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Original Research |
1 Infectious and Tropical Diseases Division, Scientific Institute for Research,
Hospitalization and Health Care (IRCCS) San Matteo, University of Pavia, Via
Taramelli 5, 27100 Pavia, Italy.
2 Radiology Department, Vimercate General Hospital, Milan, Italy.
Received December 24, 2006;
accepted after revision March 28, 2007.
Address correspondence to G. Ferraioli
(ferraiol{at}tin.it).
Abstract
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SUBJECTS AND METHODS. A sonographic training program is being conducted on Pemba Island, Tanzania. A maximum of 10 trainees participate in the program. Courses in sonography conducted by European physicians are scheduled every 4 months for 2 consecutive weeks each time. The sonographic training program lasts 5 years and is divided into three stages in which basic, advanced, and specialized courses are organized. At the end of every course, the trainees take a multiple-choice test (score, 1-10) and a practical test with patients (score, 1-5). To advance to the next stage, a trainee needs a score of at least 7 on the theory test and at least 3 on the practical.
RESULTS. Three courses have been completed. The total mean scores on the multiple-choice test were 7.4 (range, 6.5-9) at the end of the first course, 7.3 (range, 6.5-8.5) at the end of the second course, and 6.2 (range, 4.0-9.5) at the end of the third course. A shortage of electricity hindered the practical test after the first and second courses. At the end of the third course, the total mean score on the practical was 3.5 (range, 1.5-5.0). Seven of 10 trainees were admitted to the second year of the sonographic training program. The mean monthly hospital earnings during the three-course period were 673,200 Tanzanian shillings.
CONCLUSION. Sonography is an affordable technology for developing countries. Training in sonography should be included in the planning of long-term projects in which multiple access and feedback are provided in the same area.
Keywords: developing countries • medical education • sonography • sustainable technology • training
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The World Health Organization has recognized that it is necessary to raise the level of sonographic education worldwide. However, properly developed programs for training in sonography are lacking [3]. Developing countries face severe resource limitations, and there is a scarcity of imaging equipment and trained radiologists. If used as the first, and often the only, imaging technique, sonography is crucial in decision making and can maximize the benefit-to-total cost ratio [4]. In many developing countries, sonographic services are either nonexistent or inadequate, although the diagnostic problems for which sonography is particularly suited are common in such countries [5]. In general in the developing world, primary health care is provided by persons who are not physicians, primarily by medical officers. The scarcity of medical personnel is compensated by the presence of assistant medical officers, clinical officers, and radiographers. These staff members can be trained to become sonographers. Training of these personnel should include on-the-job education.
In developing countries, sonographic facilities are mainly available at tertiary centers and private hospitals. Yet district hospitals are the primary referral point and are the only medical facilities in most cases. There is a need to improve case management at these hospitals. The aims of this study were to assess the feasibility of a sonographic training program at a district hospital in a country with limited resources and to estimate the effect of implementation of sonographic technology in terms of improved efficiency and effectiveness of public health care services.
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Trainees
Ten trainees (seven men, three women; mean age, 41.6 years; range, 32-53
years) participate in the sonographic training program. Seven work on Pemba
and three on Unguja. It is mandatory that those accepted into the sonographic
training program work in a hospital where sonographic equipment is available.
Trainees' personal data and test scores are recorded. A maximum of 10 trainees
are allowed to participate in the sonographic training program. They are
chosen by the health office of Zanzibar. Because of the shortage of
physicians, nine of the trainees are medical personnel but not physicians and
come from hospitals on Unguja or Pemba. Seven of these trainees are
radiographers, and two are assistant medical officers. The radiographer is a
technician who received a diploma from a 3-year program. Assistant medical
officers rank between clinical officers, who have a 3-year diploma, and those
with degrees in clinical medicine. In Tanzania and in many other countries in
Africa, assistant medical officers are recognized and valued almost as much as
holders of degrees in clinical medicine.
Equipment
The sonographic system available at Chake Chake Hospital is an Esaote
Biomedica AU 450 unit equipped with a 3.5-MHz convex probe. Because of power
inconsistency, a voltage stabilizer is used to maintain a constant voltage
level.
Language
Although the official languages of Tanzania are Kiswahili and English,
English is the medium of instruction in all subjects in secondary schools and
all institutions of higher learning. Because all of the participants are able
to speak, read, and write English, the language of the sonographic training
program is English.
Sonographic Training Program
The sonographic training program is a capacity-building program. Courses in
sonography conducted by European physicians skilled both in teaching and in
performing sonographic examinations are scheduled every 4 months for 2
consecutive weeks each time. During each course, 24 hours of didactic lectures
and 36 hours of practice are planned. The trainees perform sonographic
examinations on outpatients and inpatients under the supervision of the
teacher.
The program lasts 5 years and is divided into three stages. Basic courses are conducted in the first stage (first and second years), advanced courses in the second stage (third and fourth years), and specialized courses in the third stage (fifth year). Trainees receive either hard copies or CDs of the lessons, depending on their access to computers. At the end of every sonography course, the trainees take an examination that consists of a 20-question multiple-choice test scored from 1 to 10 (0.5 point for every correct answer) and a practical test conducted on patients that is scored from 1 to 5 (1, insufficient; 2, mediocre; 3, sufficient; 4, good; 5, excellent). The test is composed of questions covering material taught throughout the course.
A trainee is admitted to the second year of each stage only after reaching a total annual score of 18-30 points on the theory examination and 7-15 points on the practical test. To move to the next stage, the trainee needs a final score of at least 7 in theory (score, 1-10) and at least 3 in practice (score, 1-5). Each of the first and second stages lasts 2 years. Specialized courses will be provided in the fifth year of the sonographic training program and are given depending on local needs.
The goal of the program is to train the students to become trainers themselves, to reach the self-maintenance phase. In keeping with this aim, during the fourth year of the sonographic training program, a grant will be awarded to the attendee with the best performance to allow him or her to spend at least 2 months in a European hospital with high-standard sonographic services. During this time, the trainee will be observed and guided by a supervisor on a daily basis. The trainee will be taught to teach sonography, so that the self-maintenance phase of the program can be reached.
Among the trainees, the organizers of the program choose a supervisor, who is the person with the best performance, and a person to contact in each hospital. They are responsible for maintenance of the equipment and recording the number and type of examinations performed by every trainee in each hospital. The supervisor sends a monthly report by e-mail to the organizers of the program, describing the examinations performed, the state of the equipment, and any problems that have arisen. The sonographic training program started in January 2006.
Efficiency and Effectiveness Indicators at the End of the First Year
To assess the feasibility of the program, trainees' attendance was
recorded. Test scores were used to evaluate the level of expertise and thus
the effectiveness of theoretic and practical lessons. The difficulty of the
multiple-choice tests increased steadily from the first to the third course.
Up to 40 minutes was allowed for completion of the test. In the practical
test, ability to correctly hold the probe to scan abdominal organs and to
recognize normal structures inside organs was evaluated at the end of the
first and second courses. At the end of the first year, scanning skill,
ability to obtain the necessary images, and ability to identify simple
pathologic findings were assessed. The number of sonographic examinations
performed and the hospital earnings from the examinations were used to
estimate the level of efficiency reached.
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All trainees completed the multiple-choice test in the allowed time. The total mean score in the multiple choice test was 7.4 (range, 6.5-9.0) at the end of the first sonography course, 7.3 (range, 6.5-8.5) at the end of the second course, and 6.2 (range, 4.0-9.5) at the end of the third course. It was not possible to assess performance on the practical test at the end of the first and second courses because of an electricity shortage. At the end of the third course, the total mean score was 3.5 (range, 1.5-5.0). Seven of 10 trainees reached a score of at least 3.0 on the practical (mean, 4.1; range, 3.0-5.0). Having performed well in both theory and practice, seven of 10 trainees have been admitted to the second year of the basic courses.
Zanzibar has a cost-sharing public health service. Inpatients and outpatients pay a fixed price for diagnostic imaging examinations. The rate is 4,000 Tanzanian shillings for each examination. The currency exchange in U.S. dollars is approximately 1:1,300. The monthly number of sonographic examinations and the monthly hospital earnings from them are reported in Table 1. The mean monthly hospital earnings in the period studied were 673,200 Tanzanian shillings.
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Sonography is a sustainable technology that has a relatively low cost of purchase, needs little maintenance, and is durable compared with other imaging techniques. Medical and paramedical personnel need to be trained in the use of it. Our capacity-building program has been feasible and effective. Trainee attendance has been excellent, especially in light of traveling difficulties on Pemba, where public transportation is slow and unreliable.
We did not administer a pretest to verify the entry-level knowledge of students because they were all beginners in sonography, and we did not want to place pressure on them. Full training in obstetric sonography will be provided in the second year of the program. It was important for the attendees to acquire appropriate background and basic skills in sonography before starting with more specialized sonographic examinations.
The ability to perform sonography differs from one person to another. We consider it a success that seven of 10 participants were admitted to the second year of the sonographic training program. Learning on the job may be far more powerful than training conducted abroad. The district hospital of a developing country has a case mix different from that in hospitals in developed countries. In developing countries, the prevalence and incidence of diseases among populations differ from those in developed countries on the basis of lifestyle and socioeconomic status. It is important to provide training appropriate to the environment. In our program, the trainees develop the ability to perform sonography by examining patients they see in their everyday practice in a learning-by-doing approach.
Chake Chake Hospital does not own a battery-operated portable sonographic unit to deal with the shortage of electric supply. In the sonographic training program it is of utmost importance to practice on sonographic equipment that is locally available. The attendees become accustomed to their own sonographic equipment under the supervision of the trainer and will continue performing sonography when the trainer leaves.
The sonographic training program is ongoing, so effectiveness in terms of clinical outcome remains to be evaluated. Having completed the first year, the program seems to be making good progress toward its goals. Hospital earnings are used to purchase items needed to supply the wards to improve the quality of health care. The Zanzibar islands have little money for health care, so it is a relief to have the possibility of covering the expense of the basic tools needed to run the hospitals.
Training programs require the availability of motivated teams of experts in sonography willing to share their knowledge and to contribute to raising the standard of health care in developing countries, where in-service training and continuing medical education programs are greatly needed. Maintenance of competence is a challenge faced most acutely by resource-poor countries.
The supervisor of the sonographic training program regularly sends reports by e-mail. He also sends files to get advice from experts. There is no doubt that the Internet plays an important role in improving communication and information sharing in the developing world. It has modified the approach to education [3]. In addition to provision of educational resources, the Internet allows communication and sending of files through e-mail to obtain advice from experts at distant medical facilities. Unfortunately, the costs are still too high to be affordable by most people. Our hope is that the health sector in developing countries will give priority to and provide discounted access to Internet connections.
We are aware that the lack of opportunity, poor socioeconomic conditions, and low wages paid to African professionals may lead to "brain drain" of trained personnel. The World Health Organization 2006 health report [9] identifies Tanzania as a country with a critical shortage of health service providers such as physicians, nurses, and technicians. It is recognized that there is a migration of health workers from poor to rich countries. But statistics on the global flow of health workers are incomplete, and available information is generally limited to registered physicians and nurses [9]. Because data on the movement of many other types of health workers are almost nonexistent, it is difficult to comprehend the scale of the problem [9]. In an on-site training program, where personnel are and remain employed by an organization in their own country, the risk of losing trained personnel is low. As suggested by Rosenbaum and Hildner [10], it is important that courses be presented in the trainees' home-lands because graduates are unlikely to return home after finishing training in a more advantaged country. This risk can be avoided only if the local government is committed to providing opportunities and better wages to motivate expert professionals.
In conclusion, sonography is an affordable technology for developing countries. In our experience, sonographic training should be included in long-term planning of projects in which multiple access and feedback are provided in the same area. We are aware that the sustainability of sonographic training programs is a concern in developing countries. It is for that reason that we started a long-term program with the objective of teaching trainees to become trainers themselves so that the project can become self-maintained. It also is crucial that trainees practice on sonographic equipment that is locally available. These projects must be designed to meet the needs of the area where the service is provided. Appropriate training of personnel and sufficient diagnostic equipment will help these countries to improve their success at managing the most important medical problems at the least cost. Education programs should be maintained by local experts on completion of these projects.
Acknowledgments
We gratefully acknowledge World Medical Colours for implementation of the
sonographic training program, the Ivo de Carneri Foundation and Yahya Al
Sawafy for logistic support, Ally Habib Ally for help in data collection, and
Società Italiana di Ultrasonologie in Medicina e Biologia (SIUMB) and
the Mediterranean and African Society for Ultrasound (MASU) for scientific
patronage. We are fully indebted to Carlo Filice because his precious support
made possible the realization of this program.
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