Training-of-Trainers Participants
A total of 10 participants completed the ToT courses. There were three participants from Tanzania, all participants had previously taken the WHO BEC course and worked in the emergency unit at Muhimbili National Teaching Hospital in Dar es Salaam, two as nurses and one doctor. In Uganda seven participants were trained who also had taken the BEC pilot course.
BEC Course Participants
A total of 59 participants completed the BEC courses. 46% of participants were nurses, 32% doctors, and 22% other cadres (Fig. 2). Overall course attendance, taken daily, was 97%.
Uganda Participant Characteristics |
Role | Kawolo District Hospital | Mubende Regional Referral Hospital |
Enrolled Nurse | 3 | 2 |
Nursing Officer | 4 | 5 |
Medical Officer | 3 | 3 |
Total | 10 | 10 |
|
Tanzania Participant Characteristics |
Role | Kisaware District Hospital | Bagamoyo District Hospital |
Medical Attendant | 7 | 0 |
Nurse (officer, enrolled) | 7 | 6 |
Clinical Officer | 2 | 6 |
General Doctor | 3 | 2 |
Nurse Midwife | 1 | 0 |
Other (radiographer, dental surgeon, lab tech, pharmacist, nurse anaesthetist) | 0 | 5 |
Total | 20 | 19 |
[Figure 2: Trainee Roles] |
Multiple Choice Assessment |
Post-test score improvement was statistically significant at all sites, ranging from a 10.8 to 28-point absolute increase on a 100-point scale, an average improvement of 18.8 percentage points (Fig. 3). Two participants did not complete both the pre- and post-test and were excluded from analysis. The largest improvement in test scores was seen at Bagamoyo District Hospital. |
Multiple Choice Assessments |
Site | n | Pre-Test | Post-Test | Difference | 95% CI | P value |
Kawolo | 10 | 70.0 | 80.8 | 10.8 | 5.4–16.2 | 0.0014 |
Mubende | 10 | 68.4 | 82.0 | 13.6 | 7.2–20.0 | 0.0009 |
Kisaware | 19 | 47.4 | 70.1 | 22.7 | 14.7–30.8 | < 0.0001 |
Bagamoyo | 18 | 47.1 | 75.1 | 28 | 20.9–35.1 | < 0.0001 |
Confidence Ratings |
Site | n | Pre | Post | Difference | 95% CI | P value |
Kawolo | 12 | 2.87 | 3.92 | 1.05 | 0.95–1.15 | < 0.0001 |
Mubende | 10 | 3.30 | 3.81 | 0.51 | 0.39–0.63 | < 0.0001 |
Kisaware | 20 | 3.24 | 3.63 | 0.39 | 0.21–0.55 | 0.0005 |
Bagamoyo | 19 | 2.88 | 3.88 | 1.00 | 0.88–1.12 | < 0.0001 |
[Figure 3: Knowledge Assessment Test Scores and Emergency Care Skills Confidence Scores] |
Confidence Rating |
Confidence in emergency care skills also improved significantly at all sites with an average improvement of 0.74 and ranging from a 0.39–1.05 absolute increase on a 4-point scale (Fig. 3). The largest improvements were seen at Kawolo and Bagamoyo. Improvement was observed across all topics, with the strongest being in the evaluation of a patient with altered mental status and in skills to manage an obstructed airway. This improvement achieved statistical significance for all but two questions (emergency management of the injured adult and skills to immobilise patients). The change in confidence score by question across all sites is shown in Fig. 4. |
Question | Pre (4 site average) | Post (4 site average) | Difference | 95% CI | P value |
Emergency management of the acutely ill adult | 3.06 | 3.86 | 0.79 | 0.56–1.02 | 0.0016 |
Emergency management of the acutely ill child | 3.07 | 3.86 | 0.79 | 0.19–1.40 | 0.0253 |
Emergency management of the injured adult | 3.14 | 3.833 | 0.70 | -0.06-1.45 | 0.0611 |
Emergency management of the injured child | 3.00 | 3.78 | 0.78 | 0.04–1.52 | 0.044 |
Emergency management of the patient with Shock | 3.19 | 3.90 | 0.71 | 0.11–1.31 | 0.0332 |
Emergency management of the patient with altered mental status | 2.85 | 3.72 | 0.87 | 0.06–1.69 | 0.042 |
Emergency management of the patient with difficulty in breathing | 3.24 | 3.93 | 0.70 | 0.19–1.20 | 0.0223 |
Understanding of emergency drugs | 3.09 | 3.74 | 0.65 | 0.20–1.10 | 0.02 |
Have skills to manage an obstructed (blocked) airway | 2.83 | 3.69 | 0.87 | 0.33–1.41 | 0.0143 |
Have skills to manage a patient with difficulty breathing | 3.148 | 3.86 | 0.71 | 0.23–1.19 | 0.0178 |
Have skills to manage a patient with bleeding problems | 3.25 | 3.86 | 0.61 | 0.20–1.02 | 0.0179 |
Have the skills to immobilise patients | 3.03 | 3.68 | 0.65 | -0.42-1.72 | 0.15 |
Figure 4: Change in Confidence Scores by Question Across All Sites |
Qualitative Themes/Responses |
Course Feedback: |
86% (51/59) participated in the post-course survey. 95% (19/20) of participants from Uganda returned feedback on the overall course and 82% (32/39) participants from Tanzania provided post-course feedback. Major themes included: (1) what the participants liked about the course, (2) what they learned in the course, (3) what they would change in the course, and (4) who they would recommend the course to. |
What they liked: 39.2% of participants (20/51) enjoyed the course and stated that they most enjoyed the skills aspect of the training. Many also stated that they liked the modules and knowledge that was provided with some specifically liking the topic of the ABCDE approach. Others enjoyed how the course was facilitated as well as the materials provided. A few appreciated that the course was taught in both Swahili and English at the Tanzania sites. Comments included:
“It is a comprehensive course and it has equipped me with skills in managing emergency cases using the ABCDE approach” – Clinical officer, Kawolo, Uganda
“Demonstration of all procedures was very interesting and I have understood well. Also class sessions I have understood and was excellent. Facilitators are very competent with what they are teaching” – Pharmacist, Bagamoyo, Tanzania
What they learned:
Most participants stated that they learned the ABCDE (43%, 22/51) and SAMPLE (25%, 13/51) approach in the course. Immobilization, shock and general skills and knowledge in taking care of the emergency patient was the next most cited area of learning from the course followed by topics of trauma, wound care and airway management. Comments included:
“All emergencies should be approached following ABCDE, SAMPLE history and secondary survey. Any life threatening conditions discovered in ABCDE should be handled immediately” – Clinical Officer, Mubende, Uganda
“I learned how to manage emergencies using ABCDE approach; I learned how to use SAMPLE approach in history taking; Learned the importance of Triage in a health setting; Learned the common drugs in emergency; I also learned the importance of proper hand over” – Medical Officer, Kawolo, Uganda
“I learned different skills like management of shock, obstructed airway, burn, emergency drugs. Also I learned to have unit/solidarity to the facilitate also to protect myself from infections. Sharing ideas with others.” Pharmacist, Bagamoyo, Tanzania
What they would change:
The most frequent suggestion for improvement was increased time for the course (21.5%, 11/51) while many others stated that they would not change anything about the course (13.7%, 7/51). Other suggestions for course changes included training more people, sessions on ectopic pregnancy and other obstetric topics, and more skills sessions. Comments included:
“The time has to at least go for more than these days because participants need more practice of skills before taking up the duties on the patients” – Nursing Officer, Mubende, Uganda
“Increase course duration – BEC should be conducted several times” – Nurse, Kisarawe, Tanzania
Who they would recommend the course to:
Most participants felt that this training should be provided to all health providers including nurses and doctors. Many also stated that police officers should also receive this training (17.6% 9/51). Others stated that all support staff such as security, cleaners, and administrators should take this course. Comments included:
“Yes; all health workers from the gate man, receptionists, nurses, all clinicians + administrator to learn at least the basics” – Nursing Officer, Kawolo, Uganda
“Yes; All health workers; police men/traffic officer; taxi drivers & boda boda driver; the general public should be sensitized about this” – Orthopedic Officer, Kawolo, Uganda
Overall, the course was well-received by the participants at both the Uganda and Tanzania sites. Some comments from participants included:
“This course has been an eye opener to me because I didn’t know the airway is very important and now am going to give a CME to all the people I work with on the primary approach of ABCDE 1st” – Nursing Officer, Kawolo, Uganda
“Thank you very much for this Basic emergency course. We are going to put what we have learnt into action in our hospital” - Enrolled Nurse, Kawolo, Uganda
“Am thankful for the opportunity given to train in this course and it has helped to improve my knowledge, skills and emergency in the execution of my day to day nursing clinic” - Nursing Officer, Kawolo, Uganda
“It has been a good course cause it has changed a lot about my attitude and being the fact that among the first to be trained with it” – Enrolled nurse, Kawolo, Uganda
“Thanks for the lesson and demonstration. Plan for next time after one year if possible plan another lesson – not in Bagamoyo” – Nursing Officer, Bagamoyo, Tanzania
Costs
10 trainers were trained at an average cost of United States Dollar (USD) $251 per participant (range $228–273). 59 health care providers were trained at an average cost of $240 per participant (range $161–365). The average overall site cost was $1,208 (range $820–1596) for the ToT course and $3,424 (range $1,616-4,419) for the BEC course. Major budget components were for meals (25.9% of total budget for ToT and 34% for BEC), and daily per-diem reimbursement for the attendees (41.2% for ToT and 18.4% for BEC), and local trainers (16.6% for ToT and 15.4% for BEC). (Fig. 5) Skills equipment was loaned for free from local emergency care agencies, and space was donated at some sites but required payment at others. Printing was a nominal cost.
| ToT | BEC |
Uganda | Tanzania | Uganda | Tanzania |
Kawalo | Mubende | Kisarawe | Bagamoyo |
Cost Per Participant (Average) | 228 | 273 | 365 | 161 | 200 | 232 |
Overall Site Cost (Average) | 1596 | 820 | 3659 | 1616 | 4002 | 4419 |
Meals | 426 | 200 | 1588 | 645 | 874 | 1613 |
Per-diems (participants) | 700 | 300 | 223 | 223 | 1066 | 1013 |
Per-diem (local faculty) | 200 | Included in Tanzania faculty costs | 109 | 109 | 968 | 931 |
Space, Equipment, Projector, Airtime | in-kind | 30 | 447 | in-kind | 269 | 451 |
Printing | Included in Uganda BEC costs | Included in Tanzania BEC costs | 215 | 215 | 315 | 16 |
Local Transport | 0 | 20 | 70 | 56 | 60 | 40 |
International Faculty in-country expenses | 270 | 300 | 792 | 463 | 450 | 355 |
[FIGURE 5: Cost; All costs are in USD] |