Pre-course online cases for the world health organization’s basic emergency care course in Uganda: A mixed methods analysis

Introduction
The Ministry of Health – Uganda implemented the World Health Organization’s Basic Emergency Care course (BEC1) to improve formal emergency care training and address its high burden of acute illness and injury. The BEC is an open-access, in-person, short course that provides comprehensive basic emergency training in low-resource settings. A free, open-access series of pre-course online cases available as downloadable offline files were developed to improve knowledge acquisition and retention. We evaluated BEC participants’ knowledge and self-efficacy in emergency care provision with and without these cases and their perceptions of the cases.

Methods
Multiple Choice Questions (MCQs2) and Likert-scale surveys assessed 137 providers’ knowledge and self-efficacy in emergency care provision, respectively, and focus group discussions explored 74 providers’ perceptions of the BEC course with cases in Kampala in this prospective, controlled study. Data was collected pre-BEC, post-BEC and six-months post-BEC. We used liability analysis and Cronbach alpha coefficients to establish intercorrelation between categorised Likert-scale items. We used mixed model analysis of variance to interpret Likert-scale and MCQ data and thematic content analysis to explore focus group discussions.

Results
Participants gained and maintained significant increases in MCQ averages (15%) and Likert-scale scores over time (p 0.05). Nurses experienced more significant initial gains and long-term decays in MCQ and self-efficacy than doctors (p = 0.009, p < 0.05). Providers found the cases most useful pre-BEC to preview course content but did not revisit them post-course. Technological difficulties and internet costs limited case usage. Conclusion Basic emergency care courses for low-resource settings can increase frontline providers’ long-term knowledge and self-efficacy in emergency care. Nurses experienced greater initial gains and long-term losses in knowledge than doctors. Online adjuncts may enhance health professional education in low-to-middle income countries.

Estimating the Risk of Maternal Death at Admission: A Predictive Model from a 5-Year Case Reference Study in Northern Uganda

Background. Uganda is one of the countries in the Sub-Saharan Africa with a very high maternal mortality ratio estimated at 336 deaths per 100,000 live births. We aimed at exploring the main factors affecting maternal death and designing a predictive model for estimation of the risk of dying at admission at a major referral hospital in northern Uganda. Methods. This was a retrospective matched case-control study, carried out at Lacor Hospital in northern Uganda, including 130 cases and 336 controls, from January 2015 to December 2019. Multivariate logistic regression was used to estimate the net effect of the associated factors. A cumulative risk score for each woman based on the unstandardised canonical coefficients was obtained by the discriminant equation. Results. The average maternal mortality ratio was 328 per 100,000 live births. Direct obstetric causes contributed to 73.8% of maternal deaths; the most common were haemorrhage (42.7%), sepsis (24.0%), hypertensive disorders (18.7%) and complications of abortion (2.1%), whereas malaria (23.5%) and HIV/AIDS (20.6%) were the leading indirect causes. The odds of dying were higher among women who were aged 30 years or more (OR 1.12; 95% CI, 1.04–1.19), did not attend antenatal care (OR 3.11; 95% CI, 1.36–7.09), were HIV positive (OR 3.13; 95% CI, 1.41–6.95), had a caesarean delivery (OR 2.22; 95% CI 1.13–4.37), and were referred from other facilities (OR 5.57; 95% CI 2.83–10.99). Conclusion. Mortality is high among mothers referred late from other facilities who are HIV positive, aged more than 30 years, lack antenatal care attendance, and are delivered by caesarean section. This calls for prompt and better assessment of referred mothers and specific attention to antibiotic therapy before and after caesarean section, especially among HIV-positive women.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-saharan Africa: a Co-creation Consensus Approach

Background:

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi-consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa as well as to implement the checklist in health institutions in four African countries.

Method:

The AMS checklist tool was developed using a modified Delphi approach to achieve local, expert consensus on items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, and Ghana were invited to review, score and comment on items from a published, global AMS checklist. Following their feedback, eight items were re-phrased and 25 new items added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites.

Findings:

The final tool comprised 54 items. Across the 14 sites, the checklist consistently showed improvements for all AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). Elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions.

Conclusion:

Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. The study extends existing AMS materials for low and middle-income countries and provides empirical evidence for successful use in practice.

Clinical presentation and outcomes in children with retinoblastoma managed at the Uganda Cancer Institute

Background. The majority of patients with retinoblastoma, the most common intraocular cancer of childhood, are found in low-and middle-income countries (LMICs), with leukocoria being the most common initial presenting sign and indication for referral. Findings from the current study serve to augment earlier findings on the clinical presentation and outcomes of children with retinoblastoma in Uganda. Methods. This was a retrospective study in which we reviewed records of children admitted with a diagnosis of retinoblastoma at the Uganda Cancer Institute from January 2009 to February 2020. From the electronic database, using admission numbers, files were retrieved. Patient information was recorded in a data extraction tool. Results. A total of 90 retinoblastoma patients were studied, with a mean age at the first Uganda Cancer Institute (UCI) presentation of 36.7 months. There were more males (57.8%) than females, with a male to female ratio of 1.37 : 1. The majority (54.4%) had retinoblastoma treatment prior to UCI admission. The most common presenting symptoms were leukocoria (85.6%), eye reddening (64.4%), and eye swelling (63.3%). At 3 years of follow-up after index admission at UCI, 36.7% of the patients had died, 41.1% were alive, and 22.2% had been lost to follow-up. The median 3-year survival for children with retinoblastoma in our study was 2.18 years. Significant predictors of survival in the multivariate analysis were follow-up duration (), features of metastatic spread (), history of eye swelling (), and bilateral enucleation (). Conclusions. The majority of children who presented to the Uganda Cancer Institute were referred with advanced retinoblastoma, and there was a high mortality rate. Retinoblastoma management requires a multidisciplinary team that should include paediatric ophthalmologists, paediatric oncologists, ocular oncologists, radiation oncologists, and nurses.

Enhancing the value of short term volunteer missions in health from host country perspectives: the Case of Uganda

Short-term medical missions (STMMs), estimated to involve 1.6 million volunteers and US$2-3 billion annually, can be very valuable, but there is a growing critique of practices. Serious concerns have arisen around possible harms to host countries and patients, including medical errors, non-alignment with local systems and priorities, cultural insensitivity, and the high cost compared to benefits. Scholars and practitioners across diverse sectors involved-faith-based, corporate, NGO, and educational-have questioned the value of STMMs and proposed strategies for improving them. Missing from this assessment are voices of host communities and research on host country efforts to control the quality of visiting programs. In this study, we investigated host perspectives on STMMs. The study was driven by the need to examine the regulatory and policy environment as well as to establish the perspectives of all country stakeholders on STMMs with the view of enhancing their value. This research is a collaborative effort between researchers at Uganda Christian University in Mukono, Uganda and Lehigh University, PA, United States of America. A qualitative methodology was adopted, with in-depth interviews as the main tool. A total of 46 interviews with policy makers, Non-Governmental Organisations and those who have engaged with volunteers in the communities were conducted in Uganda. The analysis was computer-assisted and thematic. The study revealed that the health needs of the country are many, and STMMs contribute to closing some of the gaps, although this may be limited given the scope of needs. Some of these health needs include limited infrastructure and budget support for health, low levels of staffing and inadequate resources such as equipment in the facilities. It was further revealed that the contributions made are bi-directional, with host communities claiming that they contribute towards pre-visit preparations, accommodation, local expertise on tropical diseases, and social support while volunteers contribute skills, treatment, equipment, awareness and research. Nevertheless, from the perspective of stakeholders interviewed, STMM volunteers face challenges such as cultural shock, inadequate resources to work with, manpower to support them, high expectations from the communities and delay in clearance for practice. Despite their contributions, the study established that host communities expressed concerns about the nature of STMMs involving lack of experience, hidden interests, misalignment with community needs, security risks, code of conduct and sustainability of support. A review of Ugandan laws reveals many that are related to the regulation of health services, but none that specifically mentions short-term mission trips. Most stakeholders interviewed were unaware of any regulatory oversight of visiting health teams, although some were aware of the need for clearance of visitors’ credentials. It is therefore recommended that in order to enhance the value of STMMs in Uganda, concrete actions be taken involving improving and making known the conditions for licensing and oversight, improving communication, enhancing collaboration and supporting capacity building for local experts.

The structure, function and implementation of an outcomes database at a Ugandan secondary hospital: the Mbarara Surgical Services Quality Assurance Database

The Mbarara Surgical Services Quality Assurance Database (Mbarara SQUAD) is an outcomes database of surgical, obstetric and anaesthetic/critical care at Mbarara Regional Referral Hospital, a secondary referral hospital in southwestern Uganda. The primary scope of SQUAD is the assessment of the outcomes of care. The primary outcome is mortality. The aim is to improve the quality of care, guide allocation of resources and provide a platform for research. The target population includes all inpatients admitted for treatment to the surgery service, the obstetrics and gynaecology services, and the intensive care unit (ICU). Data collection was initiated in 2013 and closed in 2018. Data were extracted from patient charts and hospital logbooks. The database has over 50 000 patient encounters, including over 20 000 obstetrics and gynaecology admissions, 15 000 surgical admissions and 16 000 otolaryngology outpatient visits. Entries are coded using the International Classification of Diseases, Tenth Revision (ICD-10) for diagnoses, and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for procedures. The completeness and accuracy of the data entry and the coding were validated. Governance of data use is by a local steering committee in Mbarara. The structure, function and implementation of this database may be relevant for similar hospital databases in low-income countries.

A qualitative study of an undergraduate online emergency medicine education program at a teaching Hospital in Kampala, Uganda

Background
Globally, half of all years of life lost is due to emergency medical conditions, with low- and middle-income countries (LMICs) facing a disproportionate burden of these conditions. There is an urgent need to train the future physicians in LMICs in the identification and stabilization of patients with emergency medical conditions. Little research focuses on the development of effective emergency medicine (EM) medical education resources in LMICs and the perspectives of the students themselves. One emerging tool is the use of electronic learning (e-learning) and blended learning courses. We aimed to understand Uganda medical trainees’ use of learning materials, perception of current e-learning resources, and perceived needs regarding EM skills acquisition during participation in an app-based EM course.

Methods
We conducted semi-structured interviews and focus groups of medical students and EM residents. Participants were recruited using convenience sampling. All sessions were audio recorded and transcribed verbatim. The final codebook was approved by three separate investigators, transcripts were coded after reaching consensus by all members of the coding team, and coded data were thematically analyzed.

Results
Twenty-six medical trainees were included in the study. Analysis of the transcripts revealed three major themes: [1] medical trainees want education in EM and actively seek EM training opportunities; [2] although the e-learning course supplements knowledge acquisition, medical students are most interested in hands-on EM-related training experiences; and [3] medical students want increased time with local physician educators that blended courses provide.

Conclusions
Our findings show that while students lack access to structured EM education, they actively seek EM knowledge and practice experiences through self-identified, unstructured learning opportunities. Students value high quality, easily accessible EM education resources and employ e-learning resources to bridge gaps in their learning opportunities. However, students desire that these resources be complemented by in-person educational sessions and executed in collaboration with local EM experts who are able to contextualize materials, offer mentorship, and help students develop their interest in EM to continue the growth of the EM specialty.

Antimicrobial stewardship: Attitudes and practices of healthcare providers in selected health facilities in Uganda

Though antimicrobial stewardship (AMS) programmes are the cornerstone of Uganda’s national action plan (NAP) on antimicrobial resistance, there is limited evidence on AMS attitude and practices among healthcare providers in health facilities in Uganda. We determined healthcare providers’ AMS attitudes, practices, and associated factors in selected health facilities in Uganda. We conducted a cross-sectional study among nurses, clinical officers, pharmacy technicians, medical officers, pharmacists, and medical specialists in 32 selected health facilities in Uganda. Data were collected once from each healthcare provider in the period from October 2019 to February 2020. Data were collected using an interview-administered questionnaire. AMS attitude and practice were analysed using descriptive statistics, where scores of AMS attitude and practices for healthcare providers were classified into high, fair, and low using a modified Blooms categorisation. Associations of AMS attitude and practice scores were determined using ordinal logistic regression. This study reported estimates of AMS attitude and practices, and odds ratios with 95% confidence intervals were reported. We adjusted for clustering at the health facility level using clustered robust standard errors. A total of 582 healthcare providers in 32 healthcare facilities were recruited into the study. More than half of the respondents (58%,340/582) had a high AMS attitude. Being a female (aOR: 0.66, 95% CI: 0.47–0.92, P < 0.016), having a bachelor’s degree (aOR: 1.81, 95% CI: 1.24–2.63, P < 0.002) or master’s (aOR: 2.06, 95% CI: 1.13–3.75, P < 0.018) were significant predictors of high AMS attitude. Most (46%, 261/582) healthcare providers had fair AMS practices. Healthcare providers in the western region’s health facilities were less likely to have a high AMS practice (aOR: 0.52, 95% CI 0.34–0.79, P < 0.002). In this study, most healthcare providers in health facilities had a high AMS attitude and fair AMS practice.

Antibody levels and protection after Hepatitis B vaccine in adult vaccinated healthcare workers in northern Uganda

Hepatitis B vaccine has contributed to the reduction in hepatitis B virus infections and chronic disease globally. Screening to establish extent of vaccine induced immune response and provision of booster dose are limited in most low-and-middle income countries (LMICs). Our study investigated the extent of protective immune response and breakthrough hepatitis B virus infections among adult vaccinated healthcare workers in selected health facilities in northern Uganda. A cross-sectional study was conducted among 300 randomly selected adult hepatitis B vaccinated healthcare workers in Lira and Gulu regional referral hospitals in northern Uganda. Blood samples were collected and qualitative analysis of Hepatitis B surface antigen (HBsAg), Hepatitis B surface antigen antibody (HBsAb), Hepatitis B envelop antigen (HBeAg), Hepatitis B envelop antibody (HBeAb) and Hepatitis B core antibody (HBcAb) conducted using ELISA method. Quantitative assessment of anti-hepatitis B antibody (anti-HBs) levels was done using COBAS immunoassay analyzer. Multiple logistic regression was done to establish factors associated with protective anti-HBs levels (≥ 10mIU/mL) among adult vaccinate healthcare workers at 95% level of significance. A high proportion, 81.3% (244/300) of the study participants completed all three hepatitis B vaccine dose schedules. Two (0.7%, 2/300) of the study participants had active hepatitis B virus infection. Of the 300 study participants, 2.3% (7/300) had positive HBsAg; 88.7% (266/300) had detectable HBsAb; 2.3% (7/300) had positive HBeAg; 4% (12/300) had positive HBeAb and 17.7% (53/300) had positive HBcAb. Majority, 83% (249/300) had a protective hepatitis B antibody levels (≥10mIU/mL). Hepatitis B vaccine provides protective immunity against hepatitis B virus infection regardless of whether one gets a booster dose or not. Protective immune response persisted for over ten years following hepatitis B vaccination among the healthcare workers.

Prevalence of Paediatric Surgical Conditions in Eastern Uganda: A Cross-Sectional Study

Background
The role of surgery in global health has gained greater attention in recent years. Approximately 1.8 billion children below 15 years live in low- and middle-income countries (LMIC). Many surgical conditions affect children. Therefore, paediatric surgery requires specific emphasis. Left unattended, the consequences can be dire. Despite this, there is a paucity of data regarding prevalence of surgical conditions in children in LMIC. The present objective was to investigate the prevalence of paediatric surgical conditions in children in a defined geographical area in Eastern Uganda.

Method
A cross-sectional study was carried out in the Iganga-Mayuge Health and Demographic Surveillance Site located in Eastern Uganda. Through a two-stage, cluster-based sampling process, 490 households from 49 villages were randomly selected, generating a study population of 1581 children. The children’s caregivers were interviewed, and the children were physically examined by two medical doctors to identify any surgical conditions.

Results
The interview was performed with 1581 children, and 1054 were physically examined. Among these, the overall prevalence of any surgical condition was 16.0 per cent (n = 169). Of these, 39 per cent had an unmet surgical need (66 of 169). This is equivalent to a 6.3 per cent prevalence of current unmet surgical need. The most common groups of surgical condition were congenital anomalies and trauma-related conditions.

Conclusion
Surgical conditions in children are common in eastern Uganda. The unmet need for surgery is high. With a growing population, the need for paediatric surgical capacity will increase even further. The health care system must be reinforced to provide services for children with surgical conditions if United Nations Sustainability Development Goal 3 is to be achieved by 2030.