Open hemorrhoidectomy under local anesthesia versus saddle block in western Uganda: a study protocol for a prospective equivalence randomized, double-blind controlled trial

Background
While open hemorrhoidectomy under local anesthesia has been shown to be more cost-effective with shorter operation times and lower complication rates, local anesthesia is still not considered as a first-line technique in low-income countries like Uganda. The objective of this trial is to compare open hemorrhoidectomy using local anesthesia versus saddle block among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids in western Uganda.

Methods
The protocol for a prospective equivalence randomized, double-blind controlled trial was conducted among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids. Recruitment was started in December 2021 and is expected to end in May 2022. Consenting participants who require open hemorrhoidectomy indicated at Kampala International Teaching Hospital, Uganda, will be randomized into two groups of 29 patients per arm.

Discussion
The primary outcome of this study is to compare the occurrences of postoperative pain following open hemorrhoidectomy using the visual analog scale in an interval of 2, 4, and 6 h and 7 days postoperatively. Furthermore, the mean operative time from the induction of anesthesia to the end of the surgical procedure as well as the cost-effectiveness of the 2 techniques will be assessed in both groups. Open hemorrhoidectomy under local anesthesia has the potential to offer benefits to patients but most importantly expediting return to baseline and functional status, shorter hospital stay by meeting the faster discharge criteria, and reduction in costs associated with reduced length of stay and complications.

Trial registration
Pan African Clinical Trials Registry PACTR202110667430356. Registered on 8 October 2021

Development of the anaesthesia workforce and organisation of the speciality in Uganda: a mixed-methods case study

Background: The development of modern anaesthesia practice in many low-income countries has lagged behind that of highincome countries despite early reports. Detailed descriptions of ‘surgery under anaesthesia’ in Uganda are available through Robert W. Felkin’s elaborate accounts of caesarean sections done in the Bunyoro-Kitara Kingdom. However, the earliest documented ‘modern’ surgical and anaesthesia procedures were performed by Sir Albert Cook and his brother Dr Jack Cook in 1897 at Mengo Hospital. Since then, anaesthesia has developed into an independent speciality with workforce development, professional bodies and a recognised practice. This study aimed to describe the development of the anaesthesia workforce and speciality since independence while sharing our experiences to benefit those countries on a similar journey.

Methods: We employed a mixed-methods approach, including surveys among anaesthesia providers, as well as key informant interviews and a workforce database review. Whenever possible, information was corroborated with written literature.

Results: There are three levels of training of anaesthesia providers in Uganda, including a Master of Medicine in anaesthesia for specialist physician providers, a Bachelor of Science in anaesthesia and a Higher Diploma in anaesthesia for non-physician providers. There are two Master of Medicine programmes, two Bachelor of Science in anaesthesia programmes and seven Higher Diploma programmes. The existing workforce consists of 68 specialists and more than 600 non-physician providers. The anaesthesia providers are organised under professional associations, namely the Association of Anesthesiologists of Uganda and the Uganda Anaesthetic Officers Association. International and regional collaborations have been critical in the development of anaesthesia in Uganda.

Conclusion: Uganda still has a low density of anaesthesia providers both in number and distribution but has established critical steps to substantially increase the workforce. These steps include three levels of training with numerous training programmes, professional bodies and partnerships. We present our experiences with different strategies, highlighting those that have failed, and suggest further recommendations on developing anaesthesia in Uganda.

The lived experience of people with upper limb absence living in Uganda: A qualitative study

Background: The impact of upper limb absence on people’s lived experiences is understudied, particularly in African countries, with implications for policy and service design.
Objectives: The objective of this study was to explore the lived experiences of people with upper limb absence (PWULA) living in Uganda.
Method: Informed by preliminary work, we designed a qualitative study employing semistructured interviews to understand the experience of living with upper limb absence in Uganda. Seventeen adults with upper limb absence were individually interviewed and their interviews were analysed utilising thematic analysis.
Results: Seven themes illustrating the impact on the individual’s life after amputation were identified and categorised into (1) living and adapting to life, (2) productivity and participation and (3) living within the wider environment. This study presents three main findings: (1) PWULA need psychological and occupational support services which are not available in Uganda, (2) PWULA want to work, but face multiple barriers to employment and has limited support, combined with the complex parenting and caring responsibilities, (3) the local Ugandan culture and social structures affect the everyday life of PWULA, both in positive and negative ways.
Conclusion: This study provides information on the lived experiences of PWULA in Uganda which are lacking in the literature. People with upper limb absence face ableism and hardship underpinned by a lack of formal support structures and policies, which may in turn exacerbate the impact of upper limb absence on multiple facets of lif

Exploring health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion in Central Uganda

Introduction
Women living in low- and middle-income countries still have limited access to quality second trimester post abortion care. We aim to explore health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion.

Methods
This qualitative study used the phenomenology approach. We conducted 48 in-depth interviews for doctors and midwives at 14 public health facilities in central Uganda using a flexible interview guide. We used inductive content analysis and made code frequencies based on health care provider cadre, and health facility level and then abstracted themes from categories.

Results
Well trained midwives were perceived as competent to manage second trimester post abortion care stable patients, however doctor’s supervision in case of complications was considered important. Sometimes, midwives were seen as offering better care than doctors given their stronger presence in the facilities. Misoprostol received unanimous support and viewed as: safe, effective, cheap, convenient, readily available, maintained patient privacy, and saved resources. Challenges faced included: side effects, prolonged hospital stay, treatment failure, inclination to surgical evacuation, heavy work load, inadequate space, lack of medical commodities, frequent staff rotations which affects the quality of patient care. To address these challenges, respondents coped by: giving patients psychological support, analgesics, close patient monitoring, staff mentorship, commitment to work, team work and patient involvement in care.

Conclusion
Misoprostol is perceived as an ideal uterine evacuation method for second trimester post abortion care of uncomplicated patients and trained midwives are considered competent managing these patients in a health facility setting with a back-up of a doctor. Health care providers require institutional and policy environment support for improved service delivery.

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.