. Further studies should be conducted to better estimate the burden of surgical diseases and health facility capabilities throughout India. Ideally, these results will guide resource allocation to ultimately improve surgical and trauma capabilities at all facility levels.
Investigator: Joshua Campbell
Mentor: Josh Hauser, MD
Research Site: Hospice Africa Uganda (HAU)
Background: In 2014, a consortium of global palliative care researchers created a research agenda for Africa, identifying “care outcomes and the impact of palliative care as perceived by patients and caregivers” as high priority. Because of the burden of HIV and cancer in Sub-Saharan Africa, research is critically important. At Hospice Africa Uganda (HAU), for example, 97 percent of their 25,000 patient census have diagnoses of HIV/AIDS and cancer. It has been estimated that as many as 38 percent of all hospitalized patients in Uganda need palliative care.
We hypothesized that cultural context, environmental factors, socioeconomic factors, disease burden and disease stigma contribute to unique care preferences among Ugandan patients with life limiting disease. Furthermore, these factors are likely given varying priority by patients and their caregivers, and elucidating these differences could help clarify goals of care. This study aimed to identify aspects of end of life care that HAU patients and their caregivers find most important. Secondarily, the study aimed to identify differences in care priorities between these groups.
Methods: In June and July of 2015, a convenience sample of 50 patients and 50 primary caregivers at HAU were asked to rate the importance of 31 aspects of end of life care, including symptom management, future planning, spiritual care, etc. Each respondent rated statements on a five point Likert scale. Demographic information was also collected during each survey. The survey was modified from a previous study (Steinhauser, 2003) and piloted. Trained research assistants at HAU then verbally administered the survey in either English or Luganda according to respondent preference.
Preliminary Results and Conclusions: Seven of the 31 survey questions were preliminarily analyzed for trends in response frequency. These trends suggest that caregivers feel more strongly that pain management is a priority in end of life care than do patients themselves. Both groups are split about discussing death in prognosis, perhaps reflecting the variety of cultures among the HAU patient population. Both patients and caregivers disagree that it is important to die at home, though caregivers feel more strongly about this, perhaps reflecting associated societal stigma following such an event. Both groups find it important that patients do not burden family and continue to help those around them, and both groups find spiritual care a top priority at the end of life, an area of possible expansion of services at HAU.
Limitations in this study include geographic bias for patients in the Kampala area excluding many cultures outside the Buganda Kingdom. Furthermore, survey administrators may have had bias for English speaking subjects because of the relative difficulty and slow pace of the native Luganda language. This could unintentionally exclude patients with less formal education. Finally, because the survey was designed in the US, some aspects of end of life care important to Ugandans were not included.
Investigator: Alison Murray
Mentor: Margaret Shane, MD
Research Site: Mwanza, Tanzania
Background: Pediatric residents at the Ann & Robert H. Lurie Children’s Hospital of Chicago have the chance to participate in a global health elective in Mwanza, Tanzania during their third year of training. Prior to travel, residents complete SUGAR: Simulation Use for Global Away Rotations. SUGAR focuses on emotional preparation by presenting cases that are designed to elicit common feelings encountered abroad, including frustration, floundering, futility and failure. The goal of the curriculum is to change those negative feelings into more positive ones—adaptability, awareness, acknowledgement, and adjustment—and thereby arm participants with the emotional tools and/or skills needed to properly handle potential challenges encountered during their time in low-resource areas. In preparation for conducting research investigating the impact of the SUGAR curriculum on the residents’ elective experiences, I visited three sites to gain exposure to the conditions and challenges encountered by the residents.
Experience #1: Bugando Medical Centre, Cardiac Mission
Bugando Medical Centre is a 900-bed tertiary referral hospital located in Mwanza. I shadowed a cardiologist who was organizing a pediatric cardiac surgical mission, sponsored by Mending Kids International, a group that provides surgical care to children worldwide. Cases seen included congenital heart defects and rheumatic heart disease. This is the same environment where the residents participate in morning rounds and spend the afternoon teaching.
Experience #2: Baylor International Pediatric AIDS Initiative (BIPAI), Center of Excellence
At the BIPAI clinic, I observed patient care days designated for school-aged children, adolescents, and those co-infected with tuberculosis, which is similar to what residents see when they visit. Baylor also does outreach into the community, including a camp for pre-adolescents, a monthly teen club, and Stitch by Stitch, a program where HIV-positive adolescents who are no longer in school are taught to sew and given business training to help them become self-sufficient.
Experience #3: Forever Angels Baby Home
Forever Angels is an orphanage located in Mwanza that provides care to orphaned or abandoned children. During my time at Forever Angels, I interacted with older toddlers and young infants and was able to inquire about their social and medical histories. The pediatric residents make a visit to this site during their rotation as well.
Lessons Learned: Some of the challenges I observed included prioritization of surgical care with so many children in need, loss of electrical power, insufficient blood products, and difficulties gaining access to laboratory services. In addition, social issues came to the forefront during the three experiences. These included abandonment of children with serious medical conditions, and stigmatization of those with HIV and albinism, which is still prevalent in Tanzania
Future Research: While in Tanzania, I frequently felt negative emotions related to the lack of resources and resultant impaired treatment. The SUGAR curriculum addresses these emotions head on. Surveying the pediatric residents will be key to understanding the impact of the SUGAR training and in determining if there are any emotional tools missing from the curriculum that should be further developed in the future.
Investigator: Robert Dorfman
Mentor: Lifang Hou, MD
Research Site: Fudan University, Shanghai, China
Background: Butyrate is an energy source for colonocytes, formed by bacterial fermentation of dietary fiber in the colon, that has broad anti-inflammatory activities. Although the administration of butyrate is known to improve general homeostasis in patients and to ameliorate inflammatory bowel disease (IBD)-related lesions and symptoms, the mechanism of its anti-inflammatory effects remain unclear. The purpose of this study was to compare fecal butyrate concentrations in ulcerative colitis (UC) patients and controls, as well as to elucidate the anti-inflammatory mechanisms of butyrate in a rat model.
Methods: Fresh fecal samples from both humans and rats were collected, weighed, and stored at -80˚C. The samples were then mixed with pure water and centrifuged. The supernatant was collected, filtered through a 0.22 μm filter, and mixed with ether and 98.3% sulfuric acid. Following centrifugation, the ether layer was collected and measured in an Agilent 6890N Gas Chromatograph for determination of short chain fatty acid (SCFA) concentration. For the modeling of colorectal colitis, rats (Sprague-Dawley 7 week-old males) were housed in a laminar flow, pathogen-free specific atmosphere. Colitis was induced by trinitrobenzene sulphonic acid (TNBS) administration; the TNBS solution was slowly administered to the colon (100 mg/kg body weight) via a 4.7-mm-diameter catheter, with vehicle administration as a control. Following TNBS-administration, the rats were gavaged daily with sodium butyrate solution (0.055 g/kg body weight) for 20 consecutive days, whereas the control rats were gavaged with vehicle. The rats were weighed, and blood as well as fresh fecal samples were collected. IL-10 , which can be used to assess systemic levels of inflammation, was measured using a commercially available ELISA kit according to the manufacturer’s instructions. For western blotting, cells were lysed using 0.5% NP40 lysis buffer and proteins were blotted following standard protocol.
Results: Ulcerative colitis (UC) patients had a net concentration of butyric acid that was significantly lower than that of healthy controls. Moreover, rats in the TNBS-treated colitis group had significantly lower net concentrations of butyric acid and total SCFA concentrations than did rats in the control group. Following administration of sodium butyrate, fecal concentration of butyric acid, total SCFA, and butyric acid percentages were higher in the butyrate group versus the colitis group. Rats in the TNBS-treated colitis group had significantly smaller weight gain, as well as more severe inflammation, than did control group rats. Butyrate administration significantly ameliorated the weight loss and colon inflammation in rats within the colitis group. Plasma levels of the anti-inflammatory cytokine IL-10 were higher in the butyrate group than in the colitis group. The colonic cytokine results were consistent with the plasma results.
Conclusions: Our study confirmed that UC patients had lower fecal butyrate concentrations than did the control group. It was also found that oral administration of butyrate resulted in increased percentage of butyric acid, fecal concentration of butyric acid, and total SCFA. This resulted in improved health status, including increased weight gain and lower colonic inflammation, in the butyrate group rats as compared to the colitis group. These results were further confirmed by cytokine testing. Oral administration of butyrate resulted in increased levels of IL-10 in the butyrate group, suggesting that butyrate had anti-inflammatory effects. Our results suggest that butyrate may play a role in protecting the colon mucosa against the development of IBD.
Investigator: Kevin Blair
Mentor: Mamta Swaroop, MD, Department of Surgery, Feinberg School of Medicine
Research Site: Potosi, Bolivia
Background: To guide improvements in surgical and trauma care in low- and middle-income countries (LMICs), tools to measure available resources are needed. Several tools have been developed in recent years to assess surgical and trauma care in resource poor areas, two of which are the Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool and the International Assessment of Capacity for Trauma (INTACT).
The Plurinational State of Bolivia is a land-locked country in central South America that ranks at or near the bottom for several health and development indicators, such as poverty, mortality and life expectancy. The county is divided into nine administrative departments, one of which is the department of Potosí in the southwest corner of the country. In this study, we evaluate the surgical and trauma care capacity of the public health care system in the department of Potosí using PIPES and INTACT.
Methods: An evaluation using a combined PIPES and INTACT survey was conducted in Potosí in coordination with SEDES, the departmental level of the Bolivian Ministry of Health and Sports. The inclusion criteria used for site selection were government health care facilities, either public or social security facilities, with at least one operating room (OR). Private facilities were not included. Within the department of Potosí, SEDES staff identified 22 facilities as having at least one operating room. Two facilities were excluded due geographic difficulties.
Data collection occurred during a six-week period in June and July of 2014. Site visits to 20 public hospitals were conducted by one or two of the authors. At each facility, a surgeon, head physician, director or gynecologist filled out the PIPES/INTACT survey of 121 questions. Outcomes measured included the availability of items in each subsection (personnel, infrastructure, procedures, equipment, supplies) as well as the PIPES and INTACT indices. Indices were calculated by summing the respective items for PIPES and INTACT, dividing by the total number, and multiplying by 10.
Results: Twenty hospitals were visited in ten cities within the department of Potosí. Survey results indicate a shortage of both human and physical resources needed to provide surgical and trauma care. Eight facilities had neither a surgeon nor an anesthesiologist and four of those facilities indicated that their ORs were non-functional. Similar deficiencies in procedures, equipment and supplies were noted. The two tertiary care centers, both located in the city of Potosí, scored highest on both the PIPES and INTACT indices, with scores of 10.7 and 9.5 for Caja Nacional and 10.3 and 9.5 for Daniel Bracomante.
Conclusions: The results of the present study provide SEDES with the department’s capacity to provide surgical and trauma care. After data analysis is complete, we will provide SEDES with each facility’s score as well as specific items at each facility that are deficient. SEDES and individual hospital directors can then plan and implement more directed improvement programs over the coming years, after which the survey can be administered again to track progress.
Investigator: Mac Chamberlin
Mentor: Marck Molitch, MD, Division of Endocrinology, Feinberg School of Medicine
Research Site: Centro Medico Humberto Parra, Bolivia
Background: There is a large burden of Diabetes Mellitus in low and middle-income countries. According the WHO, 347 million people currently have diabetes, and 80% of them live in these countries. The management of chronic disease in low income areas is a very complex challenge.
Centro Medico Humberto Parra serves 12 communities northwest of Santa Cruz, Bolivia. It was started 14 years ago by a collaboration between American and Bolivian doctors. Three years ago, American students and local staff started a Community Health Promoter (CHP) system to improve the care of diabetic patients. CHPs are volunteer members from the surrounding communities who serve as an extension of the health system of the clinic and strive to ensure ongoing follow up care for patients.
Description / Process: This project had two objectives:
- To qualitatively evaluate the efficacy of the health promoter system at Humberto Parra.
Interviews in Spanish were conducted with six core members of the Bolivian staff (doctor, pharmacist, nurse, social worker, community leader, and a health promoter). Average length of interview was 20 minutes, and all responses were audio-recorded. No software was used for evaluation.
All interviews were transcribed and common themes compiled into a work document. This document was in a meeting among all interviewees to facilitate discussion of an action plan.
- To work with the local staff to brainstorm and implicate changes to better the quality of care for diabetic patients.
Three concrete changes in protocol were constructed in a group meeting and implemented by the staff. All results and protocols were printed in both Spanish and English for communication with future clinic volunteers and leaders.
Conclusions / Next Steps:
We found that there was room for improvement in our health promoter system as well as enthusiasm from the local clinic management to do so. There were common points in the ideas for improvement provided by the local clinic management. These points were addressed in a meeting. Small systemic changes were created at this meeting, to be implemented going forward. Efficacy of this project was limited by time. Synthesis and discussion of interview results with the clinic management did not happen at the clinic until the final week. This means that follow up is even more vital to ensure that the changes decided upon by the staff are implemented and communicated to all future volunteers.
Investigator: Ya-Ting Chen
Mentor: Sally McFall, Department of Biomedical Engineering, McCormick School of Engineering
Research Site: Red Cross Children's Hospital (RCCH) in Rondebosch, South Africa
Background:The Center for Innovation in Global Health Technologies (CIGHT) at Northwestern University has recently designed an Integrated Management of Childhood Illness (IMCI) application on android tablets. The IMCI is a clinical protocol established for health care providers to improve the quality of child care in resource-limited settings. This new app not only walks the healthcare worker through the entire IMCI but it also provides auditory and visual resources to help them conduct effective patient exams.
The goal of this research is to assess the usability of the IMCI tablet app for healthcare workers with different levels of IMCI training, and to determine the app’s effect on reducing the service delivery time at a busy community.
Methods: We tested our app with nurses in two different settings in Cape Town, South Africa:
Classroom Setting: 36 volunteer nurses were trained at the Red Cross Children’s Hospital (RCCH) in Rondebosch. Half of the nurses were asked to test the IMCI tablet app in several hypothetical clinical cases, and the other half attempted the same cases with the IMCI paper chart. The two groups then switched IMCI devices to attempt a second set of clinical cases for another comparison.
Clinic Setting: Three IMCI-experienced nurses were observed at a community health clinic located 30 minutes away from Rondebosch. Nurses were observed treating patients with the IMCI paper chart for two days followed by them working with the tablet app for another two days. 87 patients were seen with using the paper chart, and 57 patients were examined using the app.
Results: In the classroom setting, all the nurses said that they would prefer practicing the IMCI protocol with the tablet app over the paper chart. The consensus was that the app was easier and faster to use, especially with the instructional videos demonstrating how to look for danger signs, and the automatic display of disease classifications and treatment options based on the input. All the nurses would also like to see our app being incorporated into future IMCI training course.
In the clinical setting, the average service delivery time with the tablet app was 3.2 minutes longer than with the paper chart. All three nurses stated that they still preferred using the app despite the longer service time, and the primary reason was that the app helped reduce writing and paperwork. The nurses also said that they would strongly recommend it to other health workers.
Conclusions: Based on our findings, it appears that our app is very easy to use and suitable for both IMCI training and clinical practice. The technical feedback and user experiences gained from this study are currently being incorporated into developing a better design for our app’s next version. Given the popularity we have gained from our study participants, we are optimistic about testing our next version for a longer period of time at the same clinic or other sites to better assess its impact on service delivery time as well as provider’s adherence to the IMCI protocol.
Investigator: Annette Dekker,
Mentor: Ashti Doobay-Persaud, MD, Division of Hospital Medicine, Feinberg School of Medicine
Research Site: Toledo, Belize
Background: The incidence of non-communicable diseases (NCDs) continues to rise in the developing world. Nearly eighty percent of diabetics live in middle to low income countries.1 In Belize, the prevalence of diabetes (DM) and hypertension (HTN) is 13.1% and 28.7%, respectively, and represent the two leading causes of mortality.2 Despite this little is known about the management of these chronic conditions.
Objective: To describe the current understanding and care of DM and HTN in the underdeveloped district of Toledo, Belize.
Methods: This is a mixed method evaluation of DM and HTN management from June 2014 to February 2015 at Hillside Health Care International Clinic and the surrounding villages in Toledo District. Data were collected from chart review and patient questionnaire and semi-structured interview.2 Quantitative data were analyzed using Stata Data Analysis and Statistical Software. Key variables were analyzed for frequency. Qualitative data were transcribed and hand-coded based on key themes identified through a content analysis.
Results: Sixty charts were randomly selected of individuals who receive care at Hillside. The majority of patients were female (37, 62%) and Mayan (33, 64%). The prevalence of DM and HTN were both 12 percent (DM 7, HTN 7).
One hundred seventy-eight charts of patients with DM and/or HTN were reviewed. These individuals averaged 3.6 clinic visits in the last year. Most diabetics were on metformin (89, 80%). Only half of patients with diabetes had blood glucose checked at least every six months (54, 49%) or received any annual monitoring such as a lipid panel, urinalysis, creatinine level, foot exam, or eye referral (64, 59%). Most hypertensive patients were on an angiotensin-converting-enzyme inhibitor (ACE-I) (64, 59%). Many diabetic and hypertensive patients did not receive recommended lifestyle counseling (DM 42, 39%, HTN 48, 45%).
Twenty-five individuals with DM and/or HTN were interviewed. The majority were unemployed or homemakers (19, 76%) with a primary education (21, 84%). Individuals reported a lack of consistent access to fruit (17, 68%) and vegetables (16, 64%) due to financial constraints. Preliminary results from qualitative interviews demonstrate several themes including a perception that sickness is caused by what a person consumes, and that disease onset correlates to stressful life events. There is a general understanding of a link between diet and chronic disease, however specific knowledge of common foods and their effect on blood glucose and blood pressure is not widespread.
Conclusions: Preliminary results suggest gaps in DM and HTN care in Toledo, Belize. Although most patient are prescribed medication and are seen at least annually, regular health maintenance and lifestyle counseling are often overlooked. Qualitative interviews further highlight a lack of patient knowledge of how to manage their chronic diseases beyond medical therapy. The study is limited by a small sample size that did not include individuals who only seek care from government-run facilities. Further analysis of individuals’ understanding of diabetes and hypertension as well as interviews with providers will likely provide insights into how the medical community in Toledo can support individuals living with these diseases.
Investigator: Ariella Pratzer
Mentor: Dr. Arthur Elster, Department of Preventative Medicine, Feinberg School of Medicine
Research Site: Office of the Chief Scientist; Tel Aviv, Israel
Introduction: Various investment models currently exist for the funding and delivery of foreign aid specifically dedicated to improving global health. As countries look to increase the impact of their investments, ongoing analysis and evaluation of the successes and failures of these models, upon which funding decisions can be based, is called for. The Government of Israel (GOI) is looking to launch a global health investment initiative that will effectively operate as a government-backed venture capital fund, investing in research and development projects by Israeli companies and start-ups targeted at improving global health.
Aim: To develop and track measurable outcomes of funded projects such that the success of the GOI’s investment model can be gauged and refined to increase its effectiveness
Methods: This initiative is being developed and operated by the Office of the Chief Scientist (OCS) in the Ministry of Economy. Methods include:
- Identification of short and long term metrics that can be used as indicators of success for each company
- Creation and population of database to track metrics
- Analysis to determine whether and how initiative can be improved upon to increase impact and effectiveness
Discussion: The GOI investment strategy is based on the philosophy of “integrated innovation”, which involves the coordinated application of technological, social, and business innovation. This model has been developed, refined, and endorsed by many, including The Gates Foundation and Grand Challenges Canada (GCC) – the Canadian government’s global health initiative. Evaluation of this initiative will enable the GOI to maximize its impact on global health, and to be as effective as possible with its available budget. The database and analytical tool that result from this project may also be used by GCC and other global health investors who work in close partnership with the GOI to evaluate their own investments.
Next Steps: The exact funding and launch date of the initiative are still being finalized, but expected launch is within the next year. The OCS intends to provide Stage I funding for 20 projects, 4 of which will later be awarded additional Stage II funding. Specific metrics will be collected for each project in addition to several universal metrics, such as sales, refills, and target disease/population. The evaluation database will be built to incorporate additional metrics for each funded project.
Investigator: Tyler Maiers
Mentor: Sally McFall and David Kelso, Department of Biomedical Engineering, McCormick School of Engineering
Research Site: Department of Molecular Medicine and Haematology at Wits Medical School in Johannesburg, South Africa
Introduction: Viral load (VL) quantification is an important tool in both identifying HIV-positive patients with newly-developed drug resistance to first-line antiretrovirals and patients with poor adherence to treatment. Testing in resource-limited settings may require sampling by fingerstick due to shortages in skilled phlebotomists and the expense of venipuncture supplies. The Northwestern Global Health Foundation is developing a point-of-care (POC) instrument and VL nucleic acid test (NAT). It was determined that a minimum of 150 μl of blood is required for a limit of quantification of 1,000 copies/ml of plasma. If this volume can be obtained by fingerstick instead of venipuncture, the test could potentially become available in many clinics. The primary objectives of this study included measurement of the following: (1) proportion of collection attempts that obtained 150 uL capillary blood, (2) number of puncture sites required, (3) study nurse compliance with fingerstick protocol, (4) study nurse comparison of fingerstick vs. venipuncture, and (5) patient comparison of fingerstick vs. venipuncture.
Methods: Patients were recruited by the study nurse as they queued in the blood room. Patients were asked if they had a preference for fingerstick, venipuncture, or no preference both before and after receiving a fingerstick. The study nurse was blinded with respect to the fingerstick and blood collection protocol. The fingerstick and blood collection protocol included: (1) Two gloves worn by nurse, (2), Patient sitting, (3) Fingers warmed in advance by any method, (4) Puncture site disinfected with alcohol pad, (5) First drop of blood wiped away, (6) Hand positioned palm down, (7) Collection device held above skin; scraping avoided, (8) Gentle pressure applied; strong milking avoided, and (9) Pressure applied after collection. Each step of the fingerstick protocol was observed, and their completion or omission was recorded on a protocol template for every patient. A verbal questionnaire was administered to each patient following blood collection. Upon completion of the study, the study nurse was asked if she had a preference for fingerstick, venipuncture, or no preference.
Results: Ninety-eight percent of collection attempts were successful and 86% required only one fingerstick to successfully collect 150 uL blood. Study nurse compliance to the fingerstick protocol was significantly less than 100% for several steps: two gloves worn by nurse (0%), first drop of blood wiped away (4.5%), fingers warmed in advance (7%), and hand positioned below elbow (55.5%). Following blood collection, 69% of patients preferred fingerstick over venipuncture, 16% preferred venipuncture over fingerstick, and 15% had no preference for either method. The study nurse indicated no preference for either method.
Conclusion: The findings from this study support the feasibility of collecting 150 uL capillary blood via fingerstick for POC HIV viral load testing in resource-limited settings. Omissions in many steps of the fingerstick protocol suggest that maintenance training, detailed written instructions for reference, and convenient placement of fingerstick materials may facilitate improved compliance. A patient-centered approach to viral load testing will include a transition from venipuncture to fingersticks for blood collection.
Investigator: Hillary Lane
Mentor: Sarah Rodriguez, PhD, Department of Medical Education, Feinberg School of Medicine
Research Site: Makerere University College of Health Sciences, Uganda
Male medical circumcision (MMC) may reduce transmission of HIV by up to 70%. Uganda’s Ministry of Health adopted a MMC policy in 2010, but identified barriers to implementation, including lack of trained staff and funding. The World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) also have programs promoting MMC in Uganda. How these policies are viewed by medical providers, the challenges they have faced implementing the policy, and the strategies they have used to overcome those challenges, have not been studied. To explore the logistical challenges of implementing an international and national health policy from the perspective of healthcare providers, I designed a study asking providers to identify challenges they have faced and strategies they have found useful in overcoming those challenges. Since provider knowledge and attitudes about MMC may have influenced the success of implementation, this study would also evaluate providers’ awareness of the policy and views on the role of MMC in public health.
This study is designed to be performed at district hospitals in Uganda that provide primary care, HIV care, or MMC. Potential sites include Kayunga and Kumi District hospitals. Participants will be asked to indicate the degree to which they agree with statements about MMC and MMC policy using a 5-point Likert scale. They will also be given the opportunity to answer optional free response questions. Data will be analyzed by calculating median responses and percentiles for scaled questions; open response questions will be analyzed qualitatively to identify patterns in provider comments. This will allow researchers to identify challenges and strategies that could be used to improve implementation of MMC or other health policies at other locations within Uganda and worldwide.
By eliciting information from providers, this study may identify strategies that could be used to improve implementation of MMC or other health policies at other locations within Uganda and worldwide.
Investigator: Claudia Leung
Mentor: Claudia Hawkins, MD, MPH, Division of Infectious Diseases, Feinberg School of Medicine
Research Site: Management and Development for Health, Tanzania
Background: The “dual burden of disease” is a term often used to describe the health conditions in low- and middle-income countries (LMIC). As many of these countries begin to make gains against the burden of infectious diseases, they have also become increasingly vulnerable to the risk factors associated with non-communicable diseases (NCDs). Tobacco use, physical inactivity, and malnutrition parallel a rising incidence of cardiovascular disease, cancer, chronic respiratory disease, and diabetes, the four major contributors to the global burden of NCD. Although today, Sub-Saharan Africa remains the only region in the world in which the burden of infectious diseases still outnumber that of NCDs, the World Health Organization (WHO) projects that in the next decade, these countries will experience the largest increase in deaths due to NCDs.
The burden of infectious diseases in LMIC has also led to the development of new systems of care delivery in these resource-limited areas. As treatment for HIV becomes more available and the life expectancy of patients living with HIV continues to rise, the management of this “infectious” disease has shifted towards a long-term “chronic” disease paradigm. In Dar es Salaam, Tanzania, HIV Care and Treatment Clinics (CTCs) have essentially become one of the country’s first large scale chronic disease initiatives, demonstrating themes of multidisciplinary teamwork, health education, and intentional follow up, all factors that are also important for long term NCD management. This existing framework of HIV care has the potential to guide the integration of NCD and HIV care in resource-limited settings.
Objective: The goal of this research is to quantify the status of NCD care in the CTCs, assess the resources available for NCD diagnosis and prevention, and evaluate the feasibility of incorporating the management of NCDs into current HIV-based systems of care.
Methods: We included fourteen CTCs from the three districts of Dar es Salaam, Tanzania, in an assets-based evaluation using a survey adapted from Partners in Health. A quantitative analysis was used to report the services and resources available for NCD care at each site.
Results: Our findings showed that every site, regardless of district, size, or patient/staff ratio, offered comprehensive HIV services. 67% of the sites offered nutritional services, and all had health education sessions at least once per week. In contrast, gaps in NCD service provision included a lack of specialist care, healthcare worker training, and functioning equipment for the assessment of NCD risk factors. When asked to identify challenges to NCD management, every site acknowledged that gaps exist in NCD care, with the lack of functioning equipment, specialist care, and healthcare worker training in NCD management cited as primary causes in more than 50% of the sites.
Conclusions: Based on our findings, gaps in NCD care do exist in the HIV CTCs in Dar es Salaam, and are attributable to both a lack of resources as well as trained personnel. However, a framework of comprehensive HIV care, including nutrition counseling and health education, already exists at many of these sites. This foundation of longitudinal care has the potential to guide the integration of NCD care into HIV care and treatment clinics in both Dar es Salaam and other resource-limited areas.