Community-based training of medical students is associated with malaria prevention and treatment seeking behaviour for children under 5 years in Uganda: a study of MESAU-MEPI COBERS in Uganda.

BACKGROUND: Four university medical training institutions in Uganda have trained students at off-site health facilities under community-based education and Research Service (COBERS) programme for over 5 years. One of the major components of COBERS placement is for the students to provide health education in the communities about malaria as a major public health disease in Uganda. This study seeks to assess if targeted community-based medical education programme is associated with better prevention and treatment seeking behaviours in the management of malaria, a leading cause of morbidity and mortality of children under five in Uganda. METHODS: A cross-sectional survey was done to compare communities around health facilities where medical students were placed at COBERS sites with communities around similar health facilities where medical students were not placed (non-COBERS sites). We randomly selected two villages near each health facility and consecutively selected 10 households per village for interviews using nearest-neighbour method. We used a structured questionnaire to interview household heads on malaria prevention and treatment seeking behaviour for children under 5 years. We performed univariate analysis to determine site and demographic characteristics and performed a multivariate logistic regression to assess association between dependant and independent variables. RESULTS: Five hundred twenty-three (66.8%) of the children under 5 years in COBERS communities slept under Insecticide Treated Nets (ITNs) the night before survey compared with 1451 (57.8%) in non-COBERS communities (AOR = 0.66, p = 0.017). 100 (60.0%) of children under 5 years in COBERS communities sought care for fever within 24 h of onset compared with 268 (47.0%) in non-COBERS communities (AOR = 0.71, P = 0.009). CONCLUSION: The presence of COBERS in communities is associated with improved malaria prevention and treatment-seeking behaviour for parents of children under 5 years. Further study needs to be done to determine the long-term impact of COBERS training program on malaria control and prevention in Uganda, along with other effects of COBERS.

An exploration of undergraduate medical students' satisfaction with faculty support supervision during community placements in Uganda.

INTRODUCTION: To produce health professionals who are oriented towards addressing community priority health needs, the training in medical schools has been transformed to include a component of community-based training. During this period, students spend a part of their training in the communities they are likely to serve upon graduation. They engage and empower local people in the communities to address their health needs during their placements, and at the same time learn from the people. During the community-based component, students are constantly supervised by faculty from the university to ensure that the intended objectives are achieved. The purpose of the present study was to explore student experiences of support supervision from university faculty during their community-based education, research and service (COBERS placements) and to identify ways in which the student learning can be improved through improved faculty supervision. METHODS: This was a cross-sectional study involving students at the College of Health Sciences, Makerere University, Uganda, who had a community-based component during their training. Data were collected using both questionnaires and focus group discussions. Quantitative data were analyzed using statistical software and thematic approaches were used for the analysis of qualitative data. RESULTS: Most students reported satisfaction with the COBERS supervision; however, junior students were less satisfied with the supervision than the more senior students with more experience of community-based training. Although many supervisors assisted students before departure to COBERS sites, a significant number of supervisors made little follow-up while students were in the community. Incorporating the use of information technology avenues such as emails and skype sessions was suggested as a potential way of enhancing supervision amidst resource constraints without faculty physically visiting the sites. CONCLUSIONS: Although many students were satisfied with COBERS supervision, there are still some challenges, mostly seen with the more junior students. Using information technology could be a solution to some of these challenges.

Assessing community perspectives of the community based education and service model at Makerere University, Uganda: a qualitative evaluation.

BACKGROUND: Community partnerships are defined as groups working together with shared goals, responsibilities, and power to improve the community. There is growing evidence that these partnerships contribute to the success and sustainability of community-based education and service programs (COBES), facilitating change in community actions and attitudes. Makerere University College of Health Sciences (MakCHS) is forging itself as a transformational institution in Uganda and the region. The College is motivated to improve the health of Ugandans through innovative responsive teaching, provision of service, and community partnerships. Evaluating the COBES program from the community perspective can assist the College in refining an innovative and useful model that has potential to improve the health of Ugandans. METHODS: A stratified random sample of 11 COBES sites was selected to examine the community's perception of the program. Key Informant Interviews of 11 site tutors and 33 community members were completed. The data was manually analyzed and themes developed. RESULTS: Communities stated the students consistently engaged with them with culturally appropriate behaviour. They rated the student's communication as very good even though translators were frequently needed. Half the community stated they received some feedback from the students, but some communities interpreted any contact after the initial visit as feedback. Communities confirmed and appreciated that the students provided a number of interventions and saw positive changes in health and health seeking behaviours. The community reflected that some programs were more sustainable than others; the projects that needed money to implement were least sustainable. The major challenges from the community included community fatigue, and poor motivation of community leaders to continue to take students without compensation. CONCLUSIONS: Communities hosting Makerere students valued the students' interventions and the COBES model. They reported witnessing health benefits of fewer cases of disease, increased health seeking behavior and sustainable healthcare programs. The evidence suggests that efforts to standardize objectives, implement structural adjustments, and invest in development of the program would yield even more productive community interactions and a healthcare workforce with public health skills needed to work in rural communities.

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.

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.

Expiry of medicines in supply outlets in Uganda.

PROBLEM: The expiry of medicines in the supply chain is a serious threat to the already constrained access to medicines in developing countries. APPROACH: We investigated the extent of, and the main contributing factors to, expiry of medicines in medicine supply outlets in Kampala and Entebbe, Uganda. A cross-sectional survey of six public and 32 private medicine outlets was done using semi-structured questionnaires. LOCAL SETTING: The study area has 19 public medicine outlets (three non-profit wholesalers, 16 hospital stores/pharmacies), 123 private wholesale pharmacies and 173 retail pharmacies, equivalent to about 70% of the country's pharmaceutical businesses. Our findings indicate that medicines prone to expiry include those used for vertical programmes, donated medicines and those with a slow turnover. RELEVANT CHANGES: Awareness about the threat of expiry of medicines to the delivery of health services has increased. We have adapted training modules to emphasize management of medicine expiry for pharmacy students, pharmacists and other persons handling medicines. Our work has also generated more research interest on medicine expiry in Uganda. LESSONS LEARNED: Even essential medicines expire in the supply chain in Uganda. Sound coordination is needed between public medicine wholesalers and their clients to harmonize procurement and consumption as well as with vertical programmes to prevent duplicate procurement. Additionally, national medicine regulatory authorities should enforce existing international guidelines to prevent dumping of donated medicine. Medicine selection and quantification should be matched with consumer tastes and prescribing habits. Lean supply and stock rotation should be considered.

Prevalence of borrowing and sharing prescription medicines and associated socio-demographic factors: findings from COBERS health centres in northern Uganda.

BACKGROUND: The use of prescription medications without the involvement of medical professionals is a growing public health concern. Therefore this study was conducted to determine the prevalence of borrowing and sharing prescription medicines and associated socio-demographic factors among community members who had sought health care from COBERS health centres. METHODS: We conducted analytical cross - sectional study among former patients who sought treatment during the two months period prior to data collection in nine COBERS health centres. We used cluster proportional-to-size sampling method to get the numbers of research participants to be selected for interview from each COBERS site and logistic regression model was used to assess the associations. RESULTS: The prevalence of borrowing prescription medication was found to be 35.9% (95% CI 33.5-38.2%) and sharing prescription medication was 32.7% (95% CI 30.4-34.9%). The Socio-demographic factors associated with borrowing prescription medicines were: age group ≤19 years (AOR = 2.64, 95%CI 1.47-4.74, p-value = 0.001); age group 20-29 years (AOR = 2.78, 95%CI 1.71-4.50, p-value≤0.001); age group 30-39 years (AOR = 1.90, 95%CI 1.18-3.06, p-value = 0.009); age group 40-49 (AOR = 1.83, 95%CI 1.15-2.92, p-value = 0.011); being a female (AOR = 2.01, 1.58-2.55, p-value< 0.001); being a Pentecostal by faith (AOR = 1.69, 95%CI 1.02-2.81, p-value = 0.042) and being Employed Salary Earner (AOR = 0.44, 95%CI 0.25-0.78, p-value = 0.005). The socio-demographic factors associated with sharing prescription medicines were: age group ≥19 years (AOR = 4.17, 95%CI 2.24-7.76, p-value< 0.001); age group 20-29 years (AOR = 3.91, 95%CI 2.46-6.29, p-value< 0.001); age group 30-39 years (AOR = 2.94, 95%CI 2.05-4.21, p-value< 0.001); age group 40-49 years (AOR = 2.22, 95%CI 1.29-3.82, p-value = 0.004); being female (AOR = 2.50, 95%CI 1.70-3.47, p-value< 0.001); being Pentecostal by faith (AOR = 2.15, 95%CI 1.15-4.03, p-value = 0.017); and being engaged in business (AOR = 1.80, 95%CI 1.16-2.80, p-value = 0.009). CONCLUSION: A high proportion of study participants had borrowed or shared prescription medicines during the two months prior to our study. It is recommended that stakeholders sensitise the community members on the danger of borrowing and sharing prescription medicines to avert the practice.

Health-profession students' teaching and learning expectations in Ugandan medical schools: pre- and postcommunity placement comparison.

PURPOSE: The benefits of community-based medical education for both students and teachers are becoming increasingly clear. However, there is paucity of information about the importance of incorporating students' thoughts in the community-based education curriculum and the impact it has on their intentions to work in rural communities. The purpose of this study was to assess the teaching and learning expectations before and after placement of health-profession students going for community placement for the first time and make suggestions for improvement of the community-based programs. METHODS: The study was a cross-sectional survey with both structured and unstructured questions. Participants were recruited from four medical schools in Uganda targeting 100% participation of health-profession students going for community placement in 2014. In total, 454 and 305 participants responded to self-administered questionnaires before and after community placement, respectively; and they were from different programs and years of study. RESULTS: Students' learning expectations before placement, in ranking were: community engagement, interpersonal skills, community diagnosis, clinical skills, lifestyle practices, and patient management. After placement, the order of ranking was: interpersonal skills, community engagement, community diagnosis, lifestyle practices, clinical skills, and patient management. Most of the students had prior rural exposure and expected to do community engagement. However, after community placement they indicated having developed interpersonal skills. The various health-profession students were able to harmoniously work together to achieve a common purpose, which they find difficult to do in a classroom environment. CONCLUSION: Having student teams comprised of different health programs and years of study going for community placement together promoted peer-to-peer mentorship and enhanced team building during community placement.