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Increasing Access to Diagnostic Imaging in Developing Countries: The Asha Jyoti Mobile Clinic Nandish Shah1, Dr. Kathryn Everton1, Anna Nordvig1, Bianca Nguyen1, Dr. Niranjan Khandelwal2, Dr. Daniel Mollura1
1RAD-AID International, United States; 2Post-Graduate Institute of Medical Education and Research, Chandigarh, India
Introduction
Diagnostic imaging plays an important role not only in identifying pathology and
tracking the progression of a disease, but also in preventing disease via
screening. However, according to the WHO, one-half to two-thirds of people in
the world lack adequate access to basic imaging technology, such as x-ray and
ultrasound. This figure remains unchanged from WHO estimates from the late
1970s and early 1980s. It is therefore essential to learn how to measure access
in order to best improve it.
The Definition of ‘Access’ The WHO defines it as an interaction of different factors, which include
availability, affordability, accessibility, appropriateness, acceptability, and quality.
Essential Imaging for the Developing World
Interestingly, 80-90% of the imaging need in developing countries can be met
by x-ray and ultrasound alone. These modalities not only diagnose disease, but
have been shown to impact clinical management and patient outcomes in low-
resource settings.
X-rays are essential in the diagnosis and treatment for people presenting with
pulmonary or orthopedic conditions. Regarding screening, they can screen for
breast cancer through mammograms and osteoporosis through DEXA.
Ultrasound has an established role in obstetric imaging. Additional conditions
for its use include: abdominal trauma (FAST), cardiac valvular disease, and
image guidance for procedures. Regarding breast pathology, US can be used to
evaluate findings on mammography or screen women with dense breast tissue.
Also, it can identify breast cysts and provide image guidance for biopsy.
Understanding Adequate Access
Disparity in access also exists within developing nations, specifically between
the private and public sector. While the private sector has the resources to offer
needed imaging services, it is inaccessible to many due to cost and urban
location. The public sector, however, aims to provide for all, but is overburdened
due to a lack of sufficient resources both in trained staff and imaging devices.
For public-sector facilities in more rural areas, the challenge lies in having the
resources to house, maintain, and repair the most basic imaging services as
well as entice trained staff to stay in the area to offer services.
At the core, a definition of need has to be compared with a definition of
adequate access. After looking at data from the WHO, it is easy to see that
developing countries have not reached the capacity to provide adequate access
to both x-ray and ultrasound technology.
Background
RAD-AID International has looked at the issue of access through its
Radiology Readiness survey, a 16 part survey that attempts to reveal the
infrastructural, educational, financial, and clinical barriers surrounding access.
In 2010, a RAD-AID team administered it at several sites in India. In addition to
understanding barriers, the comprehensive survey helps identify areas of
medical need. In India, the survey revealed women’s health as the most
underserved and highest priority area of need.
Currently, about 70% of people in India reside in rural areas, where patients
lack basic health care to meet medical needs. The dearth of women’s health
screening programs results in increased morbidity and mortality from
preventable and treatable diseases. In fact, there is no national screening
program for breast cancer in India. Thus, when women do present to clinics and
hospitals, a majority of the new diagnoses are of locally advanced breast
cancer. Cervical cancer, which is second in prevalence to breast cancer, also
lacks adequate screening around India. Screening is also available for
osteoporosis, a condition affecting almost 1 in 3 low-income women in India.
Through survey data and an understanding of the medical needs, the team
decided to collaborate with a prominent government hospital, Postgraduate
Institute of Medical Education and Research (PGI), in Chandigarh, one of the
sites visited. Together, they started the Asha Jyoti Mobile Health Program.
Mission
The Asha Jyoti Mobile Health Program is a sustainable and scalable mobile
healthcare van program that uses radiologic technology and community health
services to address women’s preventative health issues in the city periphery
and rural areas near Chandigarh, Punjab.
The mobile health clinic will focus on providing free preventative screening
services for women:
1. Mammography (women 40+)
2. Cervical cancer screening (women 30+)
3. Bone densitometry screening (women 40+)
Patient Visit Results
Chandigarh is divided into sectors. Currently, the van goes to an existing
primary healthcare center in sector 45 for 3 days/wk. Sector 45 in Chandigarh is
a unique area with a combination of urban, rural (Burail village) and urban slum
population (colony 5). To reach them, the van sets up camps in remote village
and select urban areas. To date, the program has screened 2904 women.
Van Staff -Public Health Nurse
-Staff Nurse from PGI
-Technologist
-PGI Radiology
Resident
-Data Entry Operator
-Social Health Worker
-Driver
Technology On the mobile unit:
•Software for machines; a text messaging interface
•Central storage system, computer, and printer
•A portable data storage device
On site at PGI, the plan relies on the following systems:
•Central server using DICOM images and network
connection
•Eventually an EMR system and PACS system
Challenge Partnerships
1. Perception that screening
is unnecessary
Through a partnership with the School of Public
Health (SPH) at PGI, Asha Jyoti provides
community education programs.
The SPH helps identify community liaisons in
each target village to be health educators. These
women educate people on the benefits of
women’s preventative health care screening.
The community liaisons facilitate continuity of care
by keeping in touch with social workers at PGI
and ensuring follow-up care as necessary.
Constant feedback from the community liaisons
regarding challenges that arise will allow the
program to reassess and improve the outreach
and education strategies
2. Low income groups
believe they cannot afford
screening or treatment, or
take off work to seek care
3. Stigma of having cancer:
fear that one will become a
social outcast
4. Lack of awareness of
screening services
Addressing Challenges through Partnerships
Availability A medical device is able to be purchased on the market. Also applies
to functional medical devices that are physically available at health
care facilities
Affordability Medical device is a cost-effective option for both the patient and health
care facility
Accessibility Individuals are geographically within reach of health care facilities that
house imaging technologies
Appropriateness A medical device or imaging technology must be scientifically valid,
address local need, and be utilized in a manner that a country can
afford
Acceptability Refers to cultural beliefs and individuals’ attitudes regarding the use of
various medical devices and imaging modalities
Quality Based on the national regulatory standards that are in place to assure
safe and effective use of all health technologies
Measuring Access
In 1979, the WHO conducted a survey to assess radiological services and
received responses from 89 countries of varying income levels.
In 2010, the WHO disseminated the Baseline Country Survey on Medical
Devices, a two page survey to understand the factors that make up ‘access.’ It
was administered to the ministries of health in 145 WHO member countries.
Needs Assessment for Medical Devices: Published by the WHO in 2011. It
outlines how a country can calculate gaps in access to medical devices.
Simply, a nation can catalog what exists regarding imaging technology
with what should be available to better define their gap in care.
Conclusion
The first step in attacking the issue of access is to understand its various
components as outlined by the WHO. Next, from looking at WHO surveys, it is
easy to see a disparity in the access to medical imaging technology, among all
modalities, between the developed and the developing world. Now, with the
needs-based assessment in place, the WHO has laid the foundation for
uncovering the overall gap in adequate imaging technology. With this
information, all parties involved, whether it is radiologists, radiologic
technologists, sonographers, NGOs, ministries of health, or developing nations,
will be able to join forces to close this gap.
The Asha Jyoti clinic is an example of such a start.
Van Layout
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