title: Perceived barriers in the use of ultrasound in developing countries.
abstract: BACKGROUND
  Access to ultrasound has increased significantly in resource-limited settings, including the developing world; however, there remains a lack of sonography education and ultrasound-trained physician support in developing countries. To further investigate this potential knowledge gap, our primary objective was to assess perceived barriers to ultrasound use in resource-limited settings by surveying care providers who practice in low- and middle-income settings.
  
  
  METHODS
  A 25-question online survey was made available to health care providers who work with an ultrasound machine in low- and middle-income countries (LMICs), including doctors, nurses, technicians, and clinical officers. This was a convenience sample obtained from list-serves of ultrasound and radiologic societies. The survey was analyzed, and descriptive results were obtained.
  
  
  RESULTS
  One hundred and thirty-eight respondents representing 44 LMICs including countries from the continents of Africa, South America, and Asia completed the survey, with a response rate of 9.6 %. Ninety-one percent of the respondents were doctors, and 9 % were nurses or other providers. Applications for ultrasound were diverse, including obstetrics (75 %), DVT evaluation (51 %), abscess evaluation (54 %), cardiac evaluation (64 %), inferior vena cava (IVC) assessment (49 %), Focused Assessment Sonography for Trauma (FAST) exam (64 %), biliary tree assessment (54 %), and other applications. The respondents identified the following barriers to use of ultrasound: lack of training (60 %), lack of equipment (45 %), ultrasound machine malfunction (37 %), and lack of ultrasound maintenance capability (47 %). Seventy-four percent of the respondents wished to have further training in ultrasound, and 82 % were open to receiving distance learning or telesonography training. Subjects used communication tools including Skype, Dropbox, emailed photos, and picture archiving and communication system (PACS) as ways to communicate and receive feedback on ultrasound images.
  
  
  CONCLUSIONS
  Health care providers in the developing world identify lack of training as a primary barrier to regular use of ultrasound in their practice. While equipment requirements including maintenance and cost of machines are also important factors, future research is warranted on best practices for training methods, including telesonography and distance learning to enhance ultrasound use in low-resource settings.
authors.affiliation: Division of Emergency Medicine, University of Washington, Box 359702, 1CT89, 325 9th, Ave, Seattle, WA, 98104-2499, USA, sachita.shah@gmail.com.
authors.forename: Sachita
authors.initials: S
authors.lastname: Shah
authors.forename: Blaise A
authors.initials: BA
authors.lastname: Bellows
authors.forename: Adeyinka A
authors.initials: AA
authors.lastname: Adedipe
authors.forename: Jodie E
authors.initials: JE
authors.lastname: Totten
authors.forename: Brandon H
authors.initials: BH
authors.lastname: Backlund
authors.forename: Dana
authors.initials: D
authors.lastname: Sajed