Background

Congenital anomaly contributes to 5–7% of perinatal and neonatal mortality in low- and middle-income countries (LMICs) [1]. The prevalence of congenital anomaly in Nepal is also high (52 per 10,000 children), and 11.1% of neonates die because of congenital anomalies [1,2,3]. Yet, literature on the care and management of defects in Nepal is limited. Birth defects is an emerging public health problem due to lack of genetic diagnostic methods and inadequacy of other identification methods [4]. Ultrasound is an important noninvasive screening tool that detects congenital anomalies and manages maternity-related risk factors for both morbidity and mortality [5, 6]. The World Health Organization (WHO) recommends pregnant women undergo at least one ultrasound scan before 24 weeks of gestation [7].

Ultrasound has become more widely available for medical professionals in LMICs [8] with decreased equipment costs. However, challenges in improving ultrasound service quantity and quality remain. Workforce shortage is considered a major challenge and a few opportunities for ultrasound training and continuing education exacerbate this challenge. Moreover, several ultrasound training in LMICs does not meet the WHO standards [9].

These challenges are also evident in Nepal. In Nepal, radiologists generally perform ultrasound scans, but Nepal has only 150 radiologists (1 per 185,000 populations), who are largely concentrated around the capital city [10]. This uneven distribution overwhelms ultrasound services in urban areas and thus, service quality control in antenatal care is difficult to achieve [10,11,12]. Moreover, non-radiologists have limited ultrasound training during their medical school, engaging only a short 15-day rotation in the radiology department. Hence, their ultrasound skill is either basic (limited to acquiring an idea on how machines operate and performing a few procedures with low-quality images) or poor [11, 13].

Previous studies show that intensive ultrasound training courses in LMICs significantly increase knowledge and self-confidence among the radiologists [13, 14]. Hence, the JW LEE Center for Global Medicine at Seoul National University College of Medicine (JW LEE CGM) of the Republic of Korea initiated the intensive ultrasound education program in Nepal since 2016 to promote ultrasound utilization and improve the quality of the practice among both radiologists and non-radiologists through continuous education and experience sharing. In this study, we evaluated the impacts of this education program from 2016 to 2018 using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework [15]. The framework includes an explicit focus on issues, dimensions, and steps in the program design, dissemination, and implementation process, which had been translated and used in different contexts, populations, settings, and cultures [15,16,17,18]. We applied the framework to evaluate the effectiveness of knowledge translation, assess broader impacts, and comprehensively understand the limitations, using quantitative and qualitative methods.

Methods

Education program development

JW LEE CGM held multiple rounds of needs assessments with key experts from Nepal. Respondents expressed multiple topics of interest such as cutting edge technology in medicine, such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI); fetal health screening for different systems using ultrasound, CT, and MRI; CT and MRI image and report interpretation; recent developments and issues in ultrasound techniques; detailed demonstration on biometry and other important indicator calculations using different imaging techniques. After exploring the perceived needs, JW LEE CGM invited lecturers/experts, Dhulikhel Hospital-Kathmandu University Hospital (DHKUH), and Nepali partners for educational purposes and created the curriculum based on the needs and availability of lecturers. The course was for two days and titled “The Ultrasound, CT and MRI Education Program for Obstetric, Fetal, Neonatal, and Congenital Anomaly” The course was conducted in collaboration with the Nepali Professional Societies. Table 1 shows the program agenda in 2016, 2017, and 2018. The contents were arranged based on feedback from the previous year’s participants and experts involved (obstetrician-gynecologists [OB-GYNs], pediatricians, radiologists, and hospital leaders). The core component of the program included lectures on obstetric image technology and techniques, case discussions, and experience sharing from both the Korean and Nepali experts. The components of CT and MRI in the program were considered as supplementary sessions because most of the hospitals in Nepal do not perform CT and MRI [19].

Table 1 Program agenda of ultrasound, CT, and MRI educational program for obstetric, fetal, neonatal and congenital anomaly in Nepal, 2016, 2017, and 2018
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Participant recruitment for the education program

A national open call for recruitment in the education program was made through various media and professional societies. The main target group of the program was OB-GYNs, pediatricians, and radiologists, but medical doctors from different specialties and non-physician healthcare providers (e.g., nurses, midwives, and paramedical staff) were also recruited. A total of 228 healthcare workers participated in the education program from 2016 to 2018.

Program evaluation framework

This study utilized the RE-AIM framework, which is a frequently used tool that evaluates multi-organizational and country projects [16]. The RE-AIM framework was applied as a conceptual guide for the study to describe the evaluation process systematically and comprehensively. This framework was selected as it is the most frequently used, and it has been tested with a wide range of interventions. The framework puts special attention on the implementation context [16]. The “Reach” dimension defines the beneficiary population and presents it in numbers covered with demographic and professional characteristics. “Effectiveness” as an impact measurement of an intervention on outcomes, “Adoption” reports settings of intervention agents can be qualitative or quantitative, and “Implementation” describes implementation context and factors influencing implementation. “Maintenance” reports the sustainability of the intervention and factors leading to sustainment. The detailed definitions, indicators, and data sources are presented in Table 2.

Table 2 Indicators and data sources for evaluating process and outcomes according to the reach, effectiveness, adoption, implementation, and maintenance framework
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Fig. 1
figure 1

Process of the implementation and evaluation of the education program

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Data collection and outcomes

This study used both quantitative and qualitative methods for evaluation. Administrative data, test data and survey data among participants were collected during the education program (2016–2018), and an online follow-up survey was conducted in 2019. Two members of the research team conducted face-to-face, in-depth interviews in English with the participants and leaders of participating institutions (n=11). The interviewees were recruited using convenience sampling.

Outcomes of the study were used in accordance with the components of the RE-AIM framework—Reach, Effectiveness, Adoption, Implementation, and Maintenance. Table 2 shows the details on the process and outcome indicators along with the utilized data sources.

Analysis

This study used proportions and means for the descriptive analysis and used the mean comparison t-test for difference in pre- and post-test scores for knowledge and pre- and post-survey scores for self-confidence. All quantitative data were analyzed using Stata version 14. For the qualitative data, voice recordings were transcribed and thematically coded using a software R Qualitative Data Analysis (RQDA) package for analysis [20]. PRS coded and formulated the themes based on the inductive method [21], and JK reviewed the codes. Both PRS and JK iteratively refined the subthemes (conceptual labels) and themes (code categories) and linked these with the RE-AIM framework dimensions.

Ethics

Regarding the tests and surveys, participants verbally consented and voluntarily participated. Written consent was obtained for the online survey and in-depth interviews. Ethical approval was obtained from Institutional Review Boards at the Seoul National University Hospital in the Republic of Korea (SNUH IRB No. 1906–036-1038).

Results

Reach

Table 3 summarizes the demographic characteristics of all participants in the ultrasound education program from 2016 to 2018. Across all years, a total of 228 healthcare workers attended the program, and most of them were aged less than 30 years (46.5, 41.3, and 75.8% in 2016, 2017, and 2018, respectively) and were affiliated with medical colleges (70.7, 54.0, and 81.8% in 2016, 2017, and 2018, respectively), but participants representing other types of institutions such as private hospital, government hospital, healthcare center, and Non-Governmental Organization (NGO) hospital were also present. In case of specialty, all the prioritized groups (OB-GYNs, pediatricians, and radiologists) had similar representation across all 3 years. In terms of geographic coverage calculated by the proportion of districts where the participants’ institution was located (Fig. 2) over the whole districts, one-third of the districts of Nepal (27.3% in 3 years, 16.9% in 2016, 12.9% in 2017, and 10.4% in 2018) were reached. Most of the participating institutes were from capital and its vicinity.

Table 3 Characteristics of the participants (2016 to 2018) and online follow-up survey respondents (2019)
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Fig. 2
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Geographical reach of ultrasound educational program from 2016 to 2018

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Effectiveness

Table 4 indicates the changes in knowledge and self-confidence before and after the education and overall satisfaction of the program. The mean post-test scores were 78.2, 50.1 and 59.3 out of 100 from 2016 to 2018. The test scores were significantly increased by 29.3, 8.7, and 23.8 (p< 0.001) compared to pre-test scores. Similarly, the mean post-self-confidence scores were 3.0 in all three years which were increased significantly by 0.6, 0.3, and 1.3 out of 4 points (p< 0.01) compared to pre-self-confidence scores. The participant’s overall satisfaction score of the education program was high (4.2, 4.1, and 4.0 out of 5 in 2016, 2017, and 2018, respectively) across all 3 years.

Table 4 Effects of ultrasound education program for obstetric, fetal, neonatal and congenital anomaly in Nepal, 2016, 2017, and 2018 on self-confidence, knowledge, and satisfaction
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Adoption

Approximately 12% (n=28) of the program participants responded to the online follow-up survey. Approximately 50% (n=14) of the online follow-up survey respondents participated for the first time in 2016, 36% (n=10) in 2017, and the remaining 14% (n=4) in 2018. Among the online follow-up survey respondents, 60.7% (n=17) indicated that they were currently using ultrasound in their daily practice (Table 5). When we divided the respondents by specialty, we found that most of the radiologists (75%, n=3) and other specialties (71.4%, n=10) and half of OB-GYNs (50%, n=4) began to use ultrasound in their daily practice after participating in the education program. None of the pediatricians who participated in the survey have reported the use of ultrasound.

Table 5 Online follow-up survey results regarding ultrasound usage
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Table 6 illustrates the in-depth interview results including major limitations of ultrasound utilization. The lack of availability of ultrasound machines and lower competency levels due to lack of regular training and practice were identified as the major challenges for the adoption of ultrasound. Moreover, restrictive institutional and national policies were also identified as limitations. Radiologists performed ultrasound in their daily practice, whereas non-radiologists used ultrasound during emergencies and for confirmation of their own diagnosis. Some non-radiologists from institutions that promote the use of ultrasound reported performing a high volume of ultrasound in their practice after participating in the education program. Fetal neurosonogram and fetal Doppler techniques were widely used (58.8 and 47.1% of ultrasound users, respectively), whereas genetic sonography, pediatric echo, and fetal genitourinary techniques have not been used. A non-radiologist expressed concerns on overuse of ultrasound, “There is a high dependency on ultrasound, leading to ultrasound overuse, in conditions where other diagnostics methods were sufficient.” A radiologist also had a concern regarding ultrasound misuse as “ultrasound can be used for commercial purposes.”

Table 6 Themes, subthemes, and quotations for adoption and maintenance dimensions
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All the interviewees expressed positive attitudes toward the education program. They attributed the program participation to the use of ultrasound in their workplaces. They also expressed that the program helped them improve their use of ultrasound in their practice. For future direction of the program, the interviewees suggested that certification and accreditation policy, educational session on the misuse of ultrasound, and online follow-up after the program should be implemented. A radiologist expressed, “...there is no system of accreditation. It encourages using ultrasound without any proper certification. There is potential misuse of ultrasound. There is no proper follow up.”

Implementation

The program was developed and implemented in collaboration with the DHKUH and Nepal Society of Obstetricians and Gynaecologists. The Ultrasound Society of Nepal joined as a co-organizer, whereas the Nepal Radiologists’ Association and Nepal Paediatric Society endorsed and promoted the education program. The Nepal Medical Association accredited the continuing medical education credits based on curriculum and content. The involvement of Nepal medical societies and associations ensured a wide acceptance of the program.

Figure 1 shows the process of implementation. The program had four major components: lectures, case discussion and experience sharing, live demonstration, and program evaluation (Fig. 1). The major difference in the program implementation across the years was the exclusion of live demonstration sessions in 2018 based on the feedback and logistic difficulties. Furthermore, major differences in the program implementation modality were not observed.

Maintenance

The Interviewees mentioned that ultrasound use is still lagging due to unclear policy and high cost for the ultrasound machines for private hospitals (Table 6). Few of the institutions have developed infrastructure such as purchasing ultrasound machines and trained human resources and fostered networks for the discussion of cases via tele chats. Both radiologists and non-radiologists expressed dissatisfaction with the current policy in terms of ambiguity in accreditation and the absences of practical guidelines for ultrasound use by non-radiologist. A radiologist expressed, “The eligibility of a healthcare worker to perform ultrasound and the guidelines used to certify a healthcare worker regarding the use of ultrasound are not yet established in Nepal. Currently, any healthcare worker (including staff nurse, health assistant, and even Ayurvedic doctor) with an ultrasound machine can perform ultrasonography. There is no proper system of accreditation.” Similarly, a non-radiologist practicing ultrasound expressed, “My findings will not be as strong as it is when evaluated by a radiologist for documentation. Even if we can identify the problem, we need to refer our findings to a radiologist.” These types of ambiguity and inefficiency in national policy on accreditation was expressed as the major limitation of ultrasound utilization by non-radiologists. The high cost of an ultrasound device makes it difficult for private hospitals to use ultrasound prohibiting them to practice and maintain the skills that they have learned. Only one institution established an ultrasound-training center and initiated regular training for doctors and healthcare workers, partly stimulated by the education program.

Discussion

To improve the ultrasound utilization and the service quality of maternal and child health in Nepal, the JW LEE CGM and the DHKUH have conducted “The Ultrasound, CT and MRI Education Program for Obstetric, Fetal, Neonatal, and Congenital Anomaly” in collaboration with the Nepali Professional Societies. This study evaluated the 2-day intensive ultrasound education program conducted in Nepal from 2016 to 2018 in terms of its Reach, Effectiveness, Adoption, Implementation, and Maintenance using the RE-AIM framework. This study showed that the ultrasound education program was effective in improving the knowledge and self-confidence of physician and non-physician participants. However, only half of the online survey respondents indicated that they used learned ultrasound techniques in their daily practices after participating in the education program. This study also observed significant heterogeneity in ultrasound utilization by site and across all healthcare professions in Nepal. Changing regulations at institutional and national levels to facilitate use of ultrasound, and improve availability of ultrasound devices may increase the adoption and maintenance of the ultrasound in practice.

The ‘Reach’ dimensions of the program were satisfactory in terms of participants’ diversity in specialty and affiliation. Geographically, however, the program reached approximately 27% of the districts in Nepal. This may be due to the uneven distribution of ultrasound services across healthcare facilities and providers in Nepal. Unavailability of machines and human resources might have resulted in lower geographical coverage. A previous study on the availability of technology for trauma care in Nepal, which accessed 56 small hospitals (with a bed capacity of 30 to 100) and 29 large hospitals, reported that ultrasound was not available in any of accessed small hospitals [19]. The health facility survey in 2015 showed that only 21.1% of the district-level hospitals had basic equipment and approximately half of the sanctioned position of medical officers and Doctor of Medicine in General Practice (MD-GP) were completed [12].

This study shows that the program was effective in increasing the healthcare workers’ knowledge and self-confidence in using ultrasound. The participants were also satisfied with this program. We observed a slight decrease in the satisfaction score from 2016 to 2018, but the mean scores were above 4 out of 5. The education program on ultrasound with several implementation modalities and durations with the use of pre- and post-test to assess knowledge also resulted in significant improvement in knowledge immediately after the programs [9, 13, 22, 23]. A previous study from Nepal on point-of-care ultrasound training also reported improvement in post-test scores in the 1-day training, which was mostly participated by doctors without prior experience [13]. Further, Shaffer et al. (2017) reported that the self-reported confidence for four specific skills increased among the participants at the end of the short-term (5-day) training program on bedside emergency ultrasound [24]. We removed the live demonstration component in 2018 due to technical and logistical difficulties, but it did not lead to a significant decrease in the three components of the ‘Effectiveness’ dimension.

This study found a mid-level (60%) of adoption at the individual level via online follow-up survey. The non-adoptees emphasized that further policy changes to encourage the use of ultrasound by non-radiologists along with infrastructure development are considered the major limitations in the use of ultrasound. Setting up and maintenance of the machines can also be significantly challenging in rural areas of Nepal [11]. Another interviewee emphasized the uncertainty in the current policies, implying the prohibitive use of ultrasound by the non-radiologists. The clinical guidelines do not also explicitly mention the protocols regarding the use of ultrasound by doctors in the non-radiology departments. A clear scope on the use of ultrasound and eligibility of performance may facilitate ultrasound utilization and service quality.

The institutional-level ‘Maintenance’ dimension of the RE-AIM framework had mixed results. Despite the challenges and limitations regarding the changes in policy and infrastructure development, one of the participating institutions in Nepal had established an ultrasound training school, and they collaborated with different specialties to develop courses for training physician and non-physician healthcare providers. However, some organizations are still having trouble in formulating clear institutional policies on ultrasound use by non-radiology doctors. The establishment of the ultrasound training center can be considered a crucial step in the sustainability of interdisciplinary educational programs.

This study has several limitations. First, we used convenience sampling methods for in-depth interviews because of time constraints and insufficient resources to travel beyond Kathmandu and its vicinity. The second limitation was low participation rates in evaluations. Participation in the evaluation was voluntary, and many of the registered participants were allowed to select sessions and skip tests and surveys. We offered flexibility since the second day of the training took place during the workday. Many participants were not able to arrange a leave for the day. In the case of the online survey, a low response rate was expected, thus we tried to mitigate this by sending three reminder emails. Due to low participation rates, the findings may have induced selection bias. Finally, the evaluation of self-confidence and use of ultrasound was based on self-reporting, which may cause social desirability bias. Despite these limitations, this study provides evidence that the education program can be used as a platform for sharing knowledge and experiences across healthcare providers with diverse backgrounds.

Conclusion

Our study found that the ultrasound education program effectively improved the knowledge and self-confidence of participants in practicing ultrasound. The program also had a positive impact on ultrasound utilization by encouraging participants to use ultrasound; however, determining the influencing institutional environment that facilitates ultrasound utilization and improves service quality was still considered challenging due to the current regulations. Future studies are required to comprehensively understand the various elements influencing the use of learned knowledge and acquired skills that translates into actual practice that significantly affects the health at the population level.