Using Patient Navigation to Reduce Time to Diagnosis of Breast Cancer in Uganda.

PURPOSE: The Ugandan Ministry of Health adopted BI-RADS as standard of care in 2016. The authors performed a medical audit of breast ultrasound practices at four tertiary-level hospitals to assess interpretive performance. The authors also determined the effect of a low-cost navigation program linking breast imaging and pathology on the percentage of patients completing diagnostic care. METHODS: The authors retrieved 966 consecutive diagnostic breast ultrasound reports, with complete data, for studies performed on women aged >18 years presenting with symptoms of breast cancer between 2018 and 2020 from participating hospitals. Ultrasound results were linked to tumor registries and patient follow-up. A medical audit was performed according to the ACR's BI-RADS Atlas, fifth edition, and results were compared with those of a prior audit performed in 2013. At Mulago Hospital, an intervention was piloted on the basis of patient navigation, cost sharing, and same-day imaging, tissue sampling, and pathology. RESULTS: In total, 888 breast ultrasound examinations (91.9%) were eligible for inclusion. Compared with 2013, the postintervention cancer detection rate increased from 38 to 148.7 cancers per 1,000 examinations, positive predictive value 2 from 29.6% to 48.9%, and positive predictive value 3 from 62.7% to 79.9%. Specificity decreased from 90.5% to 87.7% and sensitivity from 92.3% to 81.1%. The mean time from tissue sampling to receipt of a diagnosis decreased from 60 to 7 days. The intervention increased the percentage of patients completing diagnostic care from 0% to 100%. CONCLUSIONS: Efforts to establish a culture of continuous quality improvement in breast ultrasound require robust data collection that links imaging results to pathology and patient follow-up. Interpretive performance met BI-RADS benchmarks for palpable masses, except sensitivity. This resource-appropriate strategy linking imaging, tissue sampling, and pathology interpretation decreased time to diagnosis and rates of loss to follow-up and improved the precision of the audit.

Point of care obstetric ultrasound training for midwives and nurses: implementation and experiences of trainees at a rural based hospital in Sub-saharan Africa: a qualitative study.

BACKGROUND: Point of care ultrasound training has been successfully implemented in some settings. This has been done due to a shortage of radiology human resource gap especially in the rural areas of low-resource settings. The purpose of the study was to implement a point of care obstetric ultrasound training program for midwives and nurses and explore their experiences following the training at a rural based hospital in Uganda. METHODS: It was an exploratory qualitative study with some elements of implementation research design involving midwives and nurses that had undergone obstetric ultrasound training at Kiwoko hospital, a rural-based hospital in Uganda. Purposive sampling was used to select twenty-five midwives and nurses. These participants underwent a 6-weeks training in point of care obstetric ultrasound. Following the training, in-depth interviews were conducted to obtain the experiences of the participants. RESULTS: The training was conducted by qualified radiologists and sonographers and it involved both didactic sessions and rigorous practical and clinical demonstrations and eventually real-time scanning of the women. Three key themes emerged from the interviews: (1) Gaining important obstetric ultrasound skills, (2) Improving management of pregnant women and (3) Positive for task-shifting. CONCLUSION: The point of care obstetric ultrasound training program was successfully implemented at Kiwoko Hospital. The trainees reported positive experiences from the training and while only conducted at one rural health facility, the overwhelmingly positive experience from trainees underscores the importance of point of care obstetric ultrasound in delivering imaging services.

Evaluating the impact of a multicountry interprofessional training programme to improve HIV knowledge and clinical confidence among healthcare workers in sub-Saharan Africa: a cohort study.

OBJECTIVE: To assess the impact of an interprofessional case-based training programme to enhance clinical knowledge and confidence among clinicians working in high HIV-burden settings in sub-Saharan Africa (SSA). SETTING: Health professions training institutions and their affiliated clinical training sites in 12 high HIV-burden countries in SSA. PARTICIPANTS: Cohort comprising preservice and in-service learners, from diverse health professions, engaged in HIV service delivery. INTERVENTION: A standardised, interprofessional, case-based curriculum designed to enhance HIV clinical competency, implemented between October 2019 and April 2020. MAIN OUTCOME MEASURES: The primary outcomes measured were knowledge and clinical confidence related to topics addressed in the curriculum. These outcomes were assessed using a standardised online assessment, completed before and after course completion. A secondary outcome was knowledge retention at least 6 months postintervention, measured using the same standardised assessment, 6 months after training completion. We also sought to determine what lessons could be learnt from this training programme to inform interprofessional training in other contexts. RESULTS: Data from 3027 learners were collected: together nurses (n=1145, 37.9%) and physicians (n=902, 29.8%) constituted the majority of participants; 58.1% were preservice learners (n=1755) and 24.1% (n=727) had graduated from training within the prior year. Knowledge scores were significantly higher, postparticipation compared with preparticipation, across all content domains, regardless of training level and cadre (all p<0.05). Among 188 learners (6.2%) who retook the test at >6 months, knowledge and self-reported confidence scores were greater compared with precourse scores (all p<0.05). CONCLUSION: To our knowledge, this is the largest interprofessional, multicountry training programme established to improve HIV knowledge and clinical confidence among healthcare professional workers in SSA. The findings are notable given the size and geographical reach and demonstration of sustained confidence and knowledge retention post course completion. The findings highlight the utility of interprofessional approaches to enhance clinical training in SSA.

Opportunities and Challenges in North-South and South-South Global Health Collaborations During the COVID-19 Pandemic: The AFREhealth-CUGH Experience (as Reported at the CUGH 2021 Satellite Meeting).

Sustainable and equitable partnerships and collaborations between the Global North and Global South (as well as within the Global South) have been aspirations (if seldom achieved) of the "global health" endeavor over the past couple of decades. The COVID-19 pandemic led to global lockdowns that disrupted international travel and severely challenged these partnerships, providing a critical space for self-reflection on global health as a discipline. One major global north-south partnership is that between the African Forum for Research and Education in Health (AFREhealth) and the Consortium of Universities for Global Health (CUGH). This article reports on a recent Satellite meeting of the AFREhealth-CUGH Working Group (ACWG) at the CUGH 2021 virtual conference in March 2021 that provided insights on North-South and South-South global health partnerships, against the backdrop of the COVID-19 pandemic. The authors describe challenges and opportunities for research and education in these partnerships (as discussed at this ACWG Satellite meeting), and implications for the field of global health going forward as we emerge from the pandemic.

Contact Tracing and the COVID-19 Response in Africa: Best Practices, Key Challenges, and Lessons Learned from Nigeria, Rwanda, South Africa, and Uganda.

Most African countries have recorded relatively lower COVID-19 burdens than Western countries. This has been attributed to early and strong political commitment and robust implementation of public health measures, such as nationwide lockdowns, travel restrictions, face mask wearing, testing, contact tracing, and isolation, along with community education and engagement. Other factors include the younger population age strata and hypothesized but yet-to-be confirmed partially protective cross-immunity from parasitic diseases and/or other circulating coronaviruses. However, the true burden may also be underestimated due to operational and resource issues for COVID-19 case identification and reporting. In this perspective article, we discuss selected best practices and challenges with COVID-19 contact tracing in Nigeria, Rwanda, South Africa, and Uganda. Best practices from these country case studies include sustained, multi-platform public communications; leveraging of technology innovations; applied public health expertise; deployment of community health workers; and robust community engagement. Challenges include an overwhelming workload of contact tracing and case detection for healthcare workers, misinformation and stigma, and poorly sustained adherence to isolation and quarantine. Important lessons learned include the need for decentralization of contact tracing to the lowest geographic levels of surveillance, rigorous use of data and technology to improve decision-making, and sustainment of both community sensitization and political commitment. Further research is needed to understand the role and importance of contact tracing in controlling community transmission dynamics in African countries, including among children. Also, implementation science will be critically needed to evaluate innovative, accessible, and cost-effective digital solutions to accommodate the contact tracing workload.

Identifying research priorities for health professions education research in sub-Saharan Africa using a modified Delphi method.

BACKGROUND: Recent increases in health professions education (HPE) research in sub-Saharan Africa (SSA), though substantial, have predominantly originated from single institutions and remained uncoordinated. A shared research agenda can guide the implementation of HPE practices to ultimately influence the recruitment and retention of the health workforce. Thus, the authors aimed to generate and prioritise a list of research topics for HPE research (HPER) in SSA. METHODS: A modified Delphi process was designed to prioritise a shared agenda. Members of the African Forum for Research and Education in Health (AFREhealth) technical working group (TWG) were asked to first list potential research topics. Then, members of the same TWG and attendees at the annual AFREhealth academic symposium held in Lagos, Nigeria in August 2019 rated the importance of including each topic on a 3-point Likert scale, through two rounds of consensus seeking. Consensus for inclusion was predefined as ≥70% of respondents rating the topic as "must be included." RESULTS: Health professions educators representing a variety of professions and 13 countries responded to the survey rounds. Twenty-three TWG members suggested 26 initial HPER topics; subsequently 90 respondents completed round one, and 51 completed round 2 of the modified Delphi. The final list of 12 research topics which met predetermined consensus criteria were grouped into three categories: (1) creating an enabling environment with sufficient resources and relevant training; (2) enhancing student learning; and (3) identifying and evaluating strategies to improve pedagogical practice. CONCLUSIONS: Establishing research priorities for HPE is important to ensure efficient and appropriate allocation of resources. This study serves as a reminder of how the prevailing context within which HPE, and by implication research in the field, is undertaken will inevitably influence choices about research foci. It further points to a potential advocacy role for research that generates regionally relevant evidence.

An audit of registered radiology equipment resources in Uganda.

INTRODUCTION: the third Sustainable Development Goal (SDG) relates to Universal Health Coverage (UHC) and provision of quality essential health services. The Government of Uganda has operationalized this through the National Health Policy which stresses the importance of availability of functioning medical equipment in health facilities. There have been efforts by the Ministry of Health and Atomic Energy Council in Uganda to compile an inventory of imaging equipment in the country, however, this information has not been widely published. The purpose of this study was to conduct an audit of registered radiology equipment in Uganda and establish their functional status. METHODS: a cross-sectional descriptive study that involved a desktop review of the equipment registry at the Uganda Atomic Energy Council was conducted. Data was collected on a number of variables including type of equipment, location, functional status, modality and density per million people. RESULTS: the audit revealed 625 pieces of equipment spread over 354 health facilities. The majority (397) were plain X-ray machines followed by dental X-ray machines at 120. There were only 3 Radiotherapy machines. Most were recorded as being functional with only 0.1% of the equipment non-functional. Most of the equipment was in the central region which has the third highest population density. The majority of the equipment belonged to private health facilities. CONCLUSION: Uganda lags behind the WHO recommended ratio of equipment versus the population (20 per million population). Most of the equipment is the plain X-ray machine with a few more advanced technologies in both public and private health facilities.

The Medical Education Partnership Initiative (MEPI): Innovations and Lessons for Health Professions Training and Research in Africa.

MEPI was a $130 million competitively awarded grant by President's Emergency Plan for AIDS Relief (PEPFAR) and National Institutes of Health (NIH) to 13 Medical Schools in 12 Sub-Saharan African countries and a Coordinating Centre (CC). Implementation was led by Principal investigators (PIs) from the grantee institutions supported by Health Resources and Services Administration (HRSA), NIH and the CC from September, 2010 to August, 2015. The goals were to increase the capacity of the awardees to produce more and better doctors, strengthen locally relevant research, promote retention of the graduates within their countries and ensure sustainability. MEPI ignited excitement and stimulated a broad range of improvements in the grantee schools and countries. Through in-country consortium arrangements African PIs expanded the programme from the 13 grantees to over 60 medical schools in Africa, creating vibrant South-South and South-North partnerships in medical education, and research. Grantees revised curricular to competency based models, created medical education units to upgrade the quality of education and established research support centres to promote institutional and collaborative research. MEPI stimulated the establishment of ten new schools, doubling of the students' intake, in some schools, a three-fold increase in post graduate student numbers, and faculty expansion and retention.Sustainability of the MEPI innovations was assured by enlisting the support of universities and ministries of education and health in the countries thus enabling integration of the new programs into the regular national budgets. The vibrant MEPI annual symposia are now the largest medical education events in Africa attracting global participation. These symposia and innovations will be carried forward by the successor of MEPI, the African Forum for Research and Education in Health (AFREhealth). AFREhealth promises to be more inclusive and transformative bringing together other health professionals including nurses, pharmacists, and dentists.

Training for impact: the socio-economic impact of a fit for purpose health workforce on communities.

Across the globe, a "fit for purpose" health professional workforce is needed to meet health needs and challenges while capitalizing on existing resources and strengths of communities. However, the socio-economic impact of educating and deploying a fit for purpose health workforce can be challenging to evaluate. In this paper, we provide a brief overview of six promising strategies and interventions that provide context-relevant health professional education within the health system. The strategies focused on in the paper are:1. Distributed community-engaged learning: Education occurs in or near underserved communities using a variety of educational modalities including distance learning. Communities served provide input into and actively participate in the education process.2. Curriculum aligned with health needs: The health and social needs of targeted communities guide education, research and service programmes.3. Fit for purpose workers: Education and career tracks are designed to meet the needs of the communities served. This includes cadres such as community health workers, accelerated medically trained clinicians and extended generalists.4. Gender and social empowerment: Ensuring a diverse workforce that includes women having equal opportunity in education and are supported in their delivery of health services.5. Interprofessional training: Teaching the knowledge, skills and attitudes for working in effective teams across professions.6. South-south and north-south partnerships: Sharing of best practices and resources within and between countries.In sum, the sharing of resources, the development of a diverse and interprofessional workforce, the advancement of primary care and a strong community focus all contribute to a world where transformational education improves community health and maximizes the social and economic return on investment.

Medical education departments: a study of four medical schools in Sub-Saharan Africa.

BACKGROUND: Many African countries are investing in medical education to address significant health care workforce shortages and ultimately improve health care. Increasingly, training institutions are establishing medical education departments as part of this investment. This article describes the status of four such departments at sub-Saharan African medical schools supported by the Medical Education Partnership Initiative (MEPI). This article will provide information about the role of these institutional structures in fostering the development of medical education within the African context and highlight factors that enable or constrain their establishment and sustainability. METHODS: In-depth interviews were conducted with the heads or directors of the four medical education departments using a structured interview protocol developed by the study group. An inductive approach to analysis of the interview transcripts was adopted as the texts were subjected to thematic content analysis. RESULTS: Medical education departments, also known as units or centers, were established for a range of reasons including: to support curriculum review, to provide faculty development in Health Professions Education, and to improve scholarship in learning and teaching. The reporting structures of these departments differ in terms of composition and staff numbers. Though the functions of departments do vary, all focus on improving the quality of health professions education. External and internal funding, where available, as well as educational innovations were key enablers for these departments. Challenges included establishing and maintaining the legitimacy of the department, staffing the departments with qualified individuals, and navigating dependence on external funding. All departments seek to expand the scope of their services by offering higher degrees in HPE, providing assistance to other universities in this domain, and developing and maintaining a medical education research agenda. CONCLUSIONS: The establishment of medical education departments in Sub-Saharan Africa is a strategy medical schools can employ to improve the quality of health professions education. The creation of communities of practice such as has been done by the MEPI project is a good way to expand the network of medical education departments in the region enabling the sharing of lessons learned across the continent.

Problem based learning: tutors' views 5 years after implementation at a sub-Saharan University.

BACKGROUND: Curriculum evaluation is key to continuous assurance of quality of education. OBJECTIVES: To assess the teachers' perceptions on how well student teaching and learning activities were conducted at an institution that had practiced PBL for five years. METHODS: A cross sectional descriptive study. 150 teachers from 23 departments at the College of Health Sciences participated in the study. A 25 item self-administered questionnaire was used to collect data. Activities evaluated included; students assessment, self-directed learning, feedback and clinical exposure. Data were entered in epi data and analysed using SPSS. Ethical approval was obtained. RESULTS: The participants' average teaching experience was eight years. The PBL/COBES approach mostly achieved the aim of producing self-directed and lifelong learners. Half of the teaching staff actively provided regular feedback about the learning and teaching activities they were involved in. Early clinical exposure was widely accepted as a highly rewarding appropriate teaching and learning strategy. COBES activities were well organized although involvement of College staff was low. CONCLUSION: PBL/COBES program was successfully executed and had high acceptance among Faculty. The biggest challenge was getting all staff to provide regular feedback. Self institutional curriculum review can be done cheaply and quickly to provide feedback for continual curriculum improvement.

Transforming health professions' education through in-country collaboration: examining the consortia among African medical schools catalyzed by the Medical Education Partnership Initiative.

BACKGROUND: African medical schools have historically turned to northern partners for technical assistance and resources to strengthen their education and research programmes. In 2010, this paradigm shifted when the United States Government brought forward unprecedented resources to support African medical schools. The grant, entitled the Medical Education Partnership Initiative (MEPI) triggered a number of south-south collaborations between medical schools in Africa. This paper examines the goals of these partnerships and their impact on medical education and health workforce planning. METHODS: Semi-structured interviews were conducted with the Principal Investigators of the first four MEPI programmes that formed an in-country consortium. These interviews were recorded, transcribed and coded to identify common themes. RESULTS: All of the consortia have prioritized efforts to increase the quality of medical education, support new schools in-country and strengthen relations with government. These in-country partnerships have enabled schools to pool and mobilize limited resources creatively and generate locally-relevant curricula based on best-practices. The established schools are helping new schools by training faculty and using grant funds to purchase learning materials for their students. The consortia have strengthened the dialogue between academia and policy-makers enabling evidence-based health workforce planning. All of the partnerships are expected to last well beyond the MEPI grant as a result of local ownership and institutionalization of collaborative activities. CONCLUSIONS: The consortia described in this paper demonstrate a paradigm shift in the relationship between medical schools in four African countries. While schools in Africa have historically worked in silos, competing for limited resources, MEPI funding that was leveraged to form in-country partnerships has created a culture of collaboration, overriding the history of competition. The positive impact on the quality and efficiency of health workforce training suggests that future funding for global health education should prioritize such south-south collaborations.

Competency-based medical education in two Sub-Saharan African medical schools.

BACKGROUND: Relatively little has been written on Medical Education in Sub-Saharan Africa, although there are over 170 medical schools in the region. A number of initiatives have been started to support medical education in the region to improve quality and quantity of medical graduates. These initiatives have led to curricular changes in the region, one of which is the introduction of Competency-Based Medical Education (CBME). INSTITUTIONAL REVIEWS: This paper presents two medical schools, Makerere University College of Health Sciences and College of Medicine, University of Ibadan, which successfully implemented CBME. The processes of curriculum revision are described and common themes are highlighted. Both schools used similar processes in developing their CBME curricula, with early and significant stakeholder involvement. Competencies were determined taking into consideration each country's health and education systems. Final competency domains were similar between the two schools. Both schools established medical education departments to support their new curricula. New teaching methodologies and assessment methods were needed to support CBME, requiring investments in faculty training. Both schools received external funding to support CBME development and implementation. CONCLUSION: CBME has emerged as an important change in medical education in Sub-Saharan Africa with schools adopting it as an approach to transformative medical education. Makerere University and the University of Ibadan have successfully adopted CBME and show that CBME can be implemented even for the low-resourced countries in Africa, supported by external investments to address the human resources gap.

A consortium approach to competency-based undergraduate medical education in Uganda: process, opportunities and challenges.

BACKGROUND: Uganda, like the rest of Africa, is faced with serious health challenges including human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), other infectious diseases and increasing non-communicable diseases, yet it has a significant shortage of health workers. Even the few health workers available may lack desired competencies required to address current and future health challenges. Reducing Uganda's disease burden and addressing health challenges requires Ugandan medical schools to produce health workers with the necessary competencies. This study describes the process which a consortium of Ugandan medical schools and the Medical Education Partnership for Equitable Services to all Ugandans (MESAU) undertook to define the required competencies of graduating doctors in Uganda and implement competency-based medical education (CBME). METHODS: A retrospective qualitative study was conducted in which document analysis was used to collect data employing pre-defined checklists, in a desktop or secondary review of various documents. These included reports of MESAU meetings and workshops, reports from individual institutions as well as medical undergraduate curricula of the different institutions. Thematic analysis was used to extract patterns from the collected data. RESULTS: MESAU initiated the process of developing competencies for medical graduates in 2011 using a participatory approach of all stakeholders. The process involved consultative deliberations to identify priority health needs of Uganda and develop competencies to address these needs. Nine competence domain areas were collaboratively identified and agreed upon, and competencies developed in these domains. DISCUSSION: Key successes from the process include institutional collaboration, faculty development in CBME and initiating the implementation of CBME. The consortium approach strengthened institutional collaboration that led to the development of common competencies desired of all medical graduates to address priority health challenges in Uganda. It is important that the MESAU consortium continues engaging all stakeholders in medical education to support the implementation and sustainability of CBME in Uganda.

Mammography: a review of records in the Department of Radiology at a National Referral Hospital in Uganda.

INTRODUCTION: Breast cancer is one of the leading cancers amongst women world-wide. Although mortality has been reduced and survival rates increased in developed countries, mortality rates from breast cancer are still a major health challenge for many developing countries. In Uganda, there are no screening programmes and in many cases mammography is used for diagnostic purposes. The purpose of this study was to describe the clinical presentations and mammographic breast density patterns amongst women that presented to the radiology department for mammography at a national referral hospital. METHODS: This was a retrospective study carried out at Mulago Hospital in Uganda between January 2011 and January 2012. Records for patients who had mammography during this period were reviewed. RESULTS: The total number of patients was 382 with a mean age of 46 years. Majority presented with breast pain and masses. Mammograms done were normal in majority of the women with fatty breast density dominating. In Uganda, mammography was mainly performed for diagnostic purposes. CONCLUSION: There is no mammography screening programme in Uganda and many women cannot access the service due to its limited availability and costs despite its significance in breast cancer management. There is therefore need for governments in Uganda, but in other areas as well to support regular mammography screening as a way of reducing mortality from breast cancer.