Pediatric Emergency Surgery Course in Uganda: Long-Term Follow-Up and Insights From Further Dissemination

Abstract

Introduction:

Approximately 170 pediatric surgeons are needed for the 24 million children in Uganda. There are only seven. Consequently, general surgeons manage many pediatric surgical conditions. In response, stakeholders created the Pediatric Emergency Surgery Course (PESC) for rural providers, given three times in 2018–2019. We sought to understand the course’s long-term impact, current pediatric surgery needs, and determine measures for improvement.

Methods:

In October 2021, we distributed the same test given in 2018–2019. Student’s t-test was used to compare former participants’ scores to previous scores. The course was delivered again in May 2022 to new participants. We performed a quantitative needs assessment and also conducted a focus group with these participants. Finally, we interviewed Surgeon in Chiefs at previous sites.

Results:

Twenty three of the prior 45 course participants re-took the PESC course assessment. Alumni scored on average 71.9% ± 18% correct. This was higher from prior precourse test scores of 55.4% ± 22.4%, and almost identical to the 2018–2019 postcourse scores 71.9% ± 14%. Fifteen course participants completed the needs assessment. Participants had low confidence managing pediatric surgical disease (median Likert scale ≤ 3.0), 12 of 15 participants endorsed lack of equipment, and eight of 15 desired more educational resources. Qualitative feedback was positive: participants valued the pragmatic lessons and networking with in-country specialists. Further training was suggested, and Chiefs noted the need for more trained staff like anesthesiologists.

Conclusions:

Participants favorably reviewed PESC and retained knowledge over three years later. Given participants’ interest in more training, further investment in locally derived educational efforts must be prioritized.

Introduction

Pediatric surgery in Uganda has made tremendous strides in the past 15 y.¹ In 2012, there was one board-certified pediatric surgeon at Mulago National Referral Hospital in Kampala that serviced the whole country, only able to provide an estimated effective coverage of 3.5% of Uganda’s neonatal surgery burden.^2,3 Despite the reality that local surgeons at Mulago National Referral Hospital have succeeded in complex cases, such as separating a pair of conjoined twins, implementing a pediatric surgery fellowship, and continuing to collaborate with regional and international stakeholders, rural pediatric surgical capacity still needs more investment—and most urgently more providers.^1,2,4–7 In 2022, there were seven pediatric surgeons, yet given Uganda’s pediatric population there should be approximately 170.⁸ Unfortunately, Uganda’s unmet need is not unique in sub-Saharan Africa⁸ and access to surgery in rural areas remains scarce.⁹ Typically, children with emergent surgical needs present to their local clinic or district hospital if they are able to access care at all. As a result, nonsurgical physicians or general surgeons, with minimal exposure to critical principles of pediatric surgical care, manage much of the emergent pediatric surgical needs.^10,11

In Uganda, it takes three years to train a general surgeon to be a specialist pediatric surgeon, and it will take many decades to train sufficient specialist pediatric surgical capacity to serve the entire country. As a result, to meet current needs, it is vital to train and invest in general surgeons who are responsible for treating and referring children with acute surgical conditions.¹² The Pediatric Emergency Surgery Course (PESC) was created to support local physicians in addressing the current burden of pediatric surgical disease.^1,13,14 This three-day course was held for rural healthcare providers and general surgeons three times between February 2018 and November 2019 and a total of 45 providers participated. Didactic modules covering neonatal resuscitation, pediatric surgical emergencies, and common pediatric surgical conditions were given and a precourse and postcourse test was administered. The course was designed to help improve referral patterns for children with complex surgical conditions and increase provider confidence when treating selected pediatric surgical conditions.

Previous studies of the PESC course demonstrated that immediately following the course participants had improved knowledge of pediatric surgical disease and the critical points in the resuscitation and management of these children.¹³ However, little is known about the long-term impact of this course on the knowledge and care of children with pediatric surgical emergencies.

Additionally, a previous baseline needs assessment of training context and pediatric surgery capacity (priorities, level of comfort managing surgical disease, available resources, and significant challenges) in western, central, and northern Uganda was conducted in conjunction with the course.¹³ To more fully characterize pediatric surgery priorities, we completed a needs assessment of pediatric surgery in eastern Uganda.

We sought to understand the course’s long-term impact, current pediatric surgery needs in Eastern Uganda, and determine how the course could be improved and adapted.

Methods

Study design

A mixed-methods study was undertaken to assess the retention and utilization of knowledge gained from the PESC course, as well as the pediatric surgical capacity and needs in Eastern Uganda.

First, prior 2018/2019-course alumni were asked to retake the final course test in October 2021 to assess knowledge retained from the course, which was two to three years after course completion. The test contained 12 multiple-choice questions, each starting with a brief clinical vignette. Stakeholders developed these 12 specific questions based on the most common surgical scenarios that providers might face.

Second, the course was given again at Mbale Regional Referral Hospital (MRRH) in May 2022 (Fig. 1). At the onset of the course, we performed a quantitative needs assessment with course participants who were from an underserved region of Eastern Uganda. Needs assessment included prior exposure to pediatric surgical disease, frequency of pediatric surgical cases locally, and potential interventions to improve capacity. Comfort managing pediatric surgical disease was assessed using five-point Likert scales. After the three-day course, a focus group was conducted with the course participants and qualitative feedback was obtained. Study personnel then visited three rural hospitals (Fig. 1) where staff had received training and obtained qualitative feedback from the Surgeon in Chiefs.

Fig. 1 –

Study locations.

Institutional review board approval for all studies was obtained from the local institutional review board (MAKSHSREC2021–142), Ugandan National Committee of Science and Technology (Ref. # HS1895ES), and the international collaborators (Protocol # 2021–0600; IRB # 21–34335). Institutional review board waived informed consent for the focus group and the surgeon interviews.

Quantitative analysis

Descriptive analyses were used to assess all quantitative data. Student’s t-test was used to compare 2021 test scores to pre-test scores from 2018 to 2019. Needs assessment data were collated to assess the frequency of events. Likert scales were assessed using median and interquartile range to assess confidence and ability to manage different pediatric surgical disorders. A Likert scale of ≤ 3 represented overall low confidence in managing pediatric surgical disease. All statistical analyses were conducted using STATA 14.

Qualitative analysis

Semistructured interviews were done with Surgeon in Chiefs at the hospitals who previously received the course. Topics included course benefits, challenges, observed changes in clinical practice, provider confidence, and the referral processes. Course leaders developed the surveys from previous course evaluations. The first author (G.K.), who has training in public health and qualitative research methods, performed these interviews. Prior to the interview, quantitative data from all institutions were collected through collaboration with Surgeon in Chiefs. Participants were selected based on their leadership and experience at the hospitals in which the study took place. Participants were invited both in person and via e-mail to participate in the interview. All three Surgeon in Chiefs participated either in person or via e-mail. The questions were not pilot-tested and there were no repeat interviews. No audio or video recording was performed but field notes were used. Data saturation was not discussed and although transcripts were not returned to the Surgeon in Chiefs, they did review and comment on the manuscript and direct quotations were used. Themes were not identified in advance but themes from the Surgeon in Chiefs were consistent with prior course evaluations and the focus group with the Mbale participants.

Qualitative feedback from course focus group participants in May 2022 assessed course benefits, course content, potential areas for improvement, and generic feedback. Uganda PESC course facilitators and high-income country collaborators supporting the course led the focus group. All facilitators were physicians with training in either pediatric surgery or public health. As part of the course, we conducted a focus group at its conclusion with all participants. This focus group assessed the experience of all those who participated in the course and sought to gain feedback about course strengths, weaknesses, and future directions. Participants were selected based on their participation in the PESC focus group at MRRH. The focus group was conducted in person and no one refused to participate. The questions were not pilot-tested and there were no repeat interviews. No audio or video recording was performed but field notes were used. Data saturation was not discussed and direct quotations were used. Themes were not identified in advance but themes from the focus group were consistent with prior course evaluations and the interviews with the Surgeon in Chiefs.

Two physicians with formal public health training used inductive thematic analysis.

The interview and focus group guides are in the manuscript Supplementary Material.

Results

Quantitative results: PESC knowledge retention and utilization

In total, 23 of the prior 45 course participants re-took the PESC course assessment (response rate 51.1%). After excluding individuals who pursued specialized pediatric surgical training, 22 responses were analyzed. Overall, prior participants scored on average 71.9% ± 18%, median 75% interquartile range (IQR) 83%−52%, approximately 2–3 y following the PESC course. This was higher from the prior precourse test scores of 55.4% ± 22.4%, and almost identical to the 2018–2019 immediate postcourse scores 71.9% ± 14%.

Quantitative results: Eastern Ugandan needs assessment

In total, 15 medical officers completed the needs assessment of Eastern Ugandan Pediatric Surgical Capacity at our Mbale-based PESC course. The median catchment of participant hospitals was approximately 140,000 patients (IQR 20,000–282,650). Participants were medical officers at MRRH and surrounding hospitals, representing nine healthcare centers. Nine of the participants were also concurrently enrolled in the general surgery training program based at MRRH. Medical officers are general practitioners who are medical school graduates and have completed one year of broad-based clinical internship but have not completed a specialty-specific postgraduate training program. They often practice independently in rural communities and in more urban centers may work under a specialist. Participants had been in practice for ≥ 2 y and six of 15 had received no prior formal pediatric surgical training.

In the survey, participants were asked to select the number of pediatric cases performed each month at their facility from a provided range. The options provided were 0–10, 10–20, 20–30, 30–40, and >40, whereas for neonatal cases the options were 0–5, 5–10, 10–15, 15–20, and >20. Ten of 15 providers reported that their facility performed 0–10 pediatric surgical cases per month and eight of 15 facilities performed 0–5 neonatal cases monthly. Furthermore, in most locations (11/15), anesthetic officers were the primary anesthesia providers (Table 1). At the time of data collection, there were just two board-certified pediatric anesthesiologists for Uganda’s 24 million children. Anesthesia officers are a vital cadre of Uganda’s healthcare workforce. They have completed undergraduate-level training in anesthesia, but they have not completed medical school.

Table 1 –

Characteristics of participants and their hospital site.

Respondent and practice site characteristics
Type of training
Medical officer	66.7%
Surgeon	26.7%
Missing	6.7%
Years in clinical practice
0–1	6.7%
2–5	33.3%
6–10	20.0%
Missing	33.3%
Previous pediatric surgery training
Yes	60.0%
No	40.0%
Missing	0.0%
Volume of pediatric surgery cases (any age)
0–10 cases/month	66.7%
11–20 cases/month	0.0%
21–30 cases/month	13.3%
31–40 cases/month	13.3%
> 40 cases/month	6.7%
Missing	0.0%
Volume infant (< 1 year) cases
0–5 cases/month	53.3%
6–10 cases/month	13.3%
11–15 cases/month	13.3%
16–20 cases/month	13.3%
Missing	6.7%
Training of those performing anesthesia
Anesthesia officer	73.3%
Anesthesiologist	20.0%

Regarding comfort in managing pediatric surgical disease, medical officers had overall low confidence in their ability to manage pediatric surgical disease (median Likert scale 3.0, IQR 2–3). Participants were most confident in managing hernias, hydroceles, burns, trauma, and intussusception. Overall, low confidence (score 3.0) was felt in the management of all congenital anomalies, especially those of the gastrointestinal tract (Fig. 2). Similarly, when asked whether individuals could perform various procedures, few participants (two of 15) felt that any pediatric surgical management, including colostomy creation and congenital disease, was within their scope. Additionally, seven of 15 participants felt they could manage essential procedures, including appendectomy, laparotomy, and management of orthopedic fracture (Fig. 2).

Fig. 2 –

(A) Mbale course participant confidence (median Likert scale) in managing pediatric surgical disorders and (B) percentage of Mbale course participants with the ability to provide pediatric surgical care of pediatric surgical disorders.

Twelve of 15 of the medical officers surveyed endorsed lack of equipment as a problem and eight of 15 endorsed a need for educational resources (Fig. 3). When asked to choose the top three interventions that might help improve surgical care in their settings, educational interventions including hands-on surgical training (13 of 15) and frequent educational workshops (eight of 15) were the top two interventions selected. Others also selected increased resources for perioperative care including improved anesthesia delivery (seven of 15) and improved perioperative care (six of 15). Improved referral processes, teleconsultation for pediatric surgical cases, increased theater space, improved community awareness, and improved transportation systems were also cited (Table 2).

Fig. 3 –

Challenges to delivering care from Mbale PESC course participants.

Table 2 –

Interventions to improve care from Mbale PESC course participants.

Interventions to improve surgical care (n = 15)
Hands on surgical training with specific cases	86.7%
More frequent CME (i.e., regional pediatric surgery workshop)	53.3%
Improved anesthesia delivery	46.7%
Improved perioperative nursing care	40.0%
Improved referral system to higher level facilities	26.7%
Tele-consultation for pediatric cases	20.0%
Increased theater space	20.0%
Improved patient education/community awareness	20.0%
Improved transport to hospital	0.0%

PESC, pediatric emergency surgery course.

Qualitative results: participant focus group

We conducted a focus group with participants at the conclusion of the May 2022 course in Mbale. Themes fell into five primary areas: (1) Timely recognition of pediatric surgical disease, (2) Appropriate patient resuscitation and management, (3) Processes for timely patient referral, (4) Challenges not addressed by the course, and (5) Future recommended directions (Fig. 4).

Fig. 4 –

Qualitative themes from surgeon in chiefs and Mbale PESC course participants.

Participants shared many positive remarks (Table 3). One participant shared, “this is the best thing ever” while another stated that PESC “increased (his) confidence in pediatric surgical emergencies and opened up my eyes on early referrals to ensure no complications for the place I am referring to”. Specific areas highlighted included an improved understanding of the country-wide resources for pediatric surgical disease, particularly the ability to network with in-country pediatric surgical providers. Participants stated that they also benefited from the teaching style which used visuals and emphasized straightforward and safe treatment algorithms. Finally, multiple participants said that it increased their confidence with pediatric surgical emergencies and that it would make them much more attentive to congenital conditions in neonates to not miss them and allow prompt referral.

Table 3 –

Selected remarks from Mbale course participant focus group.

“Is the best thing ever—hope that it continues to happen in up country areas.”

“Has increased confidence in pediatric surgical emergencies and opened up my eyes on early referrals to ensure no complications.”

“It was very insightful, a wakeup call for some of us. There are certain things that we lost handle of during medical school that we have forgotten.”

“Patient safety which was really emphasized and so was simplicity—tell us the simple techniques that are possible for this setting and really like the way you are training us.”

“It is easier to refer if you know the person and the place you want to refer to.”

The group also endorsed a preference for future incorporation of hands-on training with surgical cases or simulation and additional information on how to pursue a career in pediatric surgery. According to the focus group, the primary challenge not addressed by the course was the lack of specialized services/vehicles for the transportation of critically ill and complex transfers.

Qualitative results: Surgeon in Chiefs

Three Surgeon in Chiefs who previously hosted the PESC course also provided feedback which was divided into five overarching themes (Fig. 4).

Specifically, the surgical chiefs noted increased confidence among physicians in properly diagnosing pediatric surgical diseases and referral for complex diseases. They also highlighted greater attention to emergent cases and shorter operative times.

Despite the general increase in referrals and improved knowledge of the centers with pediatric surgical expertise, the surgeons raised concern over continued challenges with referral processes. One area of concern highlighted was the lack of a feedback system to understand whether a referred patient made it to a tertiary center. Concerns were also raised that families’ inability to pay for transport may limit their ability to seek the recommended referral. Every surgeon interviewed also raised concerns over the lack of trained anesthesia staff and the lack of necessary surgical supplies. Many cited lack of staff as a possible reason for a lack of change in operative practice/scope, as lack of anesthesiologist skill/comfort prevented surgeons with adequate training from performing certain procedures. Surgeons also frequently described problems with sufficient training of ancillary staff, such as anesthesiologists, neonatologists, intensivists, nurses, and midwives. Thus, for future direction, these surgeons highlighted the potential benefit of training targeting medical and ancillary staff that may care for neonates and children in the perioperative period.

Discussion

This study evaluated the long-term impact of a three-day pediatric surgical emergency workshop given to rural providers at regional referral hospitals in Uganda in a locally derived context. We found that the PESC effectively delivers didactic lessons on pediatric surgical emergencies and conditions. Compared to precourse scores, postcourse test scores improved after the 2018–2019 course and remained stable during the most recent 2021 retake, demonstrating long-term knowledge retention. In addition, course participants gave extremely favorable reviews of the course during the postcourse focus group. Participants also remarked that they enjoyed the content structure and use of visuals which should be continued in any future course iterations. Knowledge retention and qualitative reviews were both positive and the needs assessment revealed that participants desired further learning opportunities. Finally, participants noted that the course provided a forum to network with specialists. They felt this was critically important to better understand in-country resources for pediatric surgical disease. Our results indicate that the PESC likely helped fill gaps in pediatric surgical capacity and that further implementation of such courses could help address critical pediatric needs in low-resource areas.

Uganda’s healthcare system is arranged in a hub and spoke model with centers in the periphery (spokes) referring more complex care to healthcare hubs.¹⁵ Uganda’s specialized pediatric surgery centers (hubs) rely on appropriate resuscitation and referral from primary health centers located around the entire country (spokes).¹⁶ Global stakeholders in pediatric surgery developed guidelines for the Optimal Resources for Children’s Surgery (OReCS) in 2019¹⁷ dividing surgical delivery into three tiers: basic surgical care, intermediate surgical care, and complex/advanced surgical care, channeling from simple to complex—similar to the hub-and-spokes model. If providers in the periphery are not given the necessary training and education at these primary health centers, then Ugandan pediatric surgical patients will not achieve optimal outcomes with the resources that are available.¹⁷ The OReCS guidelines help guide stakeholders as they optimize their existing infrastructure and human capital to deliver pediatric surgical care. Investments in outreach like PESC, therefore, augment the existing healthcare system, providing benefits to the system that do not require concomitant infrastructure upgrades. Increasing knowledge and improving referral networks are therefore a component of improving existing healthcare delivery. For this reason, we think that the PESC contributes to one aspect of the skills component of the workforce guidelines in OReCs.

Outreach efforts that support rural providers, like the PESC, which are locally driven and derived, have precedent. In addition to the positive results of our study, similar programs have shown promising results—teaching pediatric anesthesia to nonspecialists, pediatric critical care to nonintensivists, and emergency medicine to advanced nurse practitioners have improved knowledge, skills, patient outcomes, and led to sustained behavioral change for providers.^18–20 Furthermore, educational interventions adapted to the local context have been shown to be cost-effective in other healthcare disciplines such as Emergency Medicine.²¹

Nevertheless, the course does not address all of the challenges that patients and providers in under-resourced settings face such as late presentation due to poverty, access to transportation, and lack of knowledge on the severity of their child’s condition.^22,23 These factors make optimal outcomes difficult to achieve even if appropriate resuscitation and prompt referral occur.

Surgical care is multidisciplinary and a limitation of this course was that it did not reach anesthesia providers and nurses. Participant feedback about challenges with anesthesia availability has prompted an alteration to our program. Anesthesiologists now provide lectures and hands-on skills training for pediatric anesthesia during the course. It is our hope that the benefits found through this partnership will spur efforts to conduct courses such as PESC concurrently with a pediatric anesthesia course like the World Federation of Societies of Anesthesiologists SAFER anesthesia course which could significantly augment PESC.¹⁸ In addition, we have also performed educational outreach to help rural midwives identify congenital anomalies.

Another limitation of this study is that it does not assess the impact of the course on provider practice and patient outcomes. We have recently submitted a manuscript (The Pediatric Emergency Surgery Course: Impact on Provider Practice in Rural Uganda). In this study, we do find an increase in the frequency of operations performed for pediatric surgical emergencies such as intussusception and earlier referral of neonates. This supports the assertion that the measured improvement in knowledge found in this study does translate to clinical care.

Furthermore, our results show that lack of equipment and material resources were cited as significant challenges in delivering care. Given the many needs of low-resource settings, local stakeholders must drive intervention priorities.²⁴ Not only did Ugandan specialists create and deliver PESC but rural Ugandan providers also expressed a desire for more knowledge on pediatric surgical resuscitation with hands-on training. In fact, PESC participants cited increased hands-on surgical training and frequency of CME as the top interventions to improve surgical care.

Current and future course adaptations, improvements, and additions therefore must reflect participant feedback and stakeholder input. Course participants noted that they valued the relevant and straightforward lessons in the course. We plan to create a manual that outlines and expands upon the course with pragmatic and relevant information. Participants and Surgeon in Chiefs noted improved communication with specialists. We are developing a website with referral numbers, making communication easier. Perhaps both formal and informal modes of networking should also be provided during future course offerings. Participants voiced a desire for further hands-on training. Future course iterations plan to increase exposure to case-based learning and anatomic models. Surgical Chiefs and course participants also reported the need to train other ancillary providers and anesthesiologists which is why PESC now also trains anesthesia providers. In addition, Uganda has recently started a pediatric anesthesia fellowship to boost the anesthesia workforce and stakeholders have started working with midwives in Uganda on the early identification of congenital anomalies.

Finally, Chiefs and participants alike noted the need to secure transportation for sick children to tertiary centers and have the necessary pediatric surgery equipment. Although PESC focuses on education, not equipment, the course might include more lessons on the proper transportation of sick children which could support the Ministry of Health and local leaders in their ongoing development of the Emergency Medical System and the workforce in regional hospitals.

Our study has the following limitations. We used the same post-test and participants perhaps simply remembered the right answer to the question without true course knowledge retention. The response rate (51.1%) for the postcourse test was also somewhat low and participants could have self-selected. Also, previous scores were recorded anonymously, without identifiers. For this reason, we were not able to pair the test scores with the participant and could only compare group averages. In addition, we did not host a focus group with prior course participants from 2018 to 2019 but rather interviewed Surgeon in Chiefs at former sites. Although Surgeon in Chiefs gave meaningful feedback years after the course, feedback from course alumni could also have proved insightful.

Conclusion

Administration of the PESC not only increased local provider confidence in the management of pediatric surgical emergencies but also demonstrated knowledge retention over time. In addition, the course improved in-country communication between Ugandan specialists and rural providers. Positive course reviews and a desire for further learning opportunities indicate that locally driven course expansion and dissemination will help meet the critical pediatric surgical capacity needs in low-resource and rural areas.