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Evaluating Feasibility and Acceptability of Echo Autism in India: A Telementoring Model to Build Physician Capacity in Diagnoses and Management of Pediatric ASD.
A significant treatment gap exists in Low and Middle Income Countries (LMICs) for children with Autism Spectrum Disorder (ASD). Often, delayed age of diagnosis in LMICs (Samms-Vaughan,2014) translates into loss of access to intervention in the crucial early years. Potential contributors to delays in diagnoses include physician related factors- limited physician knowledge about ASD, incorrect beliefs about efficacy of therapy and long waiting lists. Additionally, both psychiatric (e.g. ADHD, Anxiety, OCD) and medical co-morbidities (e.g. constipation, sleep issues) are significantly over-represented in children with ASD requiring physician knowledge about addressing them simultaneously. Possible solutions include training professionals in diagnoses and management of ASD and co-morbidities.
Objectives: To evaluate the acceptability and feasibility of ECHO Autism-a tele-mentoring model to increase physician access to best-practise care for children with ASD, piloted in Mumbai, India.
Methods: The Extension for Community Healthcare Outcomes (ECHO) framework shown to be effective in improving self-efficacy and ASD specific practice parameters of primary care physicians in the U.S.A. (Mazurek,et al.,2017) was culturally modified and utilized for the current study. A “hub” team of multi-disciplinary experts at a child development center in Mumbai was connected by secure video-conferencing technology to the “spokes”- 27 primary care and developmental pediatricians, psychiatrists and neurologists working with children with ASD across India, Sri Lanka, Bangladesh, Nepal, Iran and Bahrain who chose to participate in the pilot. Baseline survey revealed that 87% of participating physicians “wanted to learn more about autism” and “81% “desired more confidence in ability to identify and manage ASD”. Over the course of 8 bi-weekly sessions, participants learnt through discussion of cases from their own practice, peer feedback and didactic modules. Content included best practice methods in screening, early diagnoses of autism, principles of intervention, management of challenging behaviors, psychiatric and medical co-morbidities and involving families in care. Primary outcomes evaluated included participant acceptability of the content and delivery process. In addition, feasibility was evaluated by considering participant attendance, retention rates and changes in knowledge and self-efficacy.
Results:
Participants represented a broad geographic reach spread across 18 cities in 6 Asian countries.17 participants (63%) attended ≥ 75% of the sessions (7-8/8) with average attendance per session being 19.87 (Range 17-24). On a scale of 1-5, participants rated the course as highly satisfactory (M=4.34, SD =0.64). Participant knowledge increased on completion of the course (Pre-test M= 48.5, SD=12.89; post-test M=58.0, SD=12.71; Z= -2.56, p=0.01). Total self –efficacy scores as measured by a self-reported questionnaire (Mazurek,et al,2017) adapted to the Indian pilot improved significantly from the pre-test (M= 83.8, SD=22.87) to post-test (M=120.5, SD=25.59; Z= -3.86, p=0.0001) on a Wilcoxon Signed –Rank test. Qualitative feedback from participants emphasized need for videos and demonstration of live cases and information about intervention strategies.
Conclusions: The ECHO Autism model improved physician knowledge and self-efficacy in diagnoses and management of ASD in LMICs in Asia, potentially impacting many underserved communities across these sites. While acceptable and feasible in its current format, further context-specific adaptations to meet the unique needs of physicians practicing in low resource settings are explored.