Earli19 presentation 13 aug19_charitonos_littlejohn
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@EARLI19 paper on Professional Learning in the health sector in developing countries by Koula Charitonos (Open University, UK) and Allison Littlejohn (University of Glasgow, UK)
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Earli19 presentation 13 aug19_charitonos_littlejohn
- 1. Prof Allison Littlejohn University of Glasgow Allison.littlejohn@Glasgow.ac,uk @allisonl Emerging directions in research on capacity strengthening for drug-resistant infections in LMICs Dr Koula Charitonos Institute of Educational Technology, The Open University UK Koula.charitonos@open.ac.uk @ch_koula EARLI 2019 Aachen, Germany 12-16 August 2019
- 2. Professor Allison Littlejohn Academic Director Dr Koula Charitonos Learning Advisor Tim Seal Senior Project Manager Dr Heli Kaatrakoski Researcher Dr Rachel McMullan, Lecturer in Health Sciences, OU Dr Alison Fox, Senior Lecturer in Education, OU Gail Vardy, Co-ordinator, International Development Office, OU Richard Dobson Martin Hughes, Senior Project Manager, LDS, OU Dr Ben Amos, Health Systems, Mott MacDonald Dr Saba Mussavi, Epidemiologist, Health Systems Strengthening
- 4. UK aid programme, helping low and middle income countries to tackle antimicrobial resistance (AMR). The aim is to improve the surveillance of AMR and generate relevant data that is shared nationally and globally. https://www.flemingfund.org/
- 5. Source: LSHTM, 2018. AMR Surveillance in low- and middle-income settings. A roadmap for participation in the global antimicrobial surveillance system (GLASS), p.21 AMR Surveillance Process
- 7. Design, Deliver and Evaluate Learning Events to build capacity in AMR surveillance in LMICs Develop a longer-term approach - topics, methods, modes of delivery for learning around AMR in LMICs for Year 2-Year 4 Develop understanding about the context what skills and knowledge are needed, what does the environment look like, how lab professionals in LMICs learn Year 1 Objectives Phase 2 Country visits Learning eventsExpert interviews Phase 1 Phase 3 Event A Event B
- 8. What forms of professional learning change work in ways that support global challenges? What are the knowledge gaps?
- 9. • Interviews with n=23 ‘experts’ on AMR (in person, online) • Members of the Technical Advisory Group of the Fleming Fund / DHSC (n=3) • Members of staff at a research institution in a LMIC, leading a capacity programme on AMR (n=2) • Members of the Experts Advisory Group of the Management Agency leading the implementation of the Fleming Fund (n=7); • Members of staff of the Management Agency; (n=8) and • Secondees from the UK DHSC in organisations such as World Health Organisation, World Organisation for Animal Health (OIE) and Food and Agriculture Organisation (FAO) (n=3) • Average duration 50min, recorded & transcribed. • Experience spanning multiple countries, including: Vietnam, Malawi, Cambodia, Philippines, Pakistan, Mali, Tanzania, Ghana, Uganda, Nepal, India, Laos, Kenya, Bhutan, New Zealand, Myanmar, Zimbabwe, UK. Phase 1 Participants
- 10. to establish a reliable and credible AMR surveillance system in the facility (e.g. hospital, animal facility) ACTIVITY SYSTEMS Local system (facility level) National system (country level) Regional system (district / region level) Global system (across countries) to operationalise a functioning surveillance system in the country to establish AMR surveillance networks in the districts / regions to establish GLASS guidelines across countries
- 11. “there's quite a lot of other donors involved in this area. And it's an up and coming subject. So people are investing, and taking up, and taking up the resources of a very limited number of people. So you have to be careful to pitch programmes at the right level for each country because the absorptive capacity of the countries…has been limited…” [AMR Community / Expert, P3) 1. Growing awareness of AMR as an emerging global challenge
- 12. “And that’s [One Health] been a big thing, again for our own team [Fleming Fund / Management Agency] to understand, and then for countries to understand. Because everybody from WHO, and the tripartite, DH, Mott, and to some extent on the ground uses the words One Health, and understands that One Health is important for antibiotic resistance, but without really understanding how to achieve that” [AMR Community / Expert, P23] 2. AMR is a multi-disease and multi-sectoral challenge
- 13. “most of the procurement agency in countries base their choice of reagent based on cost. And so, they will select re-agents that are unfit to provide good quality testing. And this is because there is a disconnection between the finance ministry and the technical people, even from the country. And so, these systemic issues like quality is not restricted to train lab technicians, to do good testing. They know that they need good reagents, but they don't have these reagents, because the national procurement agency is not supporting [purchase of] this reagent because they cost too much initially…And there is all this economic value chain that is not taken into consideration by the finance ministry" (P5) 3. AMR Surveillance is an outcome of well-functioning lab networks
- 14. 4. AMR Surveillance relies on Good Practice “…you know, antibiotic prescribing was a very easy task when I was a young physician because we had a lot of antibiotics and every antibiotic was working on most bacteria. So, it was very easy. Now it's very, very complicated in many instances, because we have bacteria on which very few antibiotics which are working. And depending on the patient, you have strictly to use this one or this one, at that dose or this dose. And very often, it's a great help for the clinicians to have the advice of the microbiologist to choose the right antibiotic […]” [AMR Community / Experts, P18]
- 15. “The first one is to report it to the clinician and tell him, well, you have to use antibiotic X or Y and not antibiotic Z to treat your patient…The second use is to tell a clinician every year, during the past year, we have isolated, I don't know, 564 bacteria of that type in your department…To give them the statistics. Which will help them to use this data in what we call an empiric manner… and so you can adapt your empirical treatment using the retrospective data…. And the third use of the data is to gather all the information from hospitals or health centres… and to have a global picture in the country of the susceptibility pattern of each type of bacteria. And so the leaders and the people that make the public health policy… will take specific measures against bacteria X” [P18] 5. AMR Surveillance requires data flow across local, national and global systems
- 16. “The second major issue is about trust…If you go to a UK hospital with a suspicion of infection, immediately, you will be taking a number of samples depending on the type of infection. And these samples will go to the lab, and the clinicians will use the result to treat you because they trust the results from the lab. In many, many places in developing countries, this does not happen because first, the clinician do not do the sampling. Very often, they do not do the sampling, because… they don't trust the result of the lab. And if they don't trust the results of the lab, they don't do the test because they know that they will not use the result…They don't send test, so the lab has very little tests to perform, and so they are not very good at performing tests and they are not very good at giving good results. And so it doesn't work” [P18] 6. AMR surveillance requires trust and openness among professionals
- 17. “it all comes back to resourcing: if you are a lab technician working in a poorly resourced lab…you will still feel undervalued and under-represented…” [P22]. “[difficult to] technically assess precisely the results of the susceptibility…It’s extremely difficult technically to say bacteria X is susceptible to antibiotic Z, but not to antibiotics A and B” [P18]. 7. AMR surveillance relies on motivated and skilful professionals
- 18. Key knowledge and skills needs by AMR experts Ref Priority areas / Category name 1 Diagnostics Stewardship 2 Good Laboratory Practice 3 Foundations in Microbiology 4 Molecular Advanced Microbiology 5 Data Use & Interpretation for diagnosis in Clinical and Vet Services 6 Data Use & interpretation for Public Health Policy 7 Communication, Collaboration & Advocacy 8 Surveillance System Planning & Implementation 9 One Health Multisectoral
- 19. 1. Target learning events for groups of people with specific job roles. 2. Design learning events that encourage collaborative work. 3. Expand beyond traditional ways of working, where clinicians and labs are disconnected and not engaging in direct, two-way communication. 4. Learning and capacity building has to maintain focus on new practices and be accompanied by a restructuring of work. 5. A capacity strengthening programme that only looks at achieving advancement of knowledge and skills will not bring desirable change. Capacity strengthening for drug-resistant infections in LMICs: key recommendations
- 20. Professor Allison Littlejohn Academic Director Dr Koula Charitonos Learning Advisor Tim Seal Senior Project Manager Dr Heli Kaatrakoski Researcher Koula.charitonos@open.ac.uk @ch_koula Allison.littlejohn@Glasgow.ac.uk @allisonl
- 21. Categories / Who says? DS GLP FM MAM DICV DUP CCA SSPI OH Policy Makers (n=3) 1 1 1 - 1 - 2 - - AMR Community/ Experts (n=20) 4 8 11 1 12 6 13 7 3 Total 5 9 12 1 13 6 15 7 3 The number of experts expressing what needs to be learnt (N=23) DS=Diagnostics Stewardship; GLP= Good Laboratory Practice; FM= Foundations in Microbiology; MAM=Molecular Advanced Microbiology; DUCV= Data Use & Interpretation for diagnosis in Clinical and Vet Services; DUPH=Data Use & interpretation for Public Health Policy, CCA=Communication, Collaboration & Advocacy; SSPI=Surveillance System Planning & Implementation; OH=One Health Multisectoral
- 22. Who should learn per category? DS=Diagnostics Stewardship; GLP= Good Laboratory Practice; FM= Foundations in Microbiology; MAM=Molecular Advanced Microbiology; DUCV= Data Use & Interpretation for diagnosis in Clinical and Vet Services; DUPH=Data Use & interpretation for Public Health Policy, CCA=Communication, Collaboration & Advocacy; SSPI=Surveillance System Planning & Implementation; OH=One Health Multisectoral Categories / Target groups DS GLP FM MAM DICV DUP CCA SSPI OH 1. Lab Professionals x x x x x x x x x 2. Senior Lab Professionals x x x x x x x x 3. Clinical Services Professionals x x x x x x x 4. Vet Services Professionals x x x x x 5. Senior Management staff in Clinical services x x x x x x 6. Senior Management in Vet Services x x x x 7. Policy maker x x x x x 8. AMR Community / Experts x x x x x 9. Clinical and Veterinary services clients x 10. The Public x
- 23. Roles / target groups who should be working together per identified categories DS=Diagnostics Stewardship; GLP= Good Laboratory Practice; FM= Foundations in Microbiology; MAM=Molecular Advanced Microbiology; DUCV= Data Use & Interpretation for diagnosis in Clinical and Vet Services; DUPH=Data Use & interpretation for Public Health Policy, CCA=Communication, Collaboration & Advocacy; SSPI=Surveillance System Planning & Implementation; OH=One Health Multisectoral
- 24. Event B: Foundations in Microbiology • Lab Professionals, Senior Lab Professionals. • 8-week OU OpenLearn course ‘Understanding antibiotic resistance’ • Focus on Bhutan • Objectives: appreciate the issues surrounding antibiotic resistance know about the challenges in developing new antibiotics know about alternative approaches to tackling infectious diseases. Two pilot events Event A: Data Use and Interpretation • Lab professionals, Senior Lab Professionals, (Senior) Clinical Services Professionals, (Senior) Vet Services Professionals • (Perhaps) existing resources on data use and interpretation with additional learning and assessment developed in order to provide a more contextualised response. • Objectives: Understand basic interpretation / analysis Identify how to apply this to your needs How data can be used to support your work Develop a plan to implement data use in practice Engage in knowledge sharing to support change in practice, challenges / successes
- 25. Phase 2 Country visits Phase 2 To identify existing courses training on AMR available in the countries; tensions and contradictions in the surveillance system and to map knowledge gaps and work practices among lab professionals 1x Meeting with 12 members of the AMR Committee 6x Lab visits and Lab Tours 25x Individual interviews 1x group interview Meetings: 1x Chief Laboratory Officer & 1x Medical Superintended 6x Meetings with AMR Committee 3x Lab Visits and Lab tours 21x individual interviews 4x Meetings with members of the AMR Platform 2x meetings with staff in Ghana Health Services 4x Lab Visits and Lab tours 14x Individual interviews
- 26. Phase 2 Country visits Professional Roles Country 1 Country 2 Country 3 Laboratory Professionals 9 10 5 Senior Laboratory Professionals 10 4 2 Clinical Services Professionals 1 - - Senior Management Staff in Clinical Services 1 - 1 Policymaker 3 6 4 AMR Community / Expert 1 1 2 Total 25 21 14
Hinweis der Redaktion
- Collaboration with International Development Office & IET Work with Mott & Department of Health
- The increasing use of antimicrobials worldwide has been associated with a global increase in Drug-Resistance Infections, which threatens to return clinical therapies to the pre-antibiotic era. At present, DRIs are estimated to account for 50,000 deaths each year in Europe and the USA alone by 2050 it is estimated that DRIs will account for 10 million • deaths per year worldwide posing an economic and biosecurity threat. (LSHTM Roadmap) The rise of antimicrobial resistance (AMR) poses a threat to our ability to treat common and life-threatening infections on a global scale. Identifying the emergence of AMR requires strengthening of surveillance for AMR, particularly in low and middle-income countries (LMICs) where the burden of infection is higher and health systems are least able to respond.
- In response to this global challenge, DHSC established the fleming Fund. 265million pounds investments on public health systems in 24 countries. Throughout the five years countries, 24 in total will become involved in the programme. Our work is in 3 of these countries, all three in different stages in this process. Focus is on LMICs – situation there is highly dependent on how well the health system in each country functions. Focus is not only on Human Health – instead they are underpinned by a ‘One health approach’ where sectors come together, human health, animal health, agriculture & environment.
- One of the key concepts in the Fleming Fund and also within our work is the idea of an AMR surveillance system that is functioning at global, national, regional and local level. These systems are not really established in LMICs. They are in infancy. Fleming fund is aiming to create these systems. This representation here shows this process and core activities happening in the system. it includes ‘patient’ and activity that is happening in this system by various professionals, such as clinicians and laboratory staff. Laboratories play a big role in this process. However, they are at the margins of the medical profession, usually not much valued and staff there not well recognised. Little is known about how to offer laboratory capacity strengthening in ways that bring about effective change.
- We viewed the laboratory as a key learning setting in the system. Knowledge-intensive workplace A key decision we made in early stages of the project was that we will focus on professionals in the laboratory and we wanted to understand bit more about their roles and what do they do in their everyday work. And how they see themselves fitting into the surveillance system. There’s a mandate by WHO for lab people to comply and establish knowledge on a framework developed by WHO and develop skills on doing tests and generating data and documenting this data. We were looking to unpack characteristics of this environment – what are the prominent work practices related to AMR; who are the people who are working in the labs; what are existing learning practices? How does the use of technology look like? What motivates these professionals? But of course they are not working alone. It’s a system where there are lots of interdependencies, lots of actors, global and local players, donors, complex work practice, and of course as we are talking about LMICs a completely different context.
- So this was some background information I’ll move on to explain what we were set to do in this first year and how we went about doing it. We are about to complete Year 1. In this presentation we are
- A central question guiding our inquiry was:
- Data was gathered between April and June 2018 during a series of face-to-face and online interviews with experts in AMR (total n=23). Interviews were guided by a semi-structured instrument previously validated during studies of self-regulated, professional learning (see Appendix A). It is noted that these experts had expertise on health systems research and AMR in multiple countries across the world. Note: the majority of the experts had experience in human health systems (due to the nature of the provided contacts) and this might have been reflected in their views. In parallel to this activity, Phase 1 further included a review of learning resources on AMR, including but not limited to online courses, videos, frameworks and reports. The main objective was to gain a better understanding of the AMR landscape and document the range of existing resources in order to map these resources against the identified needs that would emerged from the interviews with experts and professionals in countries.
- In our analysis we drew on the tradition of socio-cultural and cultural-historical theories and the work by Engeström (1987) to analyse learning and development in the context of their changing work environments A central system is the one at the facility level involving various actors. We viewed the work of laboratory professionals as a form of collective activity system complemented and extended with models of multiple interconnected activity systems. There is a wider global system that can be seen as an activity system itself led by WHO and UN agencies. Interconnected with: - National systems as a distinct activity system having the object of…. - There are also district/regional systems … Looking at these systems, in the analysis of the data generated through the interviews with AMR Community / Experts (n=23), we were interested in tracing the challenges/tensions that professionals in heath settings face when navigating a changing environment where they have to change their own practice to accommodate the new practice of ‘surveillance’. The analysis supported identification of tensions between elements of the AMR system, either at the global level or at the country level or local level. The analysis also surfaces potential future dilemmas associated with implementing a capacity strengthening programme. The following section in the presentation highlights key tensions that emerged through the Phase 1 interviews. The CHAT framework provided a means of analysing work and learning through identification of tensions and contradictions in context of organisational transformation. As a ‘dialectical’ theory, it views human relationships as interwoven with multiple contradictions, and conceptualises learning as a dynamic and non-linear process.
- First two findings, related to nature of the challenge The recent emergence of AMR as a global challenge is perceived as the main reason that the general lack awareness of the problem of AMR. This is also the reason why professionals working in public health facilities have limited knowledge about AMR and is considered by some as the reason why there has been limited mobilisation of resources to tackle AMR within health systems and to the lack of regulation around the use of antibiotics in LMICs. an environment that is ‘dynamic’ and ‘fluid’, careful navigation and co-ordination is needed. This quote highlights specific vested interests and competing concerns / priorities. Within, for example, Ministries / departments / donors that influence the resources available (e.g. funding). The above quote also signals that a likely outcome is a sense of fatigue among the various groups that these stakeholders are targeting. How are global challenges recognised? eg how to the vested interests and competing concerns / priorities mediate the recognition of AMR as a global challenge and prioritisation of it in work? How does it become central to what professionals do?
- AMR as a multi-disease and multi-sectoral challenge that involves farming and agriculture, the environment, human health and animal health systems. Hence AMR must be dealt with through collaborative and multi-sectoral approaches, while maintaining a focus on the local, regional, national, and global levels. Therefore, collaborative forms of work and learning across boundaries are required to ease this tension. A consequence is that different groups (acting as silos) that have been designed to work separately (e.g. Human Health systems, Animal Health systems) now have to work together. This requires a number of architectural or organisational changes, but it is not clear how these can be actuated. An example is the One Health perspective that underpins AMR work. Whilst the focus is on protecting human health, this cannot be achieved without a strong One Health component with linkages between animal and human health disciplines at the country level. Many interviewees pointed to a ‘design challenge’. The Fleming Fund has to work towards facilitating the One Health. However, this work takes place in an environment where there is limited awareness about the One Health perspective, which creates a tension in terms of how to operationalise this perspective – as illustrated in the quote. Responsibility for new/ emerging areas tends to be distributed across existing ‘mature’ domains / organisations and the need to create new collaborations/ partnerships. This issue leads to the issue in slides 17 & 18 – that a well functioning solution (ie surveillance) and good practice requires new collaborations/ partnerships and ways of working, which, in turn, requires new roles, rules and division of labour.
- Responsibility for new/ emerging areas tends to be distributed across existing ‘mature’ domains / organisations and the need to create new collaborations/ partnerships and new work practices. This issue leads to the issue in slides 17 & 18 – that a well functioning solution (ie surveillance) and good practice requires new collaborations/ partnerships and ways of working, which, in turn, requires new roles, rules and division of labour. One of the key mandates of the Fleming Fund is to establish and support AMR surveillance networks within the countries. Depending on the country, a network may already be in place, or may be developed as part of the capacity-building process. The interviews suggested that the speed and extent to which AMR surveillance can be strengthened depends on the functioning of these networks and the resources available, including funding and human resources and it heavily relies on policy commitment. In most LMICs countries there is existing laboratory capacity, yet the scale varies substantially, not only across countries, but also within the country itself. E.g. labs in rural settings differ from urban areas, the capacity and expertise in AMR reference labs is different from sentinel sites, only a few labs are accredited, AMR surveillance for human health is better developed than for animal health. A number of systemic issues were raised during the interviews, such as the infrastructure (i.e. power supply, equipment, lack of capacity to use the equipment), quality (i.e. quality control, quality assurance) but also the procurement process within the public health system in LMICs
- AMR is usually made worse by ingrained professional practices. Several examples of entrenched practice were described, such as the pharmacist who sells antibiotics over-the-counter without a prescription, the farmer who uses antibiotics in agriculture and very frequently references to the clinician who prescribes antibiotics without sufficient data. ‘Prescribing practice’ very frequently used as examples of bad practice. Clinicians were perceived as not making use of lab-diagnostics to treat patients, and, instead, relying on empirical diagnosis. Evidence in the interviews pointed to “no culture of reliance amongst clinicians for using laboratory services as part of their day to day clerical work” [P13] and, instead, relying on empirical diagnosis. This might be because of: 1. the lab service is not available, reliable, or timely, or 2. clinicians are not trained in interpreting the data and results and 3. in some facilities patients having to pay for lab tests, hence the cost of treatment may have been increased.
- new collaboration and ways of working are necessary Such new rules/ roles/ wow lay the foundation to enable the ‘flow’ of data - as a key object of work. In other words – its not simple about the ‘diffusion of knowledge to ‘plug the knowledge gap’ but its also necessary to establish the right conditions for people to work together and exchange data objects in an effective way. In most LMICs there is no systematic way of collecting and reporting these data. There are few standardised procedures and standardisation of reporting systems and data sharing and comparability with other countries is not yet possible. Links between clinical data, samples and clinical outcomes are not usually made, while any data that is available often is generated by externally funded research projects. Three different visions of data use within a surveillance system were articulated: - good quality data from the labs is shared within a facility with clinicians or vets to support diagnosis, prophylaxis and treatment at an individual level. Data is also made available in aggregated forms beyond the local facility and is shared with district and national facilities to support treatment guidelines and public health policy nationally. Data is shared in global systems Trust is critical to create these conditions for effective working.
- specific ‘norms’ within AMR systems, one of which was expressed as ‘lack of trust’ of clinicians in terms of the results generated by the laboratories This tension originates from the hierarchical structures within health systems. One interviewee noted that “the clinical staff and laboratory staff often don't talk to each other very much…” This lack of trust influences the ways in which the microbiology labs operate. One issue is that LMICs laboratories are usually run by people without a medical background, and this is sometimes perceived by clinicians as problematic, also because lab professionals cannot give advice on what antibiotics should be used.
- almost all the interviewees referred to the same issue: lab professionals do not have the technical expertise needed to perform bacterial susceptibility testing. inadequate and sometimes non-existent training as another factor contributing to the poor functioning of AMR surveillance systems. concern about low retention rates of laboratory professionals, low salaries and poor motivation. The fact that labs operate in low-resource environments, where often lab managers/heads of units cannot commit extra resources to AMR surveillance, were also seen as detrimental. You have labs with 3 people, one working on malaria, one on HIV and one of tuberculosis.
- We needed to find practical next steps and here’s what we did ie provide learning events that don’t simply disseminate knowledge but start to support the conditions specified in slides 15-21). In bold are the three top according to the experts. We mapped these against specific roles. Whilst ‘Foundations in Microbiology’ is a well-established domain in the field. But not the other two: The importance of developing communication, collaboration and advocacy skills across roles in the surveillance system. This category does not look at subject specific skills, such as in the category ‘Foundations in Microbiology’ but it underpins effective surveillance practice because surveillance activity involves numerous processes, interfaces and handoffs across different professional groups with varying levels of educational and professional training, and instances where critical information must be accurately communicated - across professionals, ranks, settings, teams and sectors. Where professionals are not communicating effectively, patient/public health safety is at risk and errors are likely to occur. Experts highlighted the need to bring clinicians and lab professionals together. Data Use & Interpretation for diagnosis - highlights the importance of data flow across local, national and global systems as discussed earlier. This gap in knowledge on how to use data might be due to the fact that AMR surveillance systems are not yet mature in LMICs. It might be because no specific roles have been created to use and interpret data, or because professionals who have this role have not yet acquired specialised skills, do not feel ownership of specific tasks or are not sufficiently supported in the performance of this activity.
- We recognise the difficulties in supporting the restructure of workplaces in ways that support effective learning and are trying to find ways to design learning events that move beyond what we traditionally think of as ‘learning’ or ‘education’ to ways of encouraging genuine advancement of working conditions in ways that help solve global challenges. These gaps cannot be dealt with in isolation. Should consider hierarchical and organisational structures at the local facility level. The roles of professionals who are close to the patient or animal should be reviewed or created to ensure their practice enables effective sampling and data use. But there is also a need to clarify what knowledge and competencies are required for sampling and data use and interpretation to be performed adequately at the local level. We have to reconsider roles within the health-care/AMR workforce, as well as the knowledge, skills and practices that are appropriate for workforce strengthening programmes. A capacity strengthening programme that only looks at achieving advancement of knowledge and skills will not bring desirable change. Review / Create roles at the local level for this activity to take place in an effective way and professionals to feel supported. Clarify / Review what knowledge and competencies are required for new practice to be performed adequately at the local level.
- Engaged with number of roles – diverse – interested not to talk just to senior people Talked to almost 100 people (and approx. 85 are structured interviews)