Nursing students’ experiences with simulation-based education as a pedagogic method in low-resource settings: A mixed-method study

Aims and Objectives
This study introduced simulation-based education in nurse education programs in Tanzania and Madagascar and explored nursing students’ experiences with this pedagogic method as a mode of learning.

Background
Simulation-based education has barely been introduced to education programs in resource-constrained settings. The study was conducted in two nurse education programs: one in rural Tanzania and the other in the mid-land of Madagascar. Both institutions offer diploma programs in nursing. Simulation-based education has not been included in the teaching methods used in these nursing programs.

Design
A descriptive and convergent mixed method design was employed.

Methods
Ninety-nine nursing students were included in the study. Simulation sessions followed by data collection took place once in 2017 and twice in 2018. Data were collected by means of several questionnaires and six focus groups. The data were analyzed using descriptive statistics and qualitative content analysis. The Standards for Reporting Qualitative Research (SRQR) was used to report the results.

Results
The quantitative data revealed that the students rated all the questions related to the simulation design elements, educational practices, and students’ satisfaction and self-confidence in learning with scores of above four on a 5-point Likert scale. The qualitative data from the first theme, building competence and confidence, further emphasized and outlined the quantitative results. Additionally, the qualitative data revealed a second theme, improving through encouragement and corrections. The students clearly expressed that they wanted to be aware of their weaknesses to be able to improve; however, the provision of feedback should be carried out in an encouraging way.

Conclusion
The findings indicated that the nursing students were satisfied with simulation as a pedagogic method, as it improved their competence and prepared them for professional practice. Further research is necessary to explore whether the students are able to transfer their knowledge into clinical practice.

Association between alcohol consumption, marijuana use and road traffic injuries among commercial motorcycle riders: A population-based, case-control study in Dares Salaam, Tanzania

Background
Alcohol consumption and psychoactive drug use are well-recognised risk factors for road traffic injuries (RTIs). Both types of use may impair and affect drivers’ performance. Yet, there is limited literature on their contribution to RTIs among commercial motorcycle riders, particularly in low- and middle-income settings. This study aimed to determine the association between alcohol consumption, marijuana use and RTIs among commercial motorcycle riders in the city of Dar es Salaam, Tanzania.

Methods
We conducted a case-control study between July 2018 and March 2019. Cases (n = 164) were commercial motorcycle riders who had sustained an RTIs and attended at a hospital. Controls (n = 400) were commercial motorcycle riders who had not experienced an RTIs that led to hospital attendance during the past six months. Alcohol consumption was assessed using the Alcohol Use Disorder Identification (AUDIT) score, which classified participants as a non-drinker, normal drinker(1–7 scores) and risky drinker (scores ≥ 8). Marijuana use was assessed through self-reported use in the past year. We estimated odds ratios (ORs) using logistic regression adjusted for sociodemographic, driver-, and work-related factors.

Results
Risky drinking was associated with close to six times the odds of RTIs compared to non-drinkers (OR = 5.98, 95% CI: 3.25 – 11.0). The association remained significant even after adjusting for sociodemographic, driving and work-related factors (OR = 2.41, 95% CI: 1.01 – 5.76). The crude odds ratios of RTIs were significantly higher among users of marijuana than non-users (OR = 2.33, 95% CI: 1.38 – 3.95). However, the association did not remain statistically significant after adjusting for confounders (OR = 1.11, 95% CI = 0.49–2.48).

Conclusion
Our findings confirm increased odds of RTIs among commercial motorcycle riders with risky drinking behaviour even after taking sociodemographic, driving and work-related factors into account. Unlike alcohol consumption the relationship between marijuana use and RTIs among commercial motorcycle riders was unclear. Since motorcycle riders are more susceptible to the effect of alcohol due to higher demands of balance and coordination and because commercial motorcyclist riders, in particular, they spend a considerable amount of time on the road, our results underscore the importance of addressing hazardous alcohol consumption and marijuana use in future prevention strategies to enhance road safety.

Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities

Background
Demographic and epidemiological changes have prompted thinking on the need to broaden the child health agenda to include care for complex and chronic conditions in the 0–19 years (paediatric) age range. Providing such services will be undermined by general and skilled paediatric workforce shortages especially in low- and middle-income countries (LMICs). In this paper, we aim to understand existing, sanctioned forms of task-sharing to support the delivery of care for more complex and chronic paediatric and child health conditions in LMICs and emerging opportunities for task-sharing. We specifically focus on conditions other than acute infectious diseases and malnutrition that are historically shifted.

Methods
We (1) reviewed the Global Burden of Diseases study to understand which conditions may need to be prioritized; (2) investigated training opportunities and national policies related to task-sharing (current practice) in five purposefully selected African countries (Kenya, Uganda, Tanzania, Malawi and South Africa); and (3) summarized reported experience of task-sharing and paediatric and child health service delivery through a scoping review of research literature in LMICs published between 1990 and 2019 using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library.

Results
We found that while some training opportunities nominally support emerging roles for non-physician clinicians and nurses, formal scopes of practices often remain rather restricted and neither training nor policy seems well aligned with probable needs from high-burden complex and chronic conditions. From 83 studies in 24 LMICs, and aside from the historically shifted conditions, we found some evidence examining task-sharing for a small set of specific conditions (circumcision, some complex surgery, rheumatic heart diseases, epilepsy, mental health).

Conclusion
As child health strategies are further redesigned to address the previously unmet needs careful strategic thinking on the development of an appropriate paediatric workforce is needed. To achieve coverage at scale countries may need to transform their paediatric workforce including possible new roles for non-physician cadres to support safe, accessible and high-quality care.

Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trial

Background
Quality of care is consistently shown to be inadequate in health-care settings in many low-income and middle-income countries, including in private facilities, which are rapidly growing in number but often do not have effective quality stewardship mechanisms. The SafeCare programme aims to address this gap in quality of care, using a standards-based approach adapted to low-resource settings, involving assessments, mentoring, training, and access to loans, to improve clinical quality and facility business performance. We assessed the effect of the SafeCare programme on quality of patient care in faith-based and private for-profit facilities in Tanzania.

Methods
In this cluster-randomised controlled trial, health facilities were eligible if they were dispensaries, health centres, or hospitals in the faith-based or private for-profit sectors in Tanzania. We randomly assigned facilities (1:1) using computer-generated stratified randomisation to receive the full SafeCare package (intervention) or an assessment only (control). Implementing staff and participants were masked to outcome measurement and the primary outcomes were measured by fieldworkers who had no knowledge of the study group allocation. The primary outcomes were health worker compliance with infection prevention and control (IPC) practices as measured by observation of provider–patient interactions, and correct case management of undercover standardised patients at endline (after a minimum of 18 months). Analyses were by modified intention to treat. The trial is registered with ISRCTN, ISRCTN93644888.

Findings
Between March 7 and Nov 30, 2016, we enrolled and randomly assigned 237 health facilities to the intervention (n=118) or control (n=119). Nine facilities (seven intervention facilities and two control facilities) closed during the trial and were not included in the analysis. We observed 29 608 IPC indications in 5425 provider–patient interactions between Feb 7 and April 5, 2018. Health facilities received visits from 909 standardised patients between May 3 and June 12, 2018. Intervention facilities had a 4·4 percentage point (95% CI 0·9–7·7; p=0.015) higher mean SafeCare standards assessment score at endline than control facilities. However, there was no evidence of a difference in clinical quality between intervention and control groups at endline. Compliance with IPC practices was observed in 8181 (56·9%) of 14 366 indications in intervention facilities and 8336 (54·7%) of 15 242 indications in control facilities (absolute difference 2·2 percentage points, 95% CI −0·2 to −4·7; p=0·071). Correct management occurred in 120 (27·0%) of 444 standardised patients in the intervention group and in 136 (29·2%) of 465 in the control group (absolute difference −2·8 percentage points, 95% CI −8·6 to −3·1; p=0·36).

Interpretation
SafeCare did not improve clinical quality as assessed by compliance with IPC practices and correct case management. The absence of effect on clinical quality could reflect a combination of insufficient intervention intensity, insufficient links between structural quality and care processes, scarcity of resources for quality improvement, and inadequate financial and regulatory incentives for improvement.

Economic Consequences of Caesarean Section Delivery: Evidence From a Household Survey in Tanzania

Background: Caesarean section (C-section) delivery is an important indicator of access to life-saving essential obstetric care. Yet, there is limited understanding of the costs of utilising C-section delivery care in sub-Saharan Africa. Thus, we estimated the direct and indirect patient cost of accessing C-section in Tanzania

Methods: Cross-sectional survey data of 2012 was used, which covered 3000 households from 11 districts in three regions. We interviewed women who had given births in the last 12 months before the survey to capture their experience of care. We used a regression model to estimate the effect of C-section on costs, while inequality on C-section coverage and delivery costs were assessed with a concentration index.

Results: C-section increased the likelihood of paying for health care by 16% compared to normal delivery. The additional cost of C-section compared to normal delivery was 20 USD, but reduced to about 11 USD when restricted to public facilities. Women with C-section delivery spent an extra 2 days at the health facility compared to normal delivery, but this was reduced slightly to 1.9 days in public facilities. The distribution of C-section coverage was significantly in favour of wealthier than poorest women (CI=0.2052, p<0.01), and this pro-rich pattern was consistent in rural districts but with unclear pattern in urban districts.

Conclusions: C-section is a life-saving intervention but is associated with significant economic burden especially among the poor families. More health resources are needed for provision of free maternal care, reduce inequality in access and improve birth outcomes in Tanzania.

Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania

Background
In response to the increasing burden of cancer in Tanzania, the Ministry of Health Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to launching of TNCTG.

Methods
In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis.

Results
Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included: capacity and infrastructure, information technology, communication, efficiency and quality of services provided. Contextual factors external to ORCI included: inter-institutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania.

Conclusion
Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI.

Invasive breast Cancer treatment in Tanzania: landscape assessment to prepare for implementation of standardized treatment guidelines

Background
Incidence of breast cancer continues to rise in low- and middle-income countries, with data from the East African country of Tanzania predicting an 82% increase in breast cancer from 2017 to 2030. We aimed to characterize treatment pathways, receipt of therapies, and identify high-value interventions to increase concordance with international guidelines and avert unnecessary breast cancer deaths.

Methods
Primary data were extracted from medical charts of patients presenting to Bugando Medical Center, Tanzania, with breast concerns and suspected to have breast cancer. Clinicopathologic features were summarized with descriptive statistics. A Poisson model was utilized to estimate prevalence ratios for variables predicted to affect receipt of life-saving adjuvant therapies and completion of therapies. International and Tanzanian guidelines were compared to current care patterns in the domains of lymph node evaluation, metastases evaluation, histopathological diagnosis, and receptor testing to yield concordance scores and suggest future areas of focus.

Results
We identified 164 patients treated for suspected breast cancer from April 2015–January 2019. Women were predominantly post-menopausal (43%) and without documented insurance (70%). Those with a confirmed histopathology diagnosis (69%) were 3 times more likely to receive adjuvant therapy (PrR [95% CI]: 3.0 [1.7–5.4]) and those documented to have insurance were 1.8 times more likely to complete adjuvant therapy (1.8 [1.0–3.2]). Out of 164 patients, 4% (n = 7) received concordant care based on the four evaluated management domains. The first most common reason for non-concordance was lack of hormone receptor testing as 91% (n = 144) of cases did not undergo this testing. The next reason was lack of lymph node evaluation (44% without axillary staging) followed by absence of abdominopelvic imaging in those with symptoms (35%) and lack of histopathological confirmation (31%).

Conclusions
Patient-specific clinical data from Tanzania show limitations of current breast cancer management including axillary staging, receipt of formal diagnosis, lack of predictive biomarker testing, and low rates of adjuvant therapy completion. These findings highlight the need to adapt and adopt interventions to increase concordance with guidelines including improving capacity for pathology, developing complete staging pathways, and ensuring completion of prescribed adjuvant therapies.

Neurosurgery in Sub-Saharan Africa – Historical Background and Development of Training Programs in East Africa.

1 INTRODUCTION
Modern Neurosurgery in Sub-Saharan Africa (SSA) has its roots in the 1960s when Neurosurgeons from Europe set up Units in West Africa and East Africa. While it would be unfair to give credit to some individuals, and inadvertently not naming others, Prof Abdeslam El Khamlichi (1) in his book, “Emerging Neurosurgery in Africa,” quoting Professor Adelola Adeloye (2), provided a valuable account: A French Neurosurgeon, Dr. Courson, set up the first neurosurgical unit in West Africa in Senegal in 1967. He was joined by two other French neurosurgeons, Dr. Claude Cournil and Dr. Alliez, in 1972 and 1975. They trained the first Senegalese Neurosurgeon, Dr. Mamadou Gueye, who joined as a trainee in 1977. Dr. Gueye was to become the first Senegalese Professor and Chairman of the Neurosurgery Department.

2 | REGIONS BEGINS

In Ivory Coast, the first unit was set up by Dr. Claude Cournil in Abidjan in 1976, having left Dakar. He joined the first Ivorian Neurosurgeon, Dr. Kanga, who set up practice in 1974 in Abidjan. In Ghana, the first Neurosurgical Unit was set up by Ghanaian Neurosurgeon Dr. Osman Mustaffah in 1969. In Nigeria, the first units were set up by Nigerian Neurosurgeon Dr. Latunde Odeku started the service in Ibadan in 1962. He was joined by two other pioneer neurosurgeons, Dr. Adelola Adeloye in 1967 and Dr. Adebayo Ajayi Olumide in 1974. A second department was set up in Lagos by Dr. de Silva and Dr. Nosiru Ojikutu; in 1968, Dr. Samuel C. Ohaegbulam started the third service in Enugu in 1974 (2). In East Africa, Neurosurgical procedures had been carried out by Dr. Peter Clifford, an ENT surgeon, in 1955 (3).
In Kenya, modern Neurosurgery was introduced by Dr. Renato Ruberti, an Italian Neurosurgeon from Napoli, who set up Private practice in the European hospital in Nairobi in 1967 part-time at the King George V Hospital, which served as the National Hospital. He was joined in 1972 by Dr. Jawahar Dar, from New Delhi. The Indian Dr. Jawahar Dar set up the First Neurosurgery Unit at the King George V hospital, renamed Kenyatta National Hospital while teaching at the University of Nairobi. They were joined by Dr. Gerishom Sande, the first Kenyan Neurosurgeon following his training in Belfast, in 1979 (3).
In Uganda, on advice and recommendation of the renowned British Neurosurgeon, Professor Valentine Logue of the Hospital for Nervous Diseases, Queen Square, London, was invited by the government in 1968 to advise the establishment of neurosurgery at Mulago Hospital, Dr. Ian Bailey moved to Uganda. He was instrumental in establishing the first neurosurgical unit in Uganda at Mulago Hospital in 1969, equipped with 54 beds for the department of neurosurgery and cardiothoracic surgery (4). He was joined by the first Ugandan Neurosurgeon, Dr. Jovan Kiryabirwe, in 1971, who became the first indigenous Ugandan Neurosurgeon and the first African Neurosurgeon in East and Central Africa. He attended medical school at Makerere University School of Medicine in Kampala and subsequently completed postgraduate training at the Royal College of Surgeons in Ireland and Scotland; he also trained at Queens Square with Professor Logue (5).
In Tanzania, the first step towards modern neurosurgery was the establishment of orthopedic and trauma services in 1971 at the
Muhimbili Medical Center (MMC) by Professor Philemon Sarangi (6). At the time, orthopedic surgeons treated most of the cranial and spinal trauma. Over the next few years, several foreign neurosurgeons from Cuba, China, and the Soviet Union spent short stints practicing neurosurgery at MMC. Dr. Reulen, Professor and Chairman of Neurosurgery at University Hospital in Inselspital, Bern, Switzerland, and later in Munich, Germany, provided the impetus for the establishment of a neurosurgery program at MMC teaching in hospital of the University of Dar-es-Salaam and creating a “sandwich” program with training split between national and international centers. He trained Dr. Simpert Kinunda, a plastic surgeon who later became the first Tanzanian with any neurosurgical training.
Peter Kadyanji was the first fully trained Tanzanian neurosurgeon, and he joined MMC in 1985 after completing his training in the Soviet Union. Yadon M. Kohi followed in Kadyanji’s footsteps, graduating from Makerere University and the Faculty of Medicine at the University of Dar-es-Salaam. He obtained his FRCS in Ireland and Glasgow and later was appointed as the General Director of the National Commission for Science and Technology. Dr. Mlay was the third neurosurgeon to join MMC in 1989, with a specialty in pediatric neurosurgery. Professor Sarungi was essential to establish the Muhimbili Orthopedic Institute (MOI), which was opened in 1993 and later combined with MMC to become Muhimbili National Hospital, the national institute of neurosurgery, orthopedics, and traumatology.
Several neurosurgeons have practiced at MOI since its founding, including Dr. Abednego Kinasha and Dr. Joseph Kahamba. They, along with Professor Laurence Museru, the Medical Director of MOI, played a pivotal role in laying the foundation for training the current generation of neurosurgeons in Tanzania (6). Contemporary, locally trained neurosurgeons form the core of the specialized expertise in the country. They provide neurosurgical training and care at MOI at several healthcare institutions around the country. There are currently 20 neurosurgeons in the country, 18 of whom are in public service, one at a Mission hospital in Moshi, one in a private hospital (the Aga Khan University Hospital) Dar-es-salaam, and one at the Mnazi Mmoja/NED Institute in Zanzibar. No dedicated neuroscience nurses or beds are available in the country; however, currently, there are eight neurosurgical intensive care unit beds at MOI. An additional 14 at the new hospital within the Muhimbili hospital complex in Dar-es-Salaam opened in 2018. There are 5 CT scanners and 3 MRI scanners available across the country, mainly in Dar-es-Salaam, the largest city in Tanzania.
In Zimbabwe, Dr. Lawrence Frazer Levy, a British neurosurgeon, started in 1956 (Zimbabwe was called Rhodesia). He set up the Neurosurgery Department at the Central Hospital in Harare (Salisbury), becoming its first Professor and Chairman in 1971. He was joined by a young Scottish neurosurgeon, Dr. Carol Auchtertonie, responsible for starting the second unit at the European Hospital in Harare. The two served patients from Zimbabwe and neighboring Zambia, Malawi, and others for quite a long time (2). From these early beginnings, progress in neurosurgery remained slow, with only a handful of neurosurgeons available in SSA. In 1959, Professor Adelola Adeloye noted that there were only 20 neurosurgeons all across Africa, the majority practicing in South Africa (2). It is against this backdrop that the need to develop neurosurgical care in Sub-Saharan Africa came into focus.

Strengthening emergency care knowledge and skills in Uganda and Tanzania with the WHO-ICRC Basic Emergency Care Course

Background There is a pressing need for emergency care (EC) training in low-resource settings. We assessed the feasibility and acceptability of training frontline healthcare providers in emergency care with the World Health Organization (WHO)-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) Course using a training-of-trainers (ToT) model with local providers.

Methods Quasiexperimental pretest and post-test study of an educational intervention at four first-level district hospitals in Tanzania and Uganda conducted in March and April of 2017. A 2-day ToT course was held in both Tanzania and Uganda. These were immediately followed by a 5-day BEC Course, taught by the newly trained trainers, at two hospitals in each country. Both prior to and immediately following each training, participants took assessments on EC knowledge and rated their confidence level in using a variety of EC skills to treat patients. Qualitative feedback from participants was collected and summarised.

Results Fifty-nine participants completed the four BEC Courses. All participants were current healthcare workers at the selected hospitals. An additional 10 participants completed a ToT course. EC knowledge scores were significantly higher for participants immediately following the training compared with their scores just prior to the training when assessed across all study sites (Z=6.23, p<0.001). Across all study sites, mean EC confidence ratings increased by 0.74 points on a 4-point Likert scale (95% CI 0.63 to 0.84, p<0.001). Main qualitative feedback included: positive reception of the sessions, especially hands-on skills; request for additional BEC trainings; request for obstetric topics; and need for more allotted training time.

Conclusions Implementation of the WHO-ICRC BEC Course by locally trained providers was feasible, acceptable and well received at four sites in East Africa. Participation in the training course was associated with a significant increase in EC knowledge and confidence at all four study sites. The BEC is a low-cost intervention that can improve EC knowledge and skill confidence across provider cadres.

Assessment of clinical and radiographic outcomes following retrograde versus antegrade nailing of infraisthmic femoral shaft fractures without the use of intraoperative fluoroscopy in Tanzania

Objectives:
To compare clinical and radiographic outcomes following antegrade versus retrograde intramedullary nailing of infraisthmic femoral shaft fractures.

Design:
Secondary analysis of prospective cohort study.

Setting:
Tertiary hospital in Tanzania.

Participants:
Adult patients with infraisthmic diaphyseal femur fractures.

Intervention:
Antegrade or retrograde SIGN intramedullary nail.

Outcomes:
Health-related quality of life (HRQOL), radiographic healing, knee range of motion, pain, and alignment (defined as less than or equal to 5 degrees of angular deformity in both coronal and sagittal planes) assessed at 6, 12, 24, and 52 weeks postoperatively.

Results:
Of 160 included patients, 141 (88.1%) had 1-year follow-up and were included in analyses: 42 (29.8%) antegrade, 99 (70.2%) retrograde. Antegrade-nailed patients had more loss of coronal alignment (P = .026), but less knee pain at 6 months (P = .017) and increased knee flexion at 6 weeks (P = .021). There were no significant differences in reoperations, HRQOL, hip pain, knee extension, radiographic healing, or sagittal alignment.

Conclusions:
Antegrade nailing of infraisthmic femur fractures had higher incidence of alignment loss, but no detectable differences in HRQOL, pain, radiographic healing, or reoperation. Retrograde nailing was associated with increased knee pain and decreased knee range of motion at early time points, but this dissipated by 1 year. To our knowledge, this is the first study to prospectively compare outcomes over 1 year in patients treated with antegrade versus retrograde SIGN intramedullary nailing of infraisthmic femur fractures.