The workplace as a learning environment: Perceptions and experiences of undergraduate medical students at a contemporary medical training university in Uganda

Background. One of the most effective ways of translating medical theory into clinical practice is through workplace learning, because practice is learnt by practising. Undergraduate medical students at Makerere University College of Health Sciences, Kampala, Uganda, have workplace rotations at Mulago National Referral and Teaching Hospital (MNRTH), Kampala, for the purpose of learning clinical medicine. Objectives. To explore undergraduate medical students’ perceptions and experiences regarding the suitability of MNRTH as a learning environment to produce competent health professionals who are ready to meet the demands of contemporary medical practice, research and training. Methods. This was a cross-sectional study with a mixed-methods approach. Students’ perceptions and experiences were assessed using the Dundee Ready Educational Environment Measure (DREEM), as well as focus group discussions (FGDs). Data from DREEM were analysed as frequencies and means of scores of perceptions of the learning environment. FGD data were analysed using thematic analysis. Results. The majority of students perceived the learning environment as having more positives than negatives. Among the positive aspects were unrestricted access to large numbers of patients and a wide case mix. Negative aspects included overcrowding due to too many students, and inadequate workplace affordances. Conclusions. The large numbers of patients, unrestricted access to patients and the wide case mix created authentic learning opportunities for students – they were exposed to a range of conditions that they are likely to encounter often once they qualify. The areas of concern identified in the study need to be addressed to optimise learning at the workplace for undergraduate medical students

Standardizing assessment practices of undergraduate medical competencies across medical schools: challenges, opportunities and lessons learned from a consortium of medical schools in Uganda

Introduction: health professions education is gradually moving away from the more traditional approaches to new innovative ways of training aimed at producing professionals with the necessary competencies to address the community health needs. In response to these emerging trends, Medical Education for Equitable Services to All Ugandans (MESAU), a consortium of Ugandan medical schools developed key competencies desirable of graduates and successfully implemented Competency Based Education (CBE) for undergraduate medical students. Objectives: to examine the current situation and establish whether assessment methods of the competencies are standardized across MESAU schools as well as establish the challenges, opportunities and lessons learned from the MESAU consortium. Methods: it was a cross-sectional descriptive study involving faculty of the medical schools in Uganda. Data was collected using focus group discussions and document reviews. Findings were presented in form of themes. Results: although the MESAU schools have implemented the developed competencies within their curricular, the assessment methods are still not standardized with each institution having its own assessment procedures. Lack of knowledge and skills regarding assessment of the competencies was evident amongst the faculty. The fear for change amongst lecturers was also noted as a major challenge. However, the institutional collaboration created while developing competencies was identified as key strength. Conclusion: findings demonstrated that despite having common competencies, there is no standardized assessment blue print applicable to all MESAU schools. Continued collaboration and faculty development in assessment is strongly recommended

Environmentalism, performance and applications: uncertainties and emancipations

This introductory article for a themed edition on environmentalism provides a particular context for those articles that follow, each of which engages with different aspects of environmentalism and performance in community-related settings. Responding to the proposition that there is a lacuna in the field of applied drama and environmentalism (Bottoms, 2010), we suggest that the more significant lack is that of ecocriticism. As the articles in this journal testify, there are many examples of applied theatre practice; what is required is sustained and rigorous critical engagement. It is to the gap of ecocriticism that we address this issue, signalling what we hope is the emergence of a critical field. One response to the multiple challenges of climate change is to more transparently locate the human animal within the environment, as one agent amongst many. Here, we seek to transparently locate the critic, intertwining the personal – ourselves, human actants – with global environmental concerns. This tactic mirrors much contemporary writing on climate change and its education, privileging personal engagement – a shift we interrogate as much as we perform. The key trope we anchor is that of uncertainty: the uncertainties that accompany stepping into a new research environment; the uncertainties arising from multiple relations (human and non-human); the uncertainties of scientific fact; the uncertainties of forecasting the future; and the uncertainties of outcomes – including those of performance practices. Having analysed a particular turn in environmental education (towards social learning) and the failure to successfully combine ‘art and reality’ in recent UK mainstream theatre events, such uncertainties lead to our suggestion for an ‘emancipated’ environmentalism. In support of this proposal, we offer up a reflection on a key weekend of performance practice that brought us to attend to the small – but not insignificant – and to consider first hand the complex relationships between environmental ‘grand narratives’ and personal experiential encounters. Locating ourselves within the field and mapping out some of the many conceptual challenges attached to it serves to introduce the territories which the following journal articles expand upon

Dramatic and sustained increase in HIV-testing rates among antenatal attendees in Eastern Uganda after a policy change from voluntary counselling and testing to routine counselling and testing for HIV: a retrospective analysis of hospital records, 2002-2009

<p>Abstract</p> <p>Background</p> <p>The burden of mother-to-child transmission of HIV in Uganda is high. The aim of this paper is to describe the experience of the first 7 years of the prevention of mother- to- child transmission of HIV (PMTCT) programme in Mbale Regional Hospital, Eastern Uganda, with particular reference to the lessons learnt in changing from voluntary counselling and testing (VCT) to routine counselling and testing (RCT) for HIV testing in antenatal services.</p> <p>Methods</p> <p>The study was a retrospective analysis of the PMTCT records of Mbale Regional Referral Hospital, Uganda, from May 2002 to April 2009. The data on HIV testing of pregnant women and their male partners was extracted from the reports and registers using a standardized data extraction form, and data was analysed using descriptive statistics. Permission to conduct the study was obtained from School of Medicine, Makerere University College of Health Sciences; Uganda National Council of Science and Technology, and Mbale Hospital.</p> <p>Results</p> <p>A total of 54 429 new antenatal (ANC) attendees and 469 male-partners accessed antenatal services at Mbale Regional Referral Hospital. There was a sustained, significant increase in HIV testing among new ANC attendees from 22% during the VCT period to 88% during the RCT period (<it>p </it>= 0.002), while among male partners, HIV testing increased from 88% to 100% (<it>p </it>= 0.010) However, the overall number of male partners who tested for HIV remained very low despite the change from VCT to RCT approach in HIV testing.</p> <p>Conclusions</p> <p>Routine offer of antenatal HIV testing dramatically increased HIV testing in pregnant women and their partners in Uganda. Our findings call for further strengthening of the policy for routine HIV testing in antenatal clinics. Our study also showed that male partner HIV testing in antenatal clinics is low and this area needs further work through research and innovative interventions in order to improve male partner involvement.</p

Skin-to-skin contact after birth : Developing a research and practice guideline

Funding Information: Funding for the two in‐person meetings (one of the Steering Group and one of the Expert Panel) was provided through a grant from Healthy Children Project, Inc., a not‐for‐profit (501c3) non‐governmental organisation (NGO) located in the United States. Publisher Copyright: © 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica. © 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.Aim: Skin-to-skin contact immediately after birth is recognised as an evidence-based best practice and an acknowledged contributor to improved short- and long-term health outcomes including decreased infant mortality. However, the implementation and definition of skin-to-skin contact is inconsistent in both practice and research studies. This project utilised the World Health Organization guideline process to clarify best practice and improve the consistency of application. Methods: The rigorous guideline development process combines a systematic review with acumen and judgement of experts with a wide range of credentials and experience. Results: The developed guideline received a strong recommendation from the Expert Panel. The result concluded that there was a high level of confidence in the evidence and that the practice is not resource intensive. Research gaps were identified and areas for continued work were delineated. Conclusion: The World Health Organization guideline development process reached the conclusion immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 g with experienced staff if assistance is needed), after all modes of birth. Delaying non-essential routine care in favour of uninterrupted skin-to-skin contact after birth has been shown to be safe and allows for the progression of newborns through their instinctive behaviours.Peer reviewe

Pregnancy outcomes after first-trimester treatment with artemisinin derivatives versus non-artemisinin antimalarials: A systematic review and individual patient data meta-analysis

Background Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisinin-based combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisinin-based treatment (ABT) versus non-ABTs in the first trimester of pregnancy. Methods For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. Findings We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5·7%) of 736 ABT-exposed pregnancies compared with 96 (8·9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0·71, 95% CI 0·49–1·03). Similar results were seen for the individual components of miscarriage (aHR=0·74, 0·47–1·17), stillbirth (aHR=0·71, 0·32–1·57), and major congenital anomalies (aHR=0·60, 0·13–2·87). The risk of adverse pregnancy outcomes was lower with artemether–lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4·8%] of 524 vs 84 [9·2%] of 915; aHR 0·58, 0·36–0·92). Interpretation We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether–lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether–lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether–lumefantrine is unavailable, other ACTs (except artesunate–sulfadoxine–pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted

Are women in Uganda gaining adequate gestational weight? A prospective study in low income urban Kampala

Abstract Background Pre-pregnancy weight and weight gained during pregnancy significantly influence maternal and infant health. Little information is available regarding optimal gestational weight gain (GWG) in relation to pre-pregnancy body mass index (BMI) in Uganda. The study aimed at determining gestational weight gain (GWG) in women pregnant for the first and second time. Methods The study was prospective cohort study which included 221 HIV negative women pregnant for the first or second time. It was conducted in the antenatal clinic of the directorate of gynecology and obstetrics, Mulago hospital and women were recruited at ≤18 weeks of gestation by dates. Follow up measurements were done at 26 and 36 weeks gestation. Measured maternal height and reported pre-pregnancy weight were used to calculate BMI. Depending on BMI category, GWG was categorized as inadequate, adequate and excessive based on the Uganda Ministry of Health guidelines. Results The participants’ mean ± standard deviation (Sd) age was 20.9 ± 2.7 years and mean ± Sd BMI was 21.40 ± 2.73 kg/m2. None of the participants was obese and 68.8% (n = 132) were pregnant for the first time. The mean ± Sd GWG at time of delivery was 10.58 ± 2.44 kg. Inadequate GWG was recorded in 62.5% (n = 120/192) while only 3.1% (n = 6/192) of the participants gained excessive weight during pregnancy. Conclusion About 62% of pregnant women in Kampala did not gain adequate weight during their first/second pregnancy. We recommend that studies be carried out to assess whether the Uganda Ministry of Health recommendations for weight gain during are appropriate for preventing adverse pregnancy outcomes across populations in Uganda

Cervicovaginal Bacteriology and Antibiotic Sensitivity Patterns among Women with Premature Rupture of Membranes in Mulago Hospital, Kampala, Uganda: A Cross-Sectional Study

Background. A 2013 Cochrane review concluded that the choice of antibiotics for prophylaxis in PROM is not clear. In Uganda, a combination of oral erythromycin and amoxicillin is the 1st line for prophylaxis against ascending infection. Our aim was to establish the current cervicovaginal bacteriology and antibiotic sensitivity patterns. Methods. Liquor was collected aseptically from the endocervical canal and pool in the posterior fornix of the vagina using a pipette. Aerobic cultures were performed on blood, chocolate, and MacConkey agar and incubated at 35–37°C for 24–48 hrs. Enrichment media were utilized to culture for GBS and facultative anaerobes. Isolates were identified using colonial morphology, gram staining, and biochemical analysis. Sensitivity testing was performed via Kirby-Bauer disk diffusion and dilution method. Pearson’s chi-squared (χ2) test and the paired t-test were applied, at a P value of 0.05. Results. Thirty percent of the cultures were positive and over 90% were aerobic microorganisms. Resistance to erythromycin, ampicillin, cotrimoxazole, and ceftriaxone was 44%, 95%, 96%, and 24%, respectively. Rupture of membranes (>12 hrs), late preterm, and term PROM were associated with more positive cultures. Conclusion. The spectrum of bacteria associated with PROM has not changed, but resistance to erythromycin and ampicillin has increased

Knowledge of danger signs during pregnancy and subsequent healthcare seeking actions among women in Urban Tanzania: a cross-sectional study

Abstract Background Tanzania is among the countries with a high maternal mortality ratio. However, it remains unclear how information and education on danger signs of pregnancy translate into appropriate actions when a woman recognizes danger signs. This study aimed to determine women’s knowledge of obstetric danger signs during pregnancy and their subsequent healthcare seeking actions. Methods The study design was a health facility-based cross-sectional study. Quantitative data were collected through interviewer-administered questionnaires. Descriptive and inferential statistics were used to analyze the data. The study enrolled 384 women from two health centers in Kinondoni Municipality, Dar es Salaam, Tanzania. A woman who had not mentioned any danger sign was categorized as having no knowledge, mentioned one to three danger signs as having low knowledge, and mentioned four or more danger signs as having sufficient knowledge. Results Among the 384 participants, 67 (17.4%) had experienced danger signs during their pregnancy and reported their healthcare seeking actions after recognizing the danger signs. Among those who recognized danger signs, 61 (91%) visited a healthcare facility. Among the 384 participants, five (1.3%) had no education, 175 (45.6%) had primary education, 172 (44.8%) had secondary education, and 32 (8.3%) had post-secondary education as their highest educational levels. When asked to spontaneously mention the danger signs, more than half of the participants (n = 222, 57.8%) were able to mention only one to three danger signs. Only 104 (31%) had correct knowledge of at least four danger signs and nine (2.7%) were not able to mention any item. The most commonly known pregnancy danger signs were vaginal bleeding (81%); swelling of the fingers, face, and legs (46%); and severe headache (44%). Older women were 1.6 times more likely to have knowledge of danger signs than young women (OR 1.61; 95% CI 1.05-2.46)”. Conclusion Women took appropriate healthcare seeking action after recognizing danger signs during pregnancy. However, the majority had low knowledge of pregnancy danger signs. Additional studies are warranted to address the knowledge gap and to plan interventions for improving health education under limited resource settings