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A study on inclusion of leprosy in the curricula of pre-service health training institutions in Uganda.

Introduction

According to the National Tuberculosis and Leprosy Control Programme (NTLP) of the Ministry of Health in Uganda, the annual new case detection rate for leprosy in 2007 was 1.4/100,000 population; since then most districts report less than 10 new leprosy cases per year implying that in most parts of the country the disease has attained a low endemic status. (1) One of the most important strategies for sustaining leprosy control services under low endemic situations is to ensure that as many health service providers as possible are involved.

Integration of leprosy care services has been repeatedly recommended and targeted at achieving a situation where general health services staff become responsible for the day to day management of people affected by leprosy. (2) In order to achieve meaningful integration, health care providers must have basic knowledge about leprosy and should appreciate their expected roles in its control. This is one of the reasons why leprosy control should be incorporated in the basic (pre-service) training of health care providers. (2,3) In order to sustain leprosy expertise within the health services, the knowledge and skills acquired during pre-service training would then be supplemented by further in service training.

Leprosy training for final year undergraduate students of Makerere University Medical School was started in 1970 and continued for almost 30 years. (4) Leprosy was also included in the training curricula of other health training institutions such as schools of nursing and midwifery, medical assistants (Clinical Officers') training schools and schools of environmental health science.

In recent years, such training has continued in a haphazard way. It is not certain if the content has been updated to reflect new advances in leprosy control and the changed levels of disease endemicity in the country. The situation is made more complex by the transfer of overall responsibility for the running of the training institutions from the ministry of health to that of education and sports.

This study was designed with the objective of establishing the categories of pre-service health training institutions in Uganda that still maintain leprosy in their curricula and how leprosy training is organised. The information collected will be used as a basis for planning and advocating for appropriate interventions to improve the coverage and quality of leprosy-related training in the various health training institutions in Uganda.

Materials and methods

A structured questionnaire was designed for the purpose of gathering information from various health training institutions about their training activities in general and leprosy- related aspects in particular. The questionnaire was administered by one of the investigators to the head of each training institution or one of the teaching staff between October 2007 and November 2008. The types of institutions covered by the study are summarised in Table 1 below.

The sample of health training institutions was selected based on ease of access, but also taking into account coverage of the four geographical divisions of Uganda as well the Zones of the National TB/Leprosy Programme (NTLP). The majority of institutions covered were located around Kampala City as there is a relatively higher concentration of such institutions when compared to other parts of the country. Table 2 illustrates the distribution of study institutions by NTLP zones.

All 42 institutions selected agreed to participate in the study. Out of the 42 interviewees, 28 (66.7%) were the incumbent heads of the institutions while the remaining 14 (33.3%) were implementers of training programmes. Fourteen (50%) of the 28 heads of institutions were not only involved in administration and policy formulation but also as trainers.

Results

INCLUSION OF LEPROSY IN TRAINING CURRICULA

Four institutions (two nursing schools and two paramedical institutions) responded that leprosy had never been included in the curriculum. Five institutions (three nursing schools and two paramedical institutions) reported that leprosy had been included in curricula in the past but had been deleted. The majority of institutions (78.6%) still had leprosy included in the training curricula. They are summarised in Table 3 below.

The reasons given for excluding or withdrawing leprosy from the curricula

were: (1) lack of awareness of the relevance of including it, (2) having no leprosy cases in the neighbouring areas, (3) lack of skills and materials for organizing training in-house and (4) lack of funds either to pay external expert trainers or to send and maintain students at the National Leprosy Training Centre.

ORGANISATION OF LEPROSY INCLUSION IN TRAINING CURRICULA

Of the 33 institutions reporting inclusion of leprosy in their training curricula, about half had it as an official requirement for completion of the training programme. Most of them conducted specific tests at the end of leprosy training. All institutions agreed that some aspect of leprosy could be selected as a theoretical or practical examination question.

Twenty of the training institutions, including 13 schools of nursing and midwifery, three paramedical schools and four universities carried out leprosy training using their usual trainers. Thirty six (85%) of the respondents reported to have undergone some form of leprosy training themselves.

Thirteen (31%) institutions took their students to a leprosy training centre where both theoretical and practical training were done by training centre staff. Table 4 below summarizes how leprosy training was implemented by the different institutions studied.

Only half (22/42) of the institutions studied had actually organised leprosy training within the previous 2 years. The total number of students trained was 3507 representing 50% of the reported annual enrollment of the institutions.

Information about the method of evaluation of the leprosy training activities was available from 27 (64.2%) of institutions. Twenty two (81%) of those institutions had employed some form of evaluation method. Twelve (44%) of them had used pre and post- tests as the evaluation method. The methods used by the various institutions studied are summarised in Table 5 below.

FUTURE PROSPECTS

The heads of 41 of the institutions studied felt that there was need to continue leprosy training over the subsequent 5 years. The majority (49%) felt that the training should continue using a mix of approaches including engaging usual local trainers, inviting external trainers and involving special institutions. Five of the institutions felt the training should continue in special centres only.

The majority of institutions (60%) felt that leprosy training should take 1 week. Table 6 shows a summary of the opinions expressed by the institution heads regarding the duration of leprosy training.

Several heads of the institutions studied acknowledged that practical (clinical skills) training is essential but should be organise taking into account the high costs of transporting and maintaining students in special centres. They recommended that NTLP should organise refresher courses for the trainers and equip the institutions with up-to-date teaching and learning materials.

Discussion

Over the last 5 years, NTLP Uganda has recorded 300-500 newly detected leprosy cases annually; about 70% of those cases were in 13 out of 80 districts. Most districts can, therefore, be classified as 'low endemic'. (1)

Under such low endemic situations, the appropriate strategy to sustain leprosy control services is through integration of the services into the general health facilities. An effective integrated programme is one in which the general health staff carry out the tasks of suspecting, diagnosing, treating and referral of suspects and patients with complications. (3) In order to carry out the tasks, the general health workers need appropriate skills training. Development of a national training plan for leprosy has been recommended as part of the integration process. (5) Uganda does not yet have such a plan in place.

A study conducted in low leprosy endemic South Africa revealed that 42% of Primary Health Care (PHC) workers interviewed had acquired leprosy related knowledge and skills through formal teaching at nursing schools; others had acquired the knowledge and skills through different learning opportunities such as in service training, leprosy video shows at PHC clinics, educational leprosy posters and leaflets and radio and television information about leprosy. (6) That and other studies recommended giving priority to leprosy training during the basic (pre-service) training of health workers. (7) The Uganda study to some extent reflects adherence to that requirement as 78% of all institutions studied had leprosy still included in their training curricula.

Leprosy training was implemented within the confines of the institutions in 48% of cases; most of the remaining 52% relied to some extent on a leprosy training institution. A World Health Organization (WHO) workshop on the future of leprosy training institutions underscored their potential role in training-of-trainers (TOT) of general staff. (8) There are, however, emerging challenges related to the shortage of skilled personnel to manage the specialised leprosy training institutions. (5) The absence of skills, lack of awareness of the remaining leprosy problems as well as the existing NTLP structures to address them, are important reasons why half of the institutions covered by this study failed to organise leprosy training during the 2 years preceding the study.

Pre-service training, like any other, should focus on the anticipated tasks of the trainees. It would be difficult for a single leprosy training centre to design the necessary training modifications to suit the expected roles of the all the different cadres of health care providers. Individual training institutions are better prepared to make that kind of orientation but need a clear outline of the expected roles of the different health care providers in the leprosy control programme. Such outlines should ideally be part of the National Leprosy Control operational manual; they can also be adopted from other existing publications. (9,10)

Course evaluation as investigated in this study is limited to what the trainers do to evaluate what they teach. There is more to evaluation than this limited scope both in the short term and also for assessing the impact on the leprosy control programme in the long term. While a good proportion of the institutions studied (81%) claimed to have carried out some form of evaluation of the training, the various methods used were all focusing on the end of the training process. It is not certain if the evaluation methods used were selected in adherence to routine practices in the institutions or after considering their appropriateness to the learning objectives. In order to assure good quality leprosy training programmes, evaluation should also cover the plan, the entire process (not only the end) and the product (how the students perform after training. (11) Such a comprehensive evaluation of leprosy- related training must involve the national leprosy control programme.

It was not possible to comment on the students' performance after training or the impact on the leprosy control programme. However, observations by others have suggested that in spite of the pre-service training in leprosy, only a limited proportion of the trainees may be found with sufficient knowledge and skills to contribute to the leprosy control activities in the primary health care services. (6,7,12)

The duration of training should be dictated by, among others, the available time, cost implications and what should be learnt. General staff need brief but practical training in dealing with the simplest problems and in recognising what needs to be referred. (2) Learning practical skills takes longer than learning facts. (11) It is therefore surprising that the proposed time allocation for university level training is shorter than that for nurses and paramedical workers.

About two thirds of the institutions studied chose to use mixed approaches i.e. training in- house but also engaging external teachers in the institution or in a leprosy training centre. The reasons for supplementing with external trainers are often related to lack of skills and facilities for practical training. Whenever possible, leprosy training should involve interaction with patients as this not only enhances the learning process but also helps to demystify leprosy among health care providers.

Conclusions and recommendations

According to this study, leprosy is still included in the curricula of most of the institutions studied but training might get neglected at the time when it is most needed for promoting effective integration of leprosy services into the general health service. Having the biggest stake in ensuring integration, NTLP has to ensure that leprosy continues to be appropriately included in the curricula of all health training institutions. The NTLP should develop a national plan for leprosy training. Such a plan should define the training of each cadre of health staff based on their task analysis.

It is possible to organise leprosy training within the confines of the various training institutions provided ample arrangements are made to include practical skills training. This can be done in collaboration with institutions specializing in leprosy training, national leprosy programme structures or dermatologists. (13) Zonal and District TB/Leprosy Supervisors who are well informed about the location of leprosy patients in their areas can be important resource persons for clinical skills training.

The NTLP should also organise in-service or refresher training-of-trainers in the various institutions and provide them with appropriate teaching and learning materials.

There is need to carry out a more comprehensive evaluation of the training programmes covering the training plan, the process and the performance of students after training.

Acknowledgements

The authors would like to thank the National Tuberculosis and Leprosy Programme in Uganda for endorsing the study. We acknowledge the cooperation of the heads of institutions and trainers that kindly agreed to be interviewed in the process of completing the study questionnaires. Special thanks go to Dr. Peter Mudiope who assisted us in data analysis. We also thank Dr. Francis Adatu the NTLP Manager for his guidance.

References

(1) Ministry of Health, Uganda. National TB/Leprosy Programme. Status Report on Leprosy Control. 2009.

(2) Feenstra P. Leprosy control through general health services and/or combined programmes. Lepr Rev, 1993; 64: 89-96.

(3) World Health Organization. Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy (2011-2015). Operational Guidelines. SEA-GLP-2009.4.

(4) St. Francis Leprosy Centre Buluba, Uganda. Buluba 50 Years. Summary of the first 50 years (1934-1984). Mariannum Press Kisubi, Uganda. June 1984.

(5) Saunderson PR, Ross WF. Training for integration. Lepr Rev, 2002; 73: 130-137.

(6) Ukpe IS. A study of health workers' knowledge and practices regarding leprosy care and control at primary care clinics in the Eerstenhoek area of Gert Sibande district in Mpumalanga Province, South Africa. S A Fam Pract, 2006; 48: 16.

(7) Shurmin C, Cunlian H, Bing L et al. A survey of the knowledge and skills in early diagnosis of leprosy in general health services in Shandong Province, the People's Republic of China. Lepr Rev, 2000; 71: 57-61.

(8) Saunderson PR. Future role of Leprosy training and/or research institutions. ALERT, February 25 -26, 1998. Lepr Rev, 1998; 69: 160-163.

(9) World Health Organization. Training in leprosy. 1986. WHO/CDS/LEP/86.2.

(10) ILEP technical Guide: Training in Leprosy. International Federation of anti-leprosy Organizations. 2003, ILEP, London.

(11) Teaching Health Care Workers. A Practical Guide. 1988. F.W. Abbatt & Rosemary McMahon. MACMILLAN EDUCATION LTD.

(12) Awofeso N. Appraisal of the knowledge and attitude of Nigerian nurses toward leprosy. Lepr Rev, 1992; 63: 169-172.

(13) Kawuma HJS. The potential role of dermatologists and dermatological services in developing and sustaining the leprosy control referral system in resource constrained settings. Lepr Rev, 2007; 78: 34-37.

HERMAN JOSEPH S. KAWUMA & MARY G. NABUKENYA-MUDIOPE

German Leprosy and TB Relief Association (GLRA), Kampala, Uganda

Accepted for publication 17 June 2011

This material has not been published in this form in any other scientific journal.

Correspondence to: Herman Joseph S. Kawuma, Medical Adviser, German Leprosy and TB Relief Association (GLRA), P.O. Box 3017 Kampala, Uganda (e-mail: kawuma@infococom.co.ug)
Table 1. Summary of type of training institution participating
in the leprosy training study

Type of institution                   Number   Percentage

Schools of nursing and/or midwifery     22         52.4
Paramedical schools                     14         33.3
Universities                             5         11.9
Rehabilitation training institute        1          2.4
Total                                   42        100

Table 2. Distribution of institutions participating in leprosy
study according to NTLP zones

                  Category of institution

NTLP Zone    Nursing   Paramed   University   Rehab

Kampala         5         9          4          0
South West      8         1          0          0
West            1         1          0          0
South East      3         0          0          1
East            2         2          0          0
North West      2         0          0          0
North           1         1          1          0
Total          22        14          5          1

                Total number
NTLP Zone    of institutions (%)

Kampala           18 (42-9)
South West         9 (21-4)
West               2 (4-8)
South East         4 (9-5)
East               4 (9-5)
North West         2 (4-8)
North              3 (7-1)
Total             42 (100)

Paramed--Paramedical, Rehab--Rehabilitation.

Table 3. Inclusion of leprosy in curricula of health training
institutions

                             Status of leprosy in curriculum

Type of institution         Included now   Included in the past

Schools of nursing and/or        17                 3
midwifery
Paramedical schools              10                 2
Universities                      5                 0
Rehabilitation training           1                 0
  institute
Total                        33 (78-6%)         5 (11-9%)

                            Status of leprosy
                              in curriculum
                                                   Total number
Type of institution           Never included     of institutions

Schools of nursing and/or           2                  22
midwifery
Paramedical schools                 2                  14
Universities                        0                   5
Rehabilitation training             0                   1
  institute
Total                            4 (9-5%)              42

Table 4. How leprosy training was implemented in the health training
institutions

                                     Category of institution

Method used                       Nursing   Paramedical   University

Engaging own trainers               13           3            4
Inviting external trainers           0           1            0
Taking students to leprosy           5           6            1
training center
Using combined approaches            2           2            0
Did not train at all                 2           2            0
Total institutions per category     22          14            5

                                   Category of
                                   institution
                                                   Total number
Method used                       Rehabilitation   of institutions

Engaging own trainers                   0              20 (48%)
Inviting external trainers              0               1 (2%)
Taking students to leprosy              1              13 (31%)
training center
Using combined approaches               0               4 (10%)
Did not train at all                    0               4 (10%)
Total institutions per category         1              42

Table 5. Methods used for evaluation of leprosy training
in the institutions studied

Method used                 Number of institutions

Pre/Post test                         12
Course work                            5
Official examination                   5
No formal evaluation                   5
Information not available             15
Total                                 42

Table 6. Duration of leprosy training as proposed by the
institutions studied

                            Category of institution

Proposed duration       Nursing   Paramedical   University

1 week                    12          11            2
3 days                     2           1            0
2 days                     5           0            0
1 day                      1           1            1
1 session (1-2 hours)      2           0            2
No response                0           1            0
Total in category         22          14            5

                         Category of
                         institution
                                          Total number
Proposed duration       Rehabilitation   of institutions

1 week                        0              25 (60%)
3 days                        1               4
2 days                        0               5
1 day                         0               3
1 session (1-2 hours)         0               4
No response                   0               1
Total in category             1              42
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Author:Kawuma, Herman Joseph S.; Nabukenya-Mudiope, Mary G.
Publication:Leprosy Review
Date:Sep 1, 2011
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