Thursday, December 20, 2018

Stroke in Low and Middle-Income Countries: UK Networking Event

In the past decade, a number of partnerships have developed between clinical and research teams working in stroke care in the UK, and their counterparts in several low and middle-income countries (LMICs). Earlier this year, an inaugural network event was hosted by the Wessex Ghana Stroke Partnership.  The event was attended by representatives from ten different projects, and was supported by the Tropical Health Education Trust (THET) as part of a Health Partnership Scheme Grant. Attendees are working with stroke services in Ghana, Sierra Leone, Rwanda, South Africa, Uganda, India, Sudan and Vietnam. Projects span practice development, capacity building, and research, across the stroke pathway.  The aim of the network is to bring together UK-based teams to:  

•          Share and reflect on the successes and challenges to supporting sustainable stroke care development in LMICs; identifying common themes and sharing potential solutions. 
•          Identify areas for collaboration, where health partnerships could work together to develop solutions and/or resources that enable stroke care development in LMICs. 
•          Provide a forum for UK-based health care professionals to reflect on the personal development opportunities and challenges associated with involvement in a LMIC health partnership.

Participants decided prior to the event on three key discussion topics: competencies and training; strategic influencing; and demonstrating impact.  The group shared their individual experiences, noting recurring themes and reflecting on what was known, what had been learned, and what could be done better. In this blog, we share some of the themes from these discussions. 

Competencies and Training 
In LMICs, there is typically a less structured system for training and development, and the concept of ‘competence’ differs between countries. Healthcare workers are less likely to be held individually accountable, and may have a different approach to their own professional development than their counterparts in higher income countries (HICs).  It is therefore important to establish what motivates health care professionals to develop their skills and knowledge.  Providing post-training certificates and financial recompense for attending training were commonly expected and appreciated by attendees. 
Staff in LMICs may be more familiar with a didactic approach to training, and can find it difficult to engage in clinical, ward-based or simulation training. Translating theoretical knowledge into consistent changes in clinical practice is particularly challenging.   Multi-disciplinary training was not common but having a variety of health care professionals attend training was useful in helping staff consider how to implement new skills clinically. Keeping focused with a small cohort of trainees also helped build relationships and reinforce clinical skills.  ‘Train the trainer’ models of staff development were useful to make the most of the limited time that UK teams are able to spend in the LMIC partner countries, and to ensure sustainability.
To keep the content appropriate, training topics should be decided and developed with local staff. Focusing on the “must do” messages, rather than the “should do” and “could do” can help avoid overwhelming trainees with too much information. Partnerships had, so far, focussed on core, evidence-based aspects of stroke care that can be improved with little resource, such as introducing bedside swallow assessments and basic dysphagia management, or encouraging early mobilisation.  Creating resources specifically for the context to help deliver messages may also be helpful: for example, in Sudan a local artist created educational posters for display in the hospital.  
Despite lack of resources and infrastructure, many LMIC stroke professionals are eager for knowledge about more advanced or technical interventions (e.g. thrombolysis).  Dedicating training time to facilitate this and continue aspirational clinical practice should be considered; keeping a balance with core stroke skills.  Furthermore, attitudes towards rehabilitation differ considerably from those in HICs, with patients often playing a passive role. Informal caregivers tend to “do for” the individual, and intensive rehabilitation and participation may be viewed by some as cruel.  Equally, expectations and beliefs regarding recovery are challenging, as patient and public understanding of stroke is limited.

Professional groups often work in silos within LMICs, in contrast to the multidisciplinary ethos of HIC stroke care.  Professional groups can be reluctant to share skills across professions, which in part may be due to how payments for services are made. Another barrier is the scarcity of some health professions, such as occupational therapy and speech and language therapy, who are not easily accessible or are totally lacking in many LMIC stroke services.  Broadening the remit of existing professions is one way to work around this.  
There are also hierarchical barriers to team working, with medical models of care predominating. Local leadership is needed to empower all team members.  Role modelling by UK teams and developing processes that enable multidisciplinary work can facilitate movement towards a more multidisciplinary approach. Provision of leadership training for stroke staff has assisted with this in Ghana.  

Demonstrating Impact
Demonstrating the impact of interventions through monitoring and evaluation (M&E) is integral to any partnership work in LMICs. It is important to have open conversations with all key stakeholders when planning any project, to agree on how impact will be measured, so that any M&E is both valuable to all and feasible to complete.  
Patient and public involvement (PPI) should not be overlooked.  However, patient roles and degree of agency are often different in LMICs, which can make engagement more difficult.  As a minimum, teams should consider how to keep patients informed, disseminate information about their projects to the public, and support LMIC clinical teams to think about considering the patient voice.   
For LMIC teams, appropriate information can help service evaluation, empower staff to lobby for change, and motivate teams to maintain positive working practices. Adapting any ongoing M&E may be easier than starting afresh. For the results to be useful to partners, they need to be able to interpret their own data and see how change may be implemented from the results.  It is therefore also important to consider cultural, organisational and hierarchical restrictions to collecting data or implementing change in their setting. 
As well as being useful to frontline staff, demonstrating impact is crucial to demonstrate success to project funders. Funders will expect to see measurable change, so when deciding what the intended impact of any intervention is, consider what is realistic, and the possible consequences if expected outcomes are achieved. 
Clinical measures are often used despite the limited research into the generalisability of common stroke outcome measures in LMIC contexts. Most partnerships have used clinical process measures (e.g. ‘swallow assessment completed’) rather than patient outcome measures to evaluate the success of projects. HIC stroke standards cannot be simply transplanted to LMIC settings; for example, access to dedicated stroke beds may be affected by local politics or funding, and time to assessment will be impacted by local service set up and funding. Standards must be culturally relevant, and must evaluate what is important to local systems and people.  There may also be issues with accurate completion of data collection tools by local staff due to a culture of not admitting error or acknowledging poor practice.  This has an impact on the validity of any M&E.
These partnerships also have an often unrecognised potential to contribute to the professional development of the HIC staff involved, who can gain invaluable skills, experience, cultural awareness and knowledge that can be used in their own workplace.  Further consideration of how to capture and demonstrate this is needed, and could be used to influence employers, governors and funders to support ongoing partnerships.
Strategic influencing
This occurs at multiple levels and settings.  In LMICs , we influence and are influenced by patients, the public, clinical teams, hospital management, and local and central governmental, while we also need to  influence HIC funders, healthcare staff and governing bodies, and other stroke clinicians and researchers.
Change should not be enforced just through applying policies from HICs (e.g. NHS policy) to LMICs; instead it is necessary to build relationships based on trust and open communication, understand cultural influences, and facilitate local staff to initiate and steer the direction and speed of change. Stakeholder analysis was recognised as being useful to enable agenda alignment.  
Many partnerships have experienced that there are often a few key individuals in partner countries who have driven forward change and had strong influence on others locally; finding these ‘door openers’ is important and can greatly influence the success of any project.  
Some common ways for motivating teams on the ground were small, context-specific gestures e.g. providing positive feedback and mentioning staff’s success in newsletters and blogs. Supporting key staff from LMICs to visit HICs can assist their collective understanding of different healthcare systems and consolidate their learning. Stroke care was acknowledged to be an unrecognised and underdeveloped clinical specialty in some LMICs and the building of pride in stroke care by developing understanding of stroke and the possibility of improved outcomes for patients is important. 
Influencing higher stakeholders and encouraging policy change is seen as a critical component in creating long-term change.  The impact of governmental buy-in varies greatly between countries; for some, governmental policy is enforced strictly, for others a policy or procedure may be in place formally but staff on the ground are not empowered to implement it. Political instability and corruption are also potential challenges. Teams may find strength, increased stability and increased influencing power though uniting with other external organisations, such as local patient/carer groups, civic organisations, and national or international stroke organisations.  
Where there is no continuous in-country presence by HIC staff, local staff should be supported via other means (e.g. Skype support) outside of visits.   Similarly, staff returning from visits to LMICs should ensure they handover purposefully and robustly to colleagues, to maintain positive influence. 

Recurring themes
Some of the key challenges experienced by stroke partnerships are: 

  • ·      A different concept of competency/training needs
  • ·      Culturally different motivations for working in healthcare
  • ·      Resource constraints
  • ·      Hierarchical systems
  • ·      Implementing  knowledge into clinical practice
  • ·      Sustaining  change 
There were also common lessons learned, and views on where to focus moving forward.  
Some of the key, take-home messages, were:

  • ·      Understand the context
  • ·      Work in partnershipand communicate
  • ·      Be realistic and address sustainability
We found that there are many parties involved in improving stroke care in LMICs, and we had much to learn from one another. Despite the diverse focus of our individual projects, we faced similar challenges and benefited from sharing knowledge and experiences.  Resources such as standards, guidelines, patient information tools and measurement approaches are useful to all, but they are not always common knowledge.  We decided a forum to share knowledge was a positive move forwards. We must also ensure partners from LMICs are involved in this in the future, to increase our reach and understanding.
Please do get in touch if you would like to join this forum!
The information within this Blog reflects the reported experiences of UK partners, who attended the networking event.  It cannot necessarily be applied to all LMIC settings, and does not directly represent the experience of LMIC partners themselves.
Written on behalf of the attendees by Sophie Bright (Kings-Sierra Leone Partnership), Amelia Shaw and Louise Johnson (Wessex-Ghana Stroke Partnership), Jo Gibson (UCLan Global Health).

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