"We are never taught anything about the elderly." Establishing the gap in elderly health care competencies in nursing education in Uganda.

BACKGROUND: Nurses contribute the largest portion of Uganda's health workforce providing care to individuals of all ages and communities. However, despite the growing number of the elderly population in Uganda with improved life expectancy, there is hardly any study that has looked at the elderly health care competencies in the nursing training programs at various levels. This paper provides an overview of the gaps in elderly health care competencies in nursing education in Uganda. METHODS: We conducted a descriptive qualitative cross-sectional study that involved document review, Key Informant Interviews (KIIs) with nursing leaders, and Focus Group Discussions ( FGDs) with faculty at all levels of nursing training and nurses in practice. Data was analyzed using latent and manifest content analysis with Open Code software 4.03. Common categories were identified and incorporated into a matrix to create themes. RESULTS: Almost all the curricula and minimum standards for training nurses at certificate, diploma, and degree levels lack a module and nursing competencies on elderly nursing care. This is aggravated by a lack of faculty trained in elderly health care skills, and a lack of specialized wards for nursing elderly care clinical training among others. CONCLUSIONS: There is hardly any elderly health care training module and elderly nursing competencies at all levels of nursing training in Uganda.

Knowledge, preparedness, and attitude towards COVID-19 among health profession students in Sub-Saharan Africa: A cross-sectional survey.

Objective: We assessed the knowledge, preparedness, and attitude of health profession students towards COVID-19 outbreak in Sub-Saharan Africa. Methods: This cross-sectional study used convenience sampling to recruit participants from institutions under African Forum for Research and Education in Health (AFREhealth). The survey was developed in QuestionPro software covering the participants' socio-demographic characteristics, knowledge, attitude, and preparedness towards the COVID-19 outbreak. Data were analysed and the association between variables was tested. Results: The mean age of the 336 students was 25•75 (±7•88) years. Most (99•7%) knew the cause of COVID-19 which could be transmitted via droplets (97•3%). Several participants vowed to adhere to preventive measures (92•3%) and claimed their curriculum equipped them with skills addressing infectious disease outbreaks (63•6%). Nursing students were better prepared than other students (p=0•001). Students from West African regions were more prepared (p=0•001) and aware they could contract COVID-19 if they cared for infected persons (p=0•001). Conclusion: Students are knowledgeable about COVID-19, adequately prepared to handle epidemics, have a positive attitude towards infection prevention, and their training institutions and government have taken adequate measures to address the COVID-19 outbreak. Funding: AFREhealth.

Adherence to Antihypertensive Medication: An Interview Analysis of Southwest Ugandan Patients' Perspectives.

Background: Hypertension is a significant cardiovascular disease (CVD) and driver to CVD disorders in sub-Saharan Africa. It is a major independent risk factor for heart failure, stroke, and kidney failure. Persons living with hypertension attend to many aspects of self-care to manage their condition, including high blood pressure medication adherence to control of blood pressure. Rates of medication non-adherence, and thus uncontrolled hypertension, remain high and contribute to poor health outcomes. Understanding barriers and facilitators to adherence to hypertension therapies can help improve health outcomes. Objective: The aim of the study was to describe the common reasons for adherence and non-adherence to antihypertensive medication from patients' perspectives. Methods: A qualitative study engaged clients of an out-patient clinic of a regional referral hospital in southwestern Uganda who were living with hypertension as participants. One-on-one in-depth interviews provided the narrative data. The interview transcripts were analyzed using thematic analysis. Findings: Sixteen participants provided the data for the findings. The themes identified as facilitators for adherence to antihypertensive medication were patients' understanding of prescribed medication, availability of medication for hypertension, family support for patients living with hypertension, and regular review appointments at the hypertensive clinics. Conversely, lack of supply in government dispensaries, use of self-prescribed analgesic medication, and stigma were identified as barriers and challenges of adherence to antihypertensive medication. Conclusions: There is an urgent need for the health ministry to improve availability of high blood pressure medication and for health care providers to deliver individualized patient centered care, and sensitization on danger of self-prescription and measures that reduce stigma. These strategies may improve adherence to high blood pressure medication.

Baccalaureate prepared nurses as the new entry-level nursing cadre in Uganda: A qualitative study of BSN student and faculty perspectives in two universities.

BACKGROUND: Low-income countries suffer chronic problems in producing, employing and distributing their health workers. The World Health Organization advocates for upgrading the number and quality of nursing professionals. As nurses and midwives comprise more than 60% of the health workforce in Uganda, the country's goal to improve nursing education is consistent with international recommendations. OBJECTIVES: To understand the dimensions of Uganda's relatively new baccalaureate-prepared nurse cadre (BSN), we explored the views of students and faculty in relation to training, job prospects, scope of practice, and satisfaction of BSNs in Uganda. DESIGN: We used a descriptive qualitative design. SETTING AND PARTICIPANTS: We interviewed BSN students and faculty at two large public nursing schools in Uganda in 2017. METHODS: We conducted focus group discussions and key informant interviews and used a thematic analysis approach to analyze data. RESULTS: The four overarching themes were: 1) BSN training is viewed as distinct from "bedside" training, 2) A rift between nursing cadres undermines workplace harmony, 3) BSNs are dissatisfied with their salary scale, and 4) BSNs are motivated to move abroad. DISCUSSION: At this moment in the transition, the professional nursing culture within Uganda is not conducive to encouraging BSN entry. To gain traction and momentum for BSNs as an entry-level cadre in Uganda, policy makers might align incentives to encourage BSN trainees, as there are few BSNs within training programs and clinical settings. Increasing lower cadre nurses' understanding of the role of BSNs may help improve relations between nursing cadres. Aligning job descriptions with pay differentials in clinical settings and expanding meaningful job opportunities could help retain BSNs within Uganda.

Experiences of patients undergoing chemotherapy - a qualitative study of adults attending Uganda Cancer Institute.

BACKGROUND: Cancer is a global public health challenge and how patients in countries with poor healthcare infrastructure experience cancer treatment is largely unknown. PURPOSE: The objective of this study was to describe adult Ugandan cancer patients' experiences of undergoing chemotherapy treatment. METHODOLOGY: Using a qualitative descriptive design, seven in-patients with varying cancer diagnoses at the Uganda Cancer Institute were interviewed about their experiences of undergoing chemotherapy treatment; the interviews were transcribed and analysed thematically. RESULTS: The analysis resulted in nine subthemes, which were categorized under three main themes: 'experiences related to the body', with the subthemes dry and sensitive skin, changes in eating and bowel habits, fever and feelings of abnormal body sensation; 'thoughts and feelings', with four subthemes reflecting the psychosocial impact of chemotherapy; and 'actively dealing with discomfort', with three subthemes describing how patients dealt with side effects, such as by sticking to a diet. CONCLUSION: Receiving chemotherapy treatment is difficult, and the side effects negatively influenced patients' bodies and moods. Dealing actively with discomfort and accepting negative impacts in hope of a cure helped the participants manage the acute complications related to the treatment. We recommend the development of interventions to ease discomfort due to chemotherapy.

Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors.

BACKGROUND: Maternal near misses occur more often than maternal deaths and could enable more comprehensive analysis of risk factors, short-term outcomes and prognostic factors of complications during pregnancy and childbirth. The study determined the incidence, determinants and prognostic factors of severe maternal outcomes (near miss or maternal death) in two referral hospitals in Uganda. METHODS: A prospective cohort study was conducted between March 1, 2013 and February 28, 2014, where cases of severe pregnancy and childbirth complications were included. The clinical conditions included abortion-related complications, obstetric haemorrhage, hypertensive disorders, obstructed labour, infection and pregnancy-specific complications such as febrile illness, anemia and premature rupture of membranes. Near miss cases were defined according to the WHO criteria. Multivariate logistic regression analysis was conducted to identify prognostic factors for severe maternal outcomes. RESULTS: Of 3100 women with severe obstetric complications, 130 (4.2%) were maternal deaths and 695 (22.7%) were near miss cases. Severe pre-eclampsia was the commonest morbidity (incidence ratio (IR) 7.0%, case-fatality rate (CFR) 2.3%), followed by postpartum haemorrhage (IR 6.7%, CFR 7.2%). Uterine rupture (IR 5.5%) caused the highest CFR (17.9%), followed by eclampsia (IR 0.4%, CFR 17.8%). The three groups (maternal deaths, near misses and non-life-threatening obstetric complications) differed significantly regarding gravidity and education level. The commonest diagnostic criteria for maternal near miss were admission to the high dependency unit (HDU) or to the intensive care unit (ICU). Thrombocytopenia, circulatory collapse, referral to a more specialized unit, intubation unrelated to anaesthesia, and cardiopulmonary resuscitation were predictive of maternal death (p < 0.05). Gravidity (ARR 1.4, 95% C1 1.0-1.2); elevated serum lactate levels (ARR 4.5, 95% CI 2.3-8.7); intubation for conditions unrelated to general anaesthesia (ARR 2.6 (95% CI 1.2-5.7), cardiovascular collapse (ARR 4.9, 95% CI 2.5-9.5); transfusion of 4 or more units of blood (ARR 1.9, 95% CI 1.1-3.1); being an emergency referral (ARR 2.6, 95% CI 1.2-5.6); and need for cardiopulmonary resuscitation (ARR 6.1, 95% CI 3.2-11.7), were prognostic factors. CONCLUSIONS: The analysis of near misses is a useful tool in the investigation of severe maternal morbidity. The prognostic factors for maternal death, if instituted, might save many women with obstetric complications.

Incidence and determinants of neonatal morbidity after elective caesarean section at the national referral hospital in Kampala, Uganda.

BACKGROUND: Elective caesarean sections (ECS) have been implicated in increased risk of adverse neonatal outcomes. The primary objective was to assess the incidence and determinants of neonatal morbidity after elective caesarean section deliveries. The secondary objective was to describe the maternal morbidity associated with elective caesarean section. METHODS: This was a prospective cohort study of women admitted for ECS, as well as their newborns, conducted at Mulago hospital from March 1, 2013 to February 28, 2014. These were followed from the time of the operation until 6 weeks after hospitalization following the caesarean delivery. Data was collected using an interviewer-administered questionnaire and review of medical records for demographic characteristics, obstetric history, current pregnancy complications and pregnancy outcomes up to hospital discharge. Study outcomes were maternal and neonatal morbidity. The data was analyzed using Stata version 12. RESULTS: There were 25,846 deliveries during the study period, of which 20,083 (77.7%) were vaginal deliveries or assisted deliveries, and 5763 (22.3%) were caesarean sections. Of the caesarean sections, 920 (15.9%) were ECS. The commonest maternal morbidity was hemorrhage (17.2%). A birth weight less than 2500 g (aRR 11.0 [95% CI 8.1-17.2]) or more than 4000 g (aRR 12.2 [95% CI 10.6-23.2]), delivery at gestation age less than or equal to 38 weeks (aRR 1.62 [95% 1.20-2.10]), multigravidity (aRR 1.70 [95% CI 1.20-2.90]) and using general anaesthesia (aRR 2.43 [95% CI 1.20-5.90]) were associated with risk of neonatal morbidity. The commonest neonatal morbidity is respiratory distress especially if delivery occurs at a gestation age of 37 weeks or lower, if the birth weight is less than 2500 g or more than 4000 g, and if general anesthesia is used. CONCLUSION: Our study shows that at Mulago Hospital, ECS is associated with significant neonatal and maternal morbidity. We recommend that elective caesarean sections be performed after 39 weeks of gestation, and preferably avoid using general anaesthesia.

Still births, neonatal deaths and neonatal near miss cases attributable to severe obstetric complications: a prospective cohort study in two referral hospitals in Uganda.

BACKGROUND: Neonatal near miss cases occur more often than neonatal deaths and could enable a more comprehensive analysis of risk factors, short-term outcomes and prognostic factors in neonates born to mothers with severe obstetric complications. The objective was to assess the incidence, presentation and perinatal outcomes of severe obstetric morbidity in two referral hospitals in Central Uganda. METHODS: A prospective cohort study was conducted between March 1, 2013 and February 28, 2014, in which all newborns from cases of severe pregnancy and childbirth complications were eligible for inclusion. The obstetric conditions included obstetric haemorrhage, hypertensive disorders, obstructed labour, chorioamnionitis and pregnancy-specific complications such as malaria, anemia and premature rupture of membranes. Still births, neonatal deaths and neonatal near miss cases (defined using criteria that employed clinical features, presence of organ-system dysfunction and management provided to the newborns were compiled). Stratified and multivariate logistic regression analysis was conducted to identify risk factors for perinatal death. RESULTS: Of the 3100 mothers, 192 (6.2%) had abortion complications. Of the remainder, there were 2142 (73.1%) deliveries, from whom the fetal outcomes were 257 (12.0%) still births, 369 (17.2%) neonatal deaths, 786 (36.7%) neonatal near misses and 730 (34.1%) were newborns with no or minimal life threatening complications. Of the 235 babies admitted to the neonatal intensive care unit (NICU), the main reasons for admission were prematurity for 64 (26.8%), birth asphyxia for 59 (23.7%), and grunting respiration for 26 (11.1%). Of the 235 babies, 38 (16.2%) died in the neonatal period, and of these, 16 died in the first 24 hours after admission. Ruptured uterus caused the highest case-specific mortality of 76.8%, and led to 16.9% of all newborn deaths. Across the four groups, there were significant differences in mean birth weight, p = 0.003. CONCLUSIONS: Antepartum hemorrhage, ruptured uterus, severe preeclampsia, eclampsia, and the syndrome of Hemolysis, Elevated Liver Enzymes, Low Platelets (HELLP syndrome), led to statistically significant attributable risk of newborn deaths (still birth or neonatal deaths). Development of severe maternal outcomes, the mothers having been referred, and gravidity of 5 or more were significantly associated with newborn deaths.

Improving Midwifery Care in Ugandan Public Hospitals: The Midwives' Perspective.

BACKGROUND: A serious shortage of nurses and midwives in public hospitals has been reported in Uganda. In addition, over 80% of the nurses and midwives working in public hospitals have been found to have job stress and only 17% to be satisfied on the job. Stress and lack of job satisfaction affect quality of nursing and midwifery care and puts patients' lives at risk. This is coupled with rampant public outcry about the deteriorating nursing and midwifery care in Ugandan public hospitals. OBJECTIVE: To explore factors that result in poor quality of midwifery care and strategies to improve this care from the perspective of the midwives. METHOD: It was a qualitative exploratory design. Participants were midwives and their supervisors working in four Regional Referral hospitals in Uganda. Data was collected by FGDs and KIIs. Content analysis was used to analyze the transcribed data from the voice recordings. RESULTS: Four major themes emerged from the study. They were organizational (poor work environment and lack of materials/equipment), professional (midwives' attitudes, lack of supervision), public/consumer issues (interference) and policy issues (remuneration, promotion and retirement). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Midwives love their work but they need support to provide quality care. Continuous neglect of midwives' serious concerns will lead to more shortages as more dissatisfied midwives leave service.

Information and communication technology and community-based health sciences training in Uganda: perceptions and experiences of educators and students.

Information and communication technology (ICT) has been advocated as a powerful tool for improving health education in low-resource settings. However, few evaluations have been performed of ICT perceptions and user experiences in low-resource settings. During late 2009, an internet-based survey on ICT was administered to students, tutors, and faculty members associated with a Community-Based Education and Service (COBES) program in Uganda. 255 surveys were completed. Response rates varied (students, 188/684, 27.5%; tutors, 14/27, 51.9%; faculty, 53/335, 15.8%). Most respondents owned mobile phones (98%). Students were less likely (p < 0.001) to own laptops (25%) compared to tutors (71%) and faculty (85%). Internet access at rural sites was uncommon; mobile phone coverage was almost universally present. Laptop ownership and internet and mobile phone access was not associated with high valuation of students' COBES experiences. Free text responses found that respondents valued ICT access for research, learning, and communication purposes. In summary, ICT penetration in this population is primarily manifest by extensive mobile phone ownership. Internet access in rural educational sites is still lacking, but students and educators appear eager to utilize this resource if availability improves. ICT may offer a unique opportunity to improve the quality of teaching and learning for COBES participants.

Occupational stress, job satisfaction and job performance among hospital nurses in Kampala, Uganda.

AIMS: To assess levels of occupational stress, job satisfaction and job performance among hospital nurses in Kampala, Uganda; and how they are influenced by work and personal characteristics. BACKGROUND: Occupational stress is reported to affect job satisfaction and job performance among nurses, thus compromising nursing care and placing patients' lives at risk. Although these factors have been studied extensively in the US and Europe, there was a need to explore them from the Ugandan perspective. METHODS: A correlational study was conducted with 333 nurses from four hospitals in Kampala, Uganda. A questionnaire measuring occupational stress, job satisfaction and job performance was used. Data were analysed using descriptive statistics and anova. RESULTS: There were significant differences in levels of occupational stress, job satisfaction and job performance between public and private not-for-profit hospitals, nursing experience and number of children. CONCLUSIONS: Organizational differences between public and private not-for-profit hospitals influence the study variables. IMPLICATIONS FOR NURSING MANAGEMENT: On-the-job training for nurse managers in human resource management to increase understanding and advocacy for organizational support policies was recommended. Research to identify organizational, family or social factors which contribute to reduction of perceived occupational stress and increase job satisfaction and job performance was recommended.

Lessons learnt from comprehensive evaluation of community-based education in Uganda: a proposal for an ideal model community-based education for health professional training institutions.

BACKGROUND: Community-based education (CBE) can provide contextual learning that addresses manpower scarcity by enabling trainees acquire requisite experiences, competence, confidence and values. In Uganda, many health professional training institutions conduct some form of community-based education (CBE). However, there is scanty information on the nature of the training: whether a curriculum exists (objectives, intended outcomes, content, implementation strategy), administration and constraints faced. The objective was to make a comprehensive assessment of CBE as implemented by Ugandan health professional training institutions to document the nature of CBE conducted and propose an ideal model with minimum requirements for health professional training institutions in Uganda. METHODS: We employed several methods: documentary review of curricula of 22 institutions, so as to assess the nature, purpose, outcomes, and methods of instruction and assessment; site visits to these institutions and their CBE sites, to assess the learning environment (infrastructure and resources); in-depth interviews with key people involved in running CBE at the institutions and community, to evaluate CBE implementation, challenges experienced and perceived solutions. RESULTS: CBE was perceived differently ranging from a subject, a course, a program or a project. Despite having similar curricula, institutions differ in the administration, implementation and assessment of CBE. Objectives of CBE, the curricula content and implementation strategies differ in similar institutions. On collaborative and social learning, most trainees do not reside in the community, though they work on group projects and write group reports. Lectures and skills demonstrations were the main instruction methods. Assessment involved mainly continuous assessment, oral or written reports and summative examination. CONCLUSION: This assessment identified deficiencies in the design and implementation of CBE at several health professional training institutions, with major flaws identified in curriculum content, supervision of trainees, inappropriate assessment, trainee welfare, and underutilization of opportunities for contextual and collaborative learning. Since CBE showed potential to benefit the trainees, community and institutions, we propose a model that delivers a minimum package of CBE and overcomes the wide variation in the concept, conduct and implementation of CBE.

The organization and implementation of community-based education programs for health worker training institutions in Uganda.

BACKGROUND: Community-based education (CBE) is part of the training curriculum for most health workers in Uganda. Most programs have a stated purpose of strengthening clinical skills, medical knowledge, communication skills, community orientation of graduates, and encouragement of graduates to work in rural areas. This study was undertaken to assess the scope and nature of community-based education for various health worker cadres in Uganda. METHODS: Curricula and other materials on CBE programs in Uganda were reviewed to assess nature, purpose, intended outcomes and evaluation methods used by CBE programs. In-depth and key informant interviews were conducted with people involved in managing CBE in twenty-two selected training institutions, as well as stakeholders from the community, Ministry of Health, Ministry of Education, civil society organizations and local government. Visits were made to selected sites where CBE training was conducted to assess infrastructure and learning resources being provided. RESULTS: The CBE curriculum is implemented in the majority of health training institutions in Uganda. CBE is a core course in most health disciplines at various levels - certificate, diploma and degree and for a range of health professionals. The CBE curriculum is systematically planned and implemented with major similarities among institutions. Organization, delivery, managerial strategies, and evaluation methods are also largely similar. Strengths recognized included providing hands-on experience, knowledge and skills generation and the linking learners to the communities. Almost all CBE implementing institutions cited human resource, financial, and material constraints. CONCLUSIONS: The CBE curriculum is a widely used instructional model in Uganda for providing trainee health workers with the knowledge and skills relevant to meet community needs. Strategies to improve curricula and implementation concerns need further development. It is still uncertain whether this approach is increasing the number graduates seeking careers in rural health service, one of the stated program goals, an outcome which requires further study.

Perception and valuations of community-based education and service by alumni at Makerere University College of Health Sciences.

BACKGROUND: Training of health professionals can be deliberately structured to enhance rural recruitment by exposing the trainees to the realities of rural life and practice through Community-Based Education and Service (COBE) programs. Few studies have surveyed the alumni of these programs to establish their post-university views and whether the positive impact of COBE programs endures into the post-university life. This study surveyed the alumni of COBE at Makerere to obtain their perceptions of the management and administration of COBE and whether COBE had helped develop their confidence as health workers, competence in primary health care and willingness and ability to work in rural communities. OBJECTIVES: • To assess the efficiency of the management and administration of COBES.• To obtain the views of the impact of COBES on its alumni. METHODS: A mixed qualitative and quantitative study was conducted using focus group discussions (FGD) and a telephone administered questionnaire. From a total of 300 COBES alumni 150 were contacted. Twenty four Alumni (13 females and 11 males) were purposefully selected by discipline, gender and place of work, and invited for the focus group discussion. The discussions were transcribed and analyzed using a manifest content analysis table. The thematic issues from the FGDs were used to develop a structured questionnaire which was administered by telephone by the authors. The data were entered into Microsoft excel template and exported to Stata for analysis. The findings of the telephone survey were used to cross-match the views expressed during the focus group discussions. RESULTS: The alumni almost unanimously agree that the initial three years of COBES were very successful in terms of administration and coordination. COBES was credited for contributing to development of confidence as health workers, team work, communication skills, competence in primary health care and willingness to work in rural areas. The COBES alumni also identified various challenges associated with administration and coordination of COBES at Makerere. CONCLUSIONS: This study has established that the positive impact of COBES endures with the alumni of the program. Health planners should take advantage of the impact of COBES and provide it with more support.

Perceptions and valuation of a community-based education and service (COBES) program in Uganda.

BACKGROUND: Community-based education and service (COBES) has been promoted to improve the education of health professionals, particularly in low-resource settings. However, few evaluations have been performed to guide program development. AIM: This study assessed student and educator perceptions and valuation of a Ugandan COBES program. METHODS: We administered an internet-based survey to students, faculty, and site tutors associated with the Makerere University College of Health Sciences COBES program. RESULTS: 255 surveys were completed. Response rates varied (students, 188/684, 27.5%; faculty-site supervisors, 15/23, 65.2%; faculty general, 38/312, 12.2%; site tutors, 14/27, 51.9%). Students valued the COBES program (93.5% some/high value). Tutors enjoyed their work (92.9% agreeing/strongly agreeing). Faculty (n = 53) felt COBES was valuable (90.2% agreeing/strongly agreeing). High student valuation was associated with high quality accommodation (aOR 4.7, 95% CI = 1.6-13.4), free accommodation (aOR 2.9, 95% CI = 1.2-6.8), and tutors who demonstrated enthusiasm for teaching (aOR 3.4, 95% CI = 1.1-10.0). Areas identified for improvement included financial support, student preparation, and tutor training, feedback, and supervision. CONCLUSION: In this study, COBES was perceived positively by students and educators and learning environment and quality of teaching both contributed to valuation of COBES. Well-implemented COBES programs may offer an opportunity to enhance health sciences education.