Sustainability of teaching the Rural Obstetric Ultrasound Triage Exam (ROUTE) to healthcare workers in low-resource settings in rural Panama

INTRODUCTION: For the past few years, teams of UCI medical students have traveled to Bocas del Toro, Panama to teach the Rural Obstetric Ultrasound Triage Exam (ROUTE) to local healthcare providers. The first group established... [ view full abstract ]

INTRODUCTION:
For the past few years, teams of UCI medical students have traveled to Bocas del Toro, Panama to teach the Rural Obstetric Ultrasound Triage Exam (ROUTE) to local healthcare providers. The first group established that medical students themselves could successfully learn the ROUTE from UCI faculty and sonographers. This group then attempted to teach the ROUTE to local midwives (parteras). They encountered multiple barriers, which most notably included that a) parteras had minimal pre-delivery interaction with pregnant women, b) there is limited access to affordable electricity to charge the ultrasound machines, and c) parteras have a wide range of literacy levels and dialects. Given these challenges, a second team attempted to teach the ROUTE to various non-partera healthcare workers. They showed that although these healthcare workers were able to successfully learn some aspects of the ROUTE, more robust training would likely be needed to master the protocol. This year we hope to more definitively determine whether non-partera healthcare workers can effectively learn the ROUTE.

Thus, this summer’s aims are to: 1) assess the effectiveness and sustainability of this training program as it pertains to non-partera healthcare workers; 2) elucidate the differences in learning according to the subset of healthcare workers being taught.

METHODS:
Dr. Jonathan Steller, chief OB-GYN resident at the UCI Medical Center (UCIMC), taught the ROUTE to eleven medical students from the UCI School of Medicine who had each already received approximately eight hours of ultrasound instruction in their first-year curriculum. Each medical student then received 12 additional hours of obstetric ultrasound training with sonographers at UCIMC.

These medical students will travel to Bocas del Toro, Panama to teach the ROUTE to local healthcare workers collaborating with the Floating Doctors organization. The healthcare workers will be recruited by Floating Doctors to participate in the program. Each healthcare worker will undergo two hours of hands-on instruction with a bedside ultrasound machine and a pregnant model. During these sessions, a medical student will explain instructional materials which cover: 1) Introduction to ultrasound and 2) the ROUTE protocol, both detailed in Table 1. These sessions will be followed by six hours of hands-on practice performing the ROUTE in the community.

Both attitudes toward and knowledge of obstetric ultrasound will be assessed via surveys given before and after the program. Competency of healthcare workers in performing the ROUTE will be assessed by comparing the measurements obtained by healthcare workers to those obtained by trained medical students.

RESULTS:
A study performed in 2014 using the same design concluded that medical students could successfully teach rural healthcare workers some aspects of the ROUTE, but that more robust training would likely be necessary. OB-US knowledge improved from a pre-course average of 31.31% to a post-course average of 70.71% correct (n=12). A two-tailed paired t-test comparing survey responses was significant (p=0.0002). Participants correctly assessed fetal number (n=26) and fetal presentation (n=10) on 100% of scans (0% error). Placenta previa (n=25) and oligohydramnios/polyhydramnios (n=8) were correctly ruled out on 100% of scans (0% error). On average, participants correctly dated pregnancies based on CRL (n=7) 57.1% of the time, and BPD (n=10) 61.1% of the time (<7% error) compared to controls.

We hope to obtain additional results in order to increase the power of previous years’ findings. We additionally plan to further analyze the teaching results by previous healthcare training; this data will be collected by self-identified category of healthcare worker.

CONCLUSION:
Previous findings show that this training program may be effective for non-partera healthcare workers. We hypothesize that by increasing sample size, our data will be able to more definitively determine the effectiveness and sustainability of a program in which medical students teach the ROUTE. Our secondary goal, to look at variations in learning by training level, may help assess project sustainability and generalizability.