CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 2, May/June 2023 90 AFRICA Methods The Uganda Heart Institute is a lone cardiovascular centre serving a population of 45 million.10 With a limited number of cardiovascular specialists, training of healthcare workers in the rural areas is critical in the prevention of ARF and RHD. In May 2018, we conducted an assessment of healthcare workers’ knowledge of ARF clinical features and the use of BPG in the treatment of ARF/RHD in the Tororo district, eastern Uganda. This district was chosen because many children from the region presented to our centre with advanced RHD, and there was strong political support from the district leaders. Tororo district is located 200 km from Uganda’s capital, Kampala. It covers an area of 1 192 km² and has a population of 597 500. More than 80% of the population reside in the rural area.11,12 Health services are decentralised within the district and are headed by a district health officer. The district has one general hospital (Tororo Hospital) that provides the highest level of healthcare, and three health centre IVs (Nagongera, Mukuju and Mulanda), 12 health centre IIIs and 33 health centre IIs.13 All the participating health units are owned by the government of Uganda under the supervision of the Ministry of Health. The district’s healthcare work force consists of six medical doctors, 27 medical clinical officers, 30 nursing officers, 22 laboratory technicians, one technologist and support staff (nursing aides, volunteers) at both Tororo Hospital and health centre IVs.11 Only 54.9% of the required health posts in the Tororo district public sector are filled and the district has no specialists.11 All healthcare workers at the Tororo Hospital and the three health centre IVs were offered assessment and training as they are most likely to manage patients with ARF and RHD. Healthcare-provider training was conducted in two phases. Phase 1 (May 2018) included a pre-test, followed by intensive training and administration of a post-training test at the end of the lectures. The intensive training involved lectures by a paediatric cardiologist (JN) and a paediatric cardiology fellow (EN) at each respective facility. Phase 2 of the training was held eight months later (January 2019) at the same health facilities, with the aim of assessing for knowledge retention. The same pre-test was given, followed by refresher lectures. We did not administer a post-test. Healthcare providers who had not participated in phase 1 training were permitted to attend the second training session. Questions were adapted from the RHD Action Needs assessment tool.9 The test included 10 multiple-choice questions with topics ranging from the causative organism for ARF, the age most affected, ARF clinical features, and treatment and prevention of RHD. Diagnostic clinical features included fever, joint pains, joint swelling (mono/polyarthritis) or abnormal movements based on the 2015 modified Jones’ criteria.4 However, our major focus was on assessing knowledge of clinical features of ARF, and the role of BPG in the treatment and prevention of ARF recurrence. To substantiate findings from the pre-training knowledge assessment, medical records were reviewed at the general hospital to assess whether health workers had made a diagnosis of ARF or RHD within the two years prior to the training. The general hospital pharmacy was inspected for the availability of BPG. A radio talk show was also held to raise community awareness of the disease and more specifically, to reach out to healthcare providers who had not received training. The study was conducted within the auspices of the Uganda national rheumatic heart disease registry by the institutional research and ethics committee of Makerere University School of Medicine, reference number: 2013-072, and the Uganda National Council for Science and Technology. Additional administrative clearance and consent were obtained from the Tororo district local government leadership. The training was conducted as routine support supervision by the Uganda Heart Institute as mandated through the Ministry of Health. Statistical analysis The data were entered into an excel sheet (Microsoft Excel 2010) and then analysed using Stata Statistical Software: Release 15 (College Station, TX: Stata Corp LLC). Descriptive statistics are presented using simple percentages. We then compared participants’ knowledge of clinical features of ARF and treatment of ARF immediately pre and post training using the chi-squared test. We also compared the pre-test results at initial training with knowledge at six months using the chi-squared test. Results A total of 109 healthcare providers participated in the pre-test phase 1 training. Of these, 34/109 (31%) were familiar with the clinical features of ARF, whereas 25/109 (23%) had knowledge of the role of BPG. Most of the participants were nurses [51 (47%)], six (5.5%) were doctors, 19 (17%) were clinical officers, and other health cadres. One hundred and twelve participated in the post-test, and of those, 85 (75.8%) passed the post-test in relation to clinical features of ARF (Table 1). There was a significant improvement in the knowledge of clinical features of ARF in phase 1 across all four health centres where training was conducted, as shown by the chi-squared test in Table 1. Level of awareness was lowest among healthcare providers in the most remote health facility (Mulanda health center IV) (Table 1). The level of knowledge of BPG use in ARF was very poor in all health units [25/109 (23%)] but improved after training, with 90/112 (80%) passing the post-test, as shown by the chi-squared test (χ2 = 0.000) in Table 2. One hundred and fifteen healthcare providers were pre-tested during the second phase and only 34/115 (30%) had knowledge of ARF clinical features prior to training. The level of knowledge was not significantly different compared to pre-training (χ2 ≥ 0.2). Twenty-six of the 115 health workers (22.6%) had knowledge of the use of BPG in the treatment of ARF (Table 3). There was no difference in knowledge about BPG use at baseline and at eight months, as shown in Table 3. Table 1. Assessment of knowledge of the clinical features of ARF in phase 1 Health unit Number passed pre-test (total) Number passed post-test (total) χ2 test Nagongera 7 (20) 16 (20) 0.004 Mulanda 5 (23) 13 (21) 0.070 Mukuju 8 (26) 30 (36) 0.000 Tororo 14 (40) 0.0007 Total 34 (109) 85 (112)
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