Overall, there were 104 respondents; 80 (76.9%) were primary care health workers, 17 (16.3%) specialists and 7 (6.7%) health care planners. Among the primary care workers, majority were clinical officers (47.3%) followed by registered nurses (18.8%). The details of the demographic characteristics of the respondents are provided in Table 1. It was not possible to ascertain the response rate because various methods were used to seek respondents including social media.
Table 1: Demographic characteristics of respondents (N=104)
Characteristic
|
Number (n)
|
Percentage (%)
|
Gender
|
Male
|
58
|
55.8
|
|
Female
|
45
|
43.3
|
|
Gender not indicated
|
1
|
0.9
|
Specialist Clinicians (n=17)
|
Pulmonologists
|
2
|
11.8
|
|
Internists
|
11
|
64.7
|
|
Pediatricians
|
1
|
5.9
|
|
*Other
|
3
|
17.6
|
Primary Care Clinicians (n=80)
|
Medical officers
|
3
|
3.8
|
|
Clinical officers
|
36
|
45.0
|
|
Midwife (degree level)
|
1
|
1.3.0
|
|
Registered Nurse
|
15
|
18.8
|
|
Enrolled Nurse
|
10
|
12.5
|
|
Enrolled midwife
|
3
|
3.8
|
|
*Other
|
7
|
9.5
|
Health Care Planners (n=7)
|
District Health Officers
|
3
|
42.9
|
|
Hospital Directors
|
1
|
14.2
|
|
Head of Department in academic institutions
|
3
|
42.9
|
|
|
|
|
Total
|
|
104
|
|
*Others included Public Health Specialists, Distr
Burden of respiratory diseases in primary care facilities
Over 90% of the clinicians (primary care health workers and specialists) reported that they frequently see patients with respiratory diseases during their day-to-day work, with majority (58%) of them indicating that at least 6 of every 10 patients present with respiratory symptoms. Similarly, the health care planners indicated that many of the patients that present in the health facilities have respiratory symptoms. Non-communicable chronic respiratory diseases such as asthma were among the top five diseases seen in primary care settings. Interestingly, COPD, which is one of the common chronic respiratory diseases and contributing significantly to mortality, was not mentioned among the five most common diseases indicating likely under-diagnosis.
Knowledge and skills of primary care health workers
When the primary care health workers were asked about how comfortable they were in diagnosing and managing respiratory diseases, only 8% indicated that they were very comfortable in doing so. More than half (52%) of the respondents indicated that they were not comfortable in diagnosing and managing respiratory diseases (Figure 1). The greatest challenges were for chronic respiratory diseases particularly COPD and asthma.
Similarly, very few primary care health workers (4%) indicated that they were comfortable to perform common procedures for diagnosis and management of respiratory conditions like pulse oximetry, nebulization, giving oxygen, performing and interpreting Mantoux test, interpreting spirometry results, demonstrating how to use a spacer and measuring Peak Expiratory Flow Rate (PEFR).
Opportunities for in-service training
The majority (75%) of the primary care health workers had received in-service training in the three years prior to the survey. However, only 4% of the respondents had received any form of in-service training on chronic respiratory diseases. Specifically, none of the respondents had received any training in COPD or lung cancer screening. Interestingly, more than half of the respondents had received training in communicable respiratory diseases such as tuberculosis.
When the respondents were asked about training in other competences which are critical in improving quality of care, such as chronic care, team-based care, communication and patient-centered care, only 5.5% had received training in any one of these areas.
The responses of the health care planners correlated with those of the health workers, with 71% of them indicating that they had provided in-service training opportunities for their staff, but none of them focused on chronic respiratory diseases.
Referral practices for patients with respiratory diseases
The findings showed that the patients that primary care health workers commonly refer to specialists are quite diverse, with both communicable and non-communicable diseases such as TB (15.3%), pneumonia (10.5%), COPD (46%), asthma (14.4%) and bronchiectasis (32.8%). However, when the specialists were asked about the type of patients that are referred to them, 72% of them indicated that many of the referrals from primary care were unnecessary because they could be managed at that level. Specifically, the specialist indicated that majority of the patients with asthma could be managed in primary care settings if the health workers were given the necessary competencies.
Barriers to care of patients with respiratory illnesses
The major barriers to provision of quality care to patients with respiratory illnesses were pervasive and diverse, and included: inadequate knowledge and skill of health workers, inadequate diagnostics, drugs and equipment, lack of opportunities for in-service training, inadequate staffing, inadequate supervision and heavy workload. Similar views were echoed by the healthcare planners and specialist clinicians.
Pre-service training programmes
The primary care health workers were asked about their views on the pre-service training they received from the training institutions and how much it prepared them for the clinical care that they are expected to provide. More than half (58%) indicated that their basic training was insufficient, and that they needed further training to be able to competently manage the patients with respiratory diseases.
In-service respiratory medicine training
All the three categories of respondents (primary care health workers, specialist clinicians and health care planners) indicated that the training of primary care health workers in respiratory medicine was important, with more than half of them indicating that it was extremely important (Figure 2).
urthermore, the health workers indicated that they needed training in majority of the respiratory diseases and procedures, with the following areas being ranked highest; COPD, Asthma, bronchitis, pneumonia, reading and interpreting chest x-rays and administering inhaled medicines.
The specialist clinicians also resonated with the primary care health workers by indicating that the training would be extremely beneficial, not only to the primary care clinicians but also to the specialists. Such benefits included; reduction in unnecessary referrals and hence workload, fewer patients who are referred late, and improvement in patient outcomes.
The specialists further highlighted specific areas which they thought the primary care workers needed training; clinical evaluation skills, interpretation of imaging tests, spirometry, respiratory pharmacology, recognizing emergencies and providing pre-referral care, non-pharmacological treatment such as nutrition and chronic care. In addition to the above areas, the policy makers suggested training in disease prevention, patient education and appropriate referrals for patients with respiratory diseases.
The respondents further suggested that a hybrid model of the training programme would be the best option for them. This would involve 3-5 days of course work at Makerere University Lung Institute, followed by self-directed learning at their work stations, supported by mentorship visits from the course instructors.
Findings from pre-service training curricula
- Nurses and midwives: The curriculum for nursing and midwifery pre-service training largely focuses on their primary roles of nursing and midwifery, with very minimal coverage on clinical aspects addressing diagnosis and management of disease conditions. For example, only about 1.3% of the entire 4-years Bachelor of Science in Nursing curriculum has some elements on lung health care
- Clinical officers: The curriculum for clinical officers showed that during their three-year course, they are expected to cover both the theoretical and practical aspects of medical care. The scope of the training includes; history taking and performing a general and systemic examination, diagnosis of medical conditions, and interpreting laboratory and radiological results. Regarding respiratory conditions, the curriculum covers history taking, general and respiratory examination, diagnosis and management of respiratory diseases such as pneumonia, tuberculosis, asthma, bronchiolitis, COPD, Pleurisy/pleural effusion and suppurative lung diseases (bronchiectasis, lung abscess and empyema thoracis), and the relevant equipment for management of these conditions. In addition, there are course units in applied microbiology, pathology and pharmacology of the respiratory system. To a large extent, the emphasis is acute and tropical respiratory illness
- Medical officers: The training for medical officers covers a wide range of aspects that would be necessary for the management of patients with respiratory symptoms. They include basic science in the physiology, anatomy, pathology, pharmacology and microbiology of respiratory system. In addition, they are trained in practical skills of history taking, physical examination, investigations and management of patients. The curriculum also covers important aspects of patient care such as communication, health systems management and chronic care.
Patients’ experiences and views about quality of care
When patients were asked about their experiences during the first visit to a primary care facility for respiratory complaints, many of them indicated that they were not satisfied with the outcome. Some of them were diagnosed with malaria and given antimalarial medicines despite having expressed their respiratory symptoms, while others thought the consultation was very brief and inadequate, and that the medicines they were given did not help them at all. Many patients were not informed about their diagnosis, and were only given medicines, some of which they had used before visiting the health facility. Multiple visits to the health facilities before arriving at a diagnosis were also reported and this was noted to have been a strain to their financial resources, time and was quite frustrating. It was not until they were referred to the specialists that they were able to understand the diagnosis and get the right treatment. These observations were irrespective of the type or cadre of primary care provider seen before going to the specialist.