Publications by authors named "Tracy L Rabin"

21 Publications

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The rural Uganda non-communicable disease (RUNCD) study: prevalence and risk factors of self-reported NCDs from a cross sectional survey.

BMC Public Health 2021 11 7;21(1):2036. Epub 2021 Nov 7.

Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.

Background: Non-communicable diseases (NCDs) are an increasing global concern, with morbidity and mortality largely occurring in low- and middle-income settings. We established the prospective Rural Uganda Non-Communicable Disease (RUNCD) cohort to longitudinally characterize the NCD prevalence, progression, and complications in rural Africa.

Methods: We conducted a population-based census for NCD research. We systematically enrolled adults in each household among three sub-counties of the larger Nakaseke Health district and collected baseline demographic, health status, and self-reported chronic disease information. We present our data on self-reported chronic disease, as stratified by age, sex, educational attainment, and sub-county.

Results: A total of 16,694 adults were surveyed with 10,563 (63%) respondents enrolled in the self-reported study. Average age was 37.8 years (SD = 16.5) and 45% (7481) were male. Among self-reported diseases, hypertension (HTN) was most prevalent (6.3%). 1.1% of participants reported a diagnosis of diabetes, 1.1% asthma, 0.7% COPD, and 0.4% kidney disease. 2.4% of the population described more than one NCD. Self-reported HTN was significantly higher in the peri-urban subcounty than in the other two rural sub-counties (p < 0.001); diagnoses for all other diseases did not differ significantly between sub-counties. Odds for self-reported HTN increased significantly with age (OR = 1.87 per 10 years of age, 95% CI 1.78-1.96). Male sex was associated with lower odds of reporting asthma (OR = 0.53, 95% CI 0.34-0.82) or HTN (OR = 0.31, 95% CI 0.26-0.40).

Conclusions: The RUNCD will establish one of the largest NCD patient cohorts in rural Africa. First analysis highlights the feasibility of systematically enrolling large numbers of adults living in a rural Ugandan district. In addition, our study demonstrates low levels of self-reported NCDs compared to the nation-wide established levels, emphasizing the need to better educate, characterize, and care for the majority of rural communities.
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http://dx.doi.org/10.1186/s12889-021-12123-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8572568PMC
November 2021

Global Health Crisis, Global Health Response: How Global Health Experiences Prepared North American Physicians for the COVID-19 Pandemic.

J Gen Intern Med 2022 01 24;37(1):217-221. Epub 2021 Sep 24.

State University of New York Downstate College of Medicine, Brooklyn, NY, USA.

The COVID-19 pandemic plunged hospital systems into resource-deprived conditions unprecedented since the 1918 flu pandemic. It brought forward concerns around ethical management of scarcity, racism and distributive justice, cross-disciplinary collaboration, provider wellness, and other difficult themes. We, a group of medical educators and global health educators and clinicians, use the education literature to argue that experience gained through global health activities has greatly contributed to the effectiveness of the COVID-19 pandemic response in North American institutions. Support for global health educational activities is a valuable component of medical training, as they build skills and perspectives that are critical to responding to a pandemic or other health system cataclysm. We frame our argument as consideration of three questions that required rapid, effective responses in our home institutions during the pandemic: How can our health system function with new limitations on essential resources? How do we work at high intensity and volume, on a new disease, within new and evolving systems, while still providing high-quality, patient-centered care? And, how do we help personnel manage an unprecedented level of morbidity and mortality, disproportionately affecting the poor and marginalized, including moral difficulties of perceived care rationing?
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http://dx.doi.org/10.1007/s11606-021-07120-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475882PMC
January 2022

Social Support for Self-Care: Patient Strategies for Managing Diabetes and Hypertension in Rural Uganda.

Ann Glob Health 2021 19;87(1):86. Epub 2021 Aug 19.

Department of Social & Behavioral Sciences, School of Global Public Health, New York University, New York, NY, USA.

Background: Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings.

Objective: We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda.

Methods: Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes.

Results: Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities.

Conclusion: Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients' social support networks.
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http://dx.doi.org/10.5334/aogh.3308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8378074PMC
September 2021

A Broader View of Risk to Health Care Workers: Perspectives on Supporting Vulnerable Health Care Professional Households During COVID-19.

Acad Med 2021 09;96(9):1233-1235

J.I. Schwartz is associate professor of medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut.

The COVID-19 pandemic has highlighted both that frontline workers face a new set of personal hazards in health care settings and that there are not well-established recommendations to address the broader risks to these workers and their families. Particularly vulnerable households include dual health care professional households, single-parent health care professional households, and households with health care professionals responsible for a high-risk family member (i.e., an older adult or immunocompromised person). While the demographics of these households are heterogeneous, it is expected that the professional and personal concerns specific to COVID-19 will be similar. These concerns include family safety, balancing full-time work with home-based schooling for children, the looming threat of illness to 1 or both partners, the potential of infecting high-risk family members, and the challenges of planning for the future during uncertain times. To elucidate these concerns in their department, the authors sought input from colleagues in dual health care professional households through an open-ended email communication. Respondents expressed a range of concerns centered on balancing professional and family responsibilities during the COVID-19 pandemic. In this commentary, the authors propose several recommendations in the areas of support networks, leadership and culture, and operations and logistics that health care institutions can adopt to minimize the burden on these vulnerable households during states of emergency. The successful implementation of these recommendations hinges on creating a work environment in which all health care providers feel comfortable voicing their concerns.
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http://dx.doi.org/10.1097/ACM.0000000000004175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8378440PMC
September 2021

Global Health Education in the Time of COVID-19: An Opportunity to Restructure Relationships and Address Supremacy.

Acad Med 2021 06;96(6):795-797

M. Barry is Shenson professor of medicine, Department of Medicine, Stanford University School of Medicine, and director, Center for Innovation in Global Health, Stanford University, Stanford, California; ORCID: https://orcid.org/0000-0002-1539-8109.

Global health and its predecessors, tropical medicine and international health, have historically been driven by the agendas of institutions in high-income countries (HICs), with power dynamics that have disadvantaged partner institutions in low- and middle-income countries (LMICs). Since the 2000s, however, the academic global health community has been moving toward a focus on health equity and reexamining the dynamics of global health education (GHE) partnerships. Whereas GHE partnerships have largely focused on providing opportunities for learners from HIC institutions, LMIC institutions are now seeking more equitable experiences for their trainees. Additionally, lessons from the COVID-19 pandemic underscore already important lessons about the value of bidirectional educational exchange, as regions gain new insights from one another regarding strategies to impact health outcomes. Interruptions in experiential GHE programs due to COVID-19-related travel restrictions provide an opportunity to reflect on existing GHE systems, to consider the opportunities and dynamics of these partnerships, and to redesign these systems for the equitable benefit of the various partners. In this commentary, the authors offer recommendations for beginning this process of change, with an emphasis on restructuring GHE relationships and addressing supremacist attitudes at both the systemic and individual levels.
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http://dx.doi.org/10.1097/ACM.0000000000003911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140628PMC
June 2021

Low- and Middle-Income Country Host Perceptions of Short-Term Experiences in Global Health: A Systematic Review.

Acad Med 2021 03;96(3):460-469

T.L. Rabin is associate professor of medicine and director, Office of Global Health, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut; ORCID: http://orcid.org/0000-0002-4829-9051.

Purpose: Stakeholders have expressed concerns regarding the impact of visiting trainees and physicians from high-income countries (HICs) providing education and/or short-term clinical care in low- and middle-income countries (LMICs). This systematic review aimed to summarize LMIC host perceptions of visiting trainees and physicians from HICs during short-term experiences in global health (STEGH).

Method: In September 2018 then again in August 2020, the authors searched 7 databases (PubMed, Embase, Scopus, Web of Science, ERIC, Cochrane Library, Global Index Medicus) for peer-reviewed studies that described LMIC host perceptions of STEGH. They extracted information pertaining to study design, participant demographics, participant perceptions, representation of LMICs and HICs, and HIC visitors' roles and used thematic synthesis to code the text, develop descriptive themes, and generate analytical themes.

Results: Of the 4,020 studies identified, 17 met the inclusion criteria. In total, the studies included 448 participants, of which 395 (88%) represented LMICs. The authors identified and organized 42 codes under 8 descriptive themes. They further organized these descriptive themes into 4 analytical themes related to STEGH: (1) sociocultural and contextual differences, (2) institutional and programmatic components, (3) impact on host institutions and individuals, and (4) visitor characteristics and conduct.

Conclusions: STEGH can have both beneficial and detrimental effects on LMIC host institutions and individuals. The authors translated these findings into a set of evidence-based best practices for STEGH that provide specific guidance for LMIC and HIC stakeholders. Moving forward, LMIC and HIC institutions must work together to focus on the quality of their relationships and create conditions in which all stakeholders feel empowered to openly communicate to ensure equity and mutual benefit for all parties.
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http://dx.doi.org/10.1097/ACM.0000000000003867DOI Listing
March 2021

A Systematic Review of Advocacy Curricula in Graduate Medical Education.

J Gen Intern Med 2019 11;34(11):2592-2601

Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.

Background: Professionalism standards encourage physicians to participate in public advocacy on behalf of societal health and well-being. While the number of publications of advocacy curricula for GME-level trainees has increased, there has been no formal effort to catalog them.

Objective: To systematically review the existing literature on curricula for teaching advocacy to GME-level trainees and synthesize the results to provide a resource for programs interested in developing advocacy curricula.

Methods: A systematic literature review was conducted to identify articles published in English that describe advocacy curricula for graduate medical education trainees in the USA and Canada current to September 2017. Two reviewers independently screened titles, abstracts, and full texts to identify articles meeting our inclusion and exclusion criteria, with disagreements resolved by a third reviewer. We abstracted information and themes on curriculum development, implementation, and sustainability. Learning objectives, educational content, teaching methods, and evaluations for each curriculum were also extracted.

Results: After reviewing 884 articles, we identified 38 articles meeting our inclusion and exclusion criteria. Curricula were offered across a variety of specialties, with 84% offered in primary care specialties. There was considerable heterogeneity in the educational content of included advocacy curriculum, ranging from community partnership to legislative advocacy. Common facilitators of curriculum implementation included the American Council for Graduate Medical Education requirements, institutional support, and preexisting faculty experience. Common barriers were competing curricular demands, time constraints, and turnover in volunteer faculty and community partners. Formal evaluation revealed that advocacy curricula were acceptable to trainees and improved knowledge, attitudes, and reported self-efficacy around advocacy.

Discussion: Our systematic review of the medical education literature identified several advocacy curricula for graduate medical education trainees. These curricula provide templates for integrating advocacy education into GME-level training programs across specialties, but more work needs to be done to define standards and expectations around GME training for this professional activity.
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http://dx.doi.org/10.1007/s11606-019-05184-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848624PMC
November 2019

Challenges to hypertension and diabetes management in rural Uganda: a qualitative study with patients, village health team members, and health care professionals.

Int J Equity Health 2019 02 28;18(1):38. Epub 2019 Feb 28.

Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.

Background: The prevalence of hypertension and diabetes are expected to increase in sub-Saharan Africa over the next decade. Some studies have documented that lifestyle factors and lack of awareness are directly influencing the control of these diseases. Yet, few studies have attempted to understand the barriers to control of these conditions in rural settings. The main objective of this study was to understand the challenges to hypertension and diabetes care in rural Uganda.

Methods: We conducted semi-structured interviews with 24 patients with hypertension and/or diabetes, 11 health care professionals (HCPs), and 12 community health workers (known as village health team members [VHTs]) in Nakaseke District, Uganda. Data were coded using NVivo software and analyzed using a thematic approach.

Results: The results replicated several findings from other settings, and identified some previously undocumented challenges including patients' knowledge gaps regarding the preventable aspects of HTN and DM, patients' mistrust in the Ugandan health care system rather than in individual HCPs, and skepticism from both HCPs and patients regarding a potential role for VHTs in HTN and DM management.

Conclusions: In order to improve hypertension and diabetes management in this setting, we recommend taking actions to help patients to understand NCDs as preventable, for HCPs and patients to advocate together for health system reform regarding medication accessibility, and for promoting education, screening, and monitoring activities to be conducted on a community level in collaboration with village health team members.
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http://dx.doi.org/10.1186/s12939-019-0934-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394065PMC
February 2019

Impact of Global Health Electives on US Medical Residents: A Systematic Review.

Ann Glob Health 2018 11 5;84(4):692-703. Epub 2018 Nov 5.

Department of Medicine, Weill Cornell Medical College, New York, NY, US.

Background: The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes.

Objectives: The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature.

Methods: An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents.

Findings: Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks.

Conclusions: Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.
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http://dx.doi.org/10.9204/aogh.2379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748170PMC
November 2018

Reconfiguring a One-Way Street: A Position Paper on Why and How to Improve Equity in Global Physician Training.

Acad Med 2019 04;94(4):482-489

J.C. Hudspeth is assistant professor and director, Residency Global Health, Department of Internal Medicine, Boston University School of Medicine, Boston, Massachusetts. T.L. Rabin is assistant professor of internal medicine and associate program director, Global and Community Health, Yale Primary Care Internal Medicine Residency Program, and associate director, Office of Global Health, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut. B.A. Dreifuss is assistant professor of emergency medicine and public health and director, Rural, Border, and Global Programs in Emergency Medicine, Colleges of Medicine and Public Health, University of Arizona, Tucson, Arizona. M. Schaaf is professor and associate director, Global Health Pathway, School of Medicine, and director, Global Outreach, University of California, San Francisco, San Francisco, California. M.S. Lipnick is assistant professor and program director, Anesthesia Global Health Fellowships, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California. C.M. Russ is assistant professor, Department of Pediatrics, Harvard University, and associate director, Global Health Program, Boston Children's Hospital, Boston, Massachusetts. A. Autry is professor and director, Graduate Medical Education, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California. M.B. Pitt is associate professor and director, Global Health Education, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota. V. Rowthorn is executive director, University of Maryland-Baltimore Center for Global Education Initiatives, Baltimore, Maryland.

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.
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http://dx.doi.org/10.1097/ACM.0000000000002511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6445611PMC
April 2019

Ethical dilemmas during international clinical rotations in global health settings: Findings from a training and debriefing program.

Med Teach 2018 01 2;40(1):53-61. Epub 2017 Nov 2.

e Department of Internal Medicine , Yale University School of Medicine , New Haven , CT , USA.

Purpose: This study describes the impact of an open-access, case-based global health ethics workshop and describes the breadth of dilemmas faced by students to inform future interventions.

Methods: Eighty-two medical students who undertook electives at 16 international sites between 2012 and 2015 received web-based surveys at three time points, incorporating quantitative and free-text probes of knowledge, skills, and attitudes related to global health clinical ethics dilemmas. Sixty students (73%) completed the pre-workshop survey, 38 (46%) completed the post-workshop survey, and 43 (52%) completed the post-trip survey.

Results: Analysis demonstrated improvement following the workshop in self-rated preparedness to manage ethical dilemmas abroad, identify ways to prepare for dilemmas, engage support persons, and manage related emotions (all comparisons, p < 0.001). Participants described 245 anticipated or actual dilemmas, comprising nine domains. Nearly one-third of the dilemmas that were experienced involved the student as an active participant. Only 21% of respondents experiencing a dilemma discussed the dilemma with a local support person.

Conclusions: This analysis describes an ethics curriculum that prepares students to face ethical dilemmas during international clinical rotations. It broadens the representation of the dilemmas that students face, and highlights areas for curricular focus and optimization of on-site and post-trip student support resources.
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http://dx.doi.org/10.1080/0142159X.2017.1391374DOI Listing
January 2018

Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.

Bull World Health Organ 2017 May 24;95(5):343-352E. Epub 2017 Mar 24.

Department of Economics, University College London, London, England.

Objective: To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme - the World Health Partners' Sky Program.

Methods: We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers' performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models.

Findings: The programme did not significantly improve health-care providers' knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered.

Conclusion: Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.
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http://dx.doi.org/10.2471/BLT.16.179556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418816PMC
May 2017

Global Health Without Boundaries: Structuring Domestic and International Opportunities to Explore Global Health in a Graduate Internal Medicine Training Program.

Ann Glob Health 2016 Nov - Dec;82(6):1026-1033

Yale University School of Medicine, Department of Internal Medicine, New Haven, CT. Electronic address:

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http://dx.doi.org/10.1016/j.aogh.2016.11.007DOI Listing
September 2018

Medical Education Capacity-Building Partnerships for Health Care Systems Development.

AMA J Ethics 2016 Jul 1;18(7):710-7. Epub 2016 Jul 1.

Professor of medicine and the director of the Office of Global Health in the Department of Medicine at the Yale School of Medicine in New Haven, Connecticut.

Health care workforce development is a key pillar of global health systems strengthening that requires investment in health care worker training institutions. This can be achieved by developing partnerships between training institutions in resource-limited and resource-rich areas and leveraging the unique expertise and opportunities both have to offer. To realize their full potential, however, these relationships must be equitable. In this article, we use a previously described global health ethics framework and our ten-year experience with the Makerere University-Yale University (MUYU) Collaboration to provide an example of an equity-focused global health education partnership.
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http://dx.doi.org/10.1001/journalofethics.2016.18.7.medu2-1607DOI Listing
July 2016

Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement.

Health Aff (Millwood) 2015 Sep;34(9):1506-13

Jeremy I. Schwartz is an assistant professor in the Department of Internal Medicine at the Yale School of Medicine.

The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health.
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http://dx.doi.org/10.1377/hlthaff.2015.0382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568565PMC
September 2015

The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India.

JAMA Pediatr 2015 Apr;169(4):349-57

Sambodhi Research and Communications, Pvt, Ltd, New Delhi, India.

Importance: In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners' knowledge of appropriate care and the actual care delivered (the know-do gap).

Objective: To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India.

Design, Setting, And Participants: We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs).

Main Outcomes And Measures: For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners' characteristics. We also examined correct treatment recommended by practitioners with both methods.

Results: Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia.

Conclusions And Relevance: Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.
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http://dx.doi.org/10.1001/jamapediatrics.2014.3445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5023324PMC
April 2015

Towards reframing health service delivery in Uganda: the Uganda Initiative for Integrated Management of Non-Communicable Diseases.

Glob Health Action 2015 5;8:26537. Epub 2015 Jan 5.

Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.

Background: The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development.

Methods: Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs.

Results: In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs.

Discussion: Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292588PMC
http://dx.doi.org/10.3402/gha.v8.26537DOI Listing
September 2015

Integrated care of refugees in a primary care residency clinic.

J Grad Med Educ 2012 Dec;4(4):551

Instructor, Department of Internal Medicine, Yale University School of Medicine.

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http://dx.doi.org/10.4300/JGME-D-12-00176.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546595PMC
December 2012

The global health chief resident: modifying an established role, strengthening a collaboration.

Med Educ 2012 Nov;46(11):1128-9

Office of Global Health, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, PO Box 208030, New Haven, Connecticut 06510, USA.

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http://dx.doi.org/10.1111/medu.12028DOI Listing
November 2012

Testing therapies less effective than the best current standard: ethical beliefs in an international sample of researchers.

Am J Bioeth 2003 ;3(2):W11

Tufts-New England Medical Center, Boston, USA.

To test the range of beliefs regarding the ethics of testing, in resource poor settings, new therapies that are less efficacious but more affordable and feasible than the best current therapeutic standard.
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http://dx.doi.org/10.1162/152651603322874898DOI Listing
December 2003
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