Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll

BACKGROUND

Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017.

METHODS

We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers.

RESULTS

At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future.

CONCLUSIONS

Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.

Podoconiosis instruction at nursing schools in Kenya, Rwanda, and Uganda

BACKGROUND

Podoconiosis is a preventable, progressive, and non-infectious form of elephantiasis that can contribute to significant disability and economic burden when not treated early. Nurses play a critical role in early detection and response in rural Africa, but it is unclear if they receive adequate training on podoconiosis. We aimed to characterize podoconiosis instruction at all government accredited, post-secondary nursing institutions in three African countries.

METHODS

Data for this cross-sectional study was collected through a quantitative survey with several open-answer questions. Through a rigorous online search, we identified all post-secondary institutions in Kenya, Rwanda and Uganda accredited to teach human nursing. A total of 289 accredited programs, including 85 certificate, 56 degree and 148 diploma programs were invited to participate. Respondents completed surveys online or by telephone. Measures focused on podoconiosis knowledge, perceptions of quality/quantity of podoconiosis instruction, and barriers to sufficient podoconiosis education.

RESULTS

We obtained information about 212 curricula across 149 nursing institutions in the three countries (participation rate: 73.4%). Podoconiosis coverage was limited across programs (certificate-24.1%; diploma-55.6%; degree-30.3%). Most respondents felt that the quality and quantity of instruction were insufficient (60.6%, 62.9%), respectively. Exclusion from government curricula, low priority and faculty lack of knowledge were commonly reported barriers to podoconiosis inclusion.

CONCLUSIONS

This study demonstrated clear gaps in podoconiosis training for nurses across the three countries and highlights a serious challenge in eliminating podoconiosis as a public health problem. Interventions to improve nurses' knowledge could include the development and free distribution of podoconiosis teaching materials, designed for integration into pre-existing courses.

Provider perspectives on the acceptability and tolerability of dolutegravir-based anti-retroviral therapy after national roll-out in Uganda: a qualitative study

BACKGROUND

The World Health Organization recommends dolutegravir (DTG) as the for first-line and second-line antiretroviral therapy (ART) worldwide. However, little is known about the acceptability and tolerability of DTG-based ART at routine points-of-care in Uganda. We set out to explore the perceptions of clinicians in ART clinics regarding the acceptability and tolerability of DTG-based ART since national roll-out in March 2018 in Uganda.

METHODS

We adopted a qualitative exploratory design involving 49 participants. Between September 2020 and February 2021, we conducted 22 in-depth interviews with clinicians in the ART clinics of 12 purposively selected health facilities across Uganda. The selection of study sites ensured diversity in facility ownership-type (public/private), level of service delivery (tertiary/secondary/primary) and the four major geographic sub-regions of Uganda. We conducted three focus group discussions with 27 clinicians in the participating facilities. Data were analyzed by thematic approach.

RESULTS

Clinicians in ART clinics acknowledged that DTG-based ART is well tolerated by the majority of their patients who appreciate the reduced pill burden, perceived less side effects and superior viral load suppression. However, they reported that a number of their patients experience adverse drug reactions (ADRs) after being transitioned to DTG. Hyperglycemia is, by far, the most commonly reported suspected ADR associated with DTG-based regimens and was cited in all but two participating facilities. Insomnia, weight gain and reduced libido are among the other frequently cited suspected ADRs. In addition, clinicians in ART clinics perceived some of the suspected ADRs as resulting from drug interactions between dolutegravir and isoniazid. Weak diagnostic capacities and shortage of associated commodities (e.g. glucometers and test kits) were reported as impediments to understanding the full extent of ADRs associated DTG-based ART.

CONCLUSION

While DTG-based regimens were perceived by clinicians in ART clinics to be well tolerated by the majority of their patients, they also reported that a number of patients experience suspected ADRs key among which were hyperglycemia, insomnia and reduced libido. Based on the perspectives of clinicians, we recommend that future studies examine the prevalence of dolutegravir-induced hyperglycemia in patients in Uganda.