Global Health Educators 

Program Report from Uganda Trip  

May 2018

Travelers:  Judy Gustafson MD, MPH, James Drougas MD, Wilton  Kennedy, DHSc., PA-C, with Five Physician Assistant students from Jefferson College of Health Sciences:  Annie Hamner,  Syndey Garst, Jamie Knapp, Caroline Schieber, and Naid Allassain

Our Vision:

Improve women and newborn health in the developing world. 

Mission:

Improve the health of communities through educational teaching programs and sustainable interventions.   

Goals:

• Improve maternal and newborn health.

• Strengthen medical care at the level of the health center.

• Improve community health through educational and sustainable interventions.

The following is a brief report on events, programs, and some of the projects addressed during our most recent visit.

Magale Health Center Level 4 - Health System Strengthening

Surgical and Anesthesia Mentoring:  

All surgical procedures were done in collaboration with the Ugandan medical staff.  Multiple surgeries were performed with emergency c-sections, wounds, and hernia repairs being the most common surgical cases.  Most cases were done with spinal anesthesia to reduce anesthetic risks and improve mother and newborn outcomes.  Dr. Patrick Akena became especially adept at spinal anesthesia placement with the numbers of   cesarean sections needed at Magale HC4.  

Surgical safety checklist:  

The challenge:  To improve patient safety in the operating room with a checklist for a population where English is the second language.  The project:  The World Health Organization’s recommended checklist for surgery was modified by adding visual images in addition to the written words.  This checklist was presented during an organized training program and the laminated page mounted on the wall in the operating theatre.

Maternal/Newborn Checklist:   

The World Health Organization checklist for safe births was presented at a conference at Magale HC 4 with midwives representing Magale HC and 12 surrounding health centers that refer their complicated patients to Magale HC.  The 5 traveling PA students all presented at the meeting.  The World Health Organization’s checklist was adapted to the local culture by adding visual images as reminders.  Each of the 15 Health Centers received a laminated copy of the  visually adapted checklist that are to be mounted in the maternity wards. 

Maternal Health extended to 2 additional health centers for a total of 15 Health Centers included in the Community Health Program

Time was taken to travel to these additional clinics to welcome them with the delivery of blood bressure machines, rubber boots, women’s hygeine kits, and  maternal/newborn safety checklists.  

Women’s Hygiene Kits:  The challenge:  Many mothers come to deliver at Magale HC4 with limited supplies for personal hygeine following the birth of their children.  The Project:  Each mother birthing at Magale HC4 were given women’s hygeine kits through a donation by the U.S. organization “Days For Girls.”  Each kit contains instructions on using the washable sanitary napkin pads, holders with snaps, underwear, a washcloth, and a bar of soap.   

A Rough Way to Come Into the World

There are many reasons why a newborn baby born in Magale HC4 in Uganda, Africa has significantly less of a chance for survival than a baby born here in Roanoke, Virginia.  Access to a medical center is very difficult for multiple personal and financial reasons.  Especially during the rainy season, transportation on muddy, unpaved roads is nearly impossible.  Modern fetal monitoring that can detect fetal distress is not available at any of these health centers we work with in rural Eastern Uganda.  Because of all of these challenges, it is likely that many newborns will require resuscitation at birth in order to survive.  The donated Ambu bags are absolutely critical to the success of the newborn resuscitation training program conducted by Global Health Educators. 

A big thanks to Sara Wohlford and her team at Carilion for taking the time to collect these bags for us to take to Uganda. Special thanks to Susan Hill, CRNA in taking the lead on this project and taking time to help train our student travelers on the technique of newborn resuscitation.

Newborn Warming

This program was initiated in 2015 when it was noted that low birth weight infants had a much higher mortality rate if their core temperatures dropped with the cool nights, lack of incubators, and mothers with limited supplies delivering at Magale HC4.  Each morning the team helped to delivery supplies to the mothers and their newborns, thanks to the generous donation of baby hats and blankets from friends and families in the U.S.

Community Health Program 

Bubulo East Traditional Birth Referral Agents BETBRA

Rural Eastern Uganda is challenged with difficult terrain making access to health centers nearly impossible at times, especially during the rainy season.  Community members referred to as “Traditional Birth Attendants” have been assisting more than 50% of mothers deliver their babies outside of a formal health center. Global Health Educators has been working with community health leaders and midwives to improve maternal and infant health by forming an organization of Traditional Birth attendants to refer the patients to one of the 13 local health centers for delivery and also recognize the warning signs of diseases of pregnancy such as eclampsia.  

Transportation is predominantly on foot, especially during the rainy season.  Rubber Boots, locally known as “Gum Boots,” are of extreme value to help get the patients to the health centers.  One hundred pairs of rainboots were purchased with prior funding in 2017, but with the help of generous U.S donations made to Global Health Educators in 2018, 300 more rain boots were purchased in Uganda with most of the boots distributed to the active Bubulo East Referrral Agents who attended the training program at Magale Health Center.  The rest of the boots were delivered over the following 3 days to those active members where were unable to attend the  program.  

Albinism Awareness:  The leadership of the TBRAs also organized the “Albinism Awareness Program,” that had been initiated in October 2015 with the help of Jefferson College of Health Sciences in Roanoke. There are an estimated 192 Ugandans with albinism located in the areas surrounding Magale Health Center 4.  The group from GHE delivered hats and sunglasses that will be distributed by members of the Community Health Organization. 

Vision Project:  This project was initiated in October 2015 with the PA students from Jefferson College.  Again, donated reading glassed were taken to Uganda and delivered to the Community Health Leaders of BETBRA program to distribute to Ugandans needing reading glasses.  Sincere thanks to all of our friends and family who donated glasses for this program. 

  

Just For Fun

St. Angela’s Boarding School

Dr. Wilton Kennedy and PA students deliver 12 donated soccer balls to St. Angela’s Boarding School.  

Water Sports on the Nile River 

On the way back to the airport, the group had a stopover in Jinja for a well deserved rest before taking the long flight back to the United States.  Jinja is in a beautiful location situated on Lake Victoria, the source of the Nile River.  

Final Thoughts

This was my 11th trip to Uganda since 2013.  The sisters at Magle Convent provided us with safe food and lodging with close proximity to Magale Health Center. As always, the sisters also provide all of our travelers the ability to learn the culture first hand with their kind hearts and generous spirits. The nuns living and working at the convents, schools, and associated health clinics devote their lives to caring for their community and visitors regardless of religious beliefs or affiliations.   Their ability to laugh, sing, and dance despite their challenging conditions is always an inspiration. 

My sincerest gratitude to all those who make GHE possible at both my homes in the United States and Magale Trading Center, Uganda, Africa.   A very special thanks to the medical staff at Magale Health Center 4 and Dr. Patrick Akena in particular who worked with us in May 2017.  Patrick took his only free time off from his clinical training in Mbale Regional hospital in order to spend time with us during our visit one year later! His devotion to the practice of medicine is truly inspirational.  

We hope to see you again soon!

:)  Judy

Director Global Health Educators

Newsletter Global Health Educators Uganda May Trip 2017

Travelers and Educators 

Physician Assistant Students (left) from Jefferson College of Health Sciences:  Andrea Hawkins, Annie Poetker, Chadwick Kanney, and Elyse Pope

GHE Board Members Traveling:  Stephen Hill, MD, Susan Hill, CRNA, Mark Gustafson MD, MPH, and Judy Gustafson MD, MPH

Educational Programs at Magale Health Center IV

NewbornsPrograms to address techniques to improve survival under challenging conditions included newborn resuscitation, exclusive breast feeding, and warming strategies using blankets, hats, and skin to skin contact.

Susan Hill CRNA directing newborn teaching program along with PA students Andrea and Chadwick

Surgery

Multiple surgeries were accomplished in collaboration with the Ugandan medical staff.  A suture training workshop and trainings on surgical and C-section techniques were conducted with the medical staff at Magale HCIV.

Steve Hill MD,  Mark Gustafson MD, and Susan Hill CRNA assist in a c-section delivery with the Ugandan Medical Staff.

Annie and Elyse work with Uganda Medical Staff with Suture Training

Anesthesia

Oxygen and anesthetic supplies are limited for mothers who require C-sections in the rural health centers in Uganda, To help improve maternal and newborn health, a spinal anesthetic program was begun in January 2013.  With each return visit, more spinal supplies are delivered along with anesthetic mentoring for the medical staff at Magale HCIV. 

C-section under spinal anesthesia.  Ugandan medical staff:  Dr. Lukia, Dr. Patrick, and Emmanuel 

Maternal Health Programs

Topics discussed with the medical staff at Magale HCIV included basic ultrasound techniques and hands-on training, postpartum hemorrhage management,  urinary incontinence diagnosis and management, and management of cesarean section complications. 

To improve mother’s attendance to Magale Health Center antenatal clinics, Mercy for Mamas, a NGO based in the US, donated 100 “mama kits.” These kits contain the supplies necessary for mothers to have a safe and clean delivery of their newborns and is especially helpful for those mothers who do not have the finances to purchase their supplies. 

Community Health Programs

 for the Manafwa District Eastern Uganda

Albinism

Albinism, and it’s associated complications of skin cancer, sensitivity to light, and social stigma, has been a problem for large numbers of Ugandans living with this genetiic disorder.  Since 2014, GHE travelers continue to provide education materials along with donated hats and sunglasses to be distributed to the Albinism communities by the Ugandan leadership of the TBRA program. 

Vision

Since very few individuals in this rural area wear glasses, vision testing clinics were held to identify people over the age of 50 who would benefit from reading glasses.  Teachers, community health leaders, convent nuns, and medical staff were especially targeted for this program.  

Annie and Chadwick testing for the correct reading prescription

A leader/teacher of the local birth attendants

Alice, a midwife at Magale HC4

Thanks to the generous donations of reading glasses, many people were delighted to be able to read again without difficultly.

St. Angela’s Convent, School, and Orphanage

The Nuns at the nearby convent again provided lodging and food for the travelers.  Their generosity has allowed us to spend more time at this remote clinic without having to travel long distances to reach a tourist hotel. The children at the school presented song, dance, as well as gifts for all of the travelers.  GHE and Jefferson College PA program presented a financial donation to help with the orphanage along with soccer balls for the children.

Bubulo East Traditional Birth Referral Agent Program (BETBRA)
Meetings and Site Visits with the Executive Committee of BETBRA

Map showing the terrain and location of the 13 health clinics associated with BUTBRA and GHE

The BETBRA program is now officially recognized by the Ugandan Government as a Community Based Organization!  Their numbers now include nearly 400 members and cover 13 health centers in the Manafwa District.  Their goals are to educate mothers and communities about maternal and newborn health along with the need to receive antenatal care and deliver at the health centers by trained medical staff.

Financial Review of Program

Of note is the leadership of the Traditional Birth Referral Agent Program (TBRA) work as volunteers.  The financial donations made to run the program are carefully managed to augment local funding for targeted items necessary for the programs success including communications, supplies/fuel for traiinings, and rain gear to help local TBRAs to transport mothers to the clinics.

Review of Program Data

Eighteen months of data was collected by Gerald Mukhwana, the secretary of BETBRA.   This data was presented in graph format (2 shown below) to identify trends in patient clinic referrals and deliveries, and discuss recommendations for improvements for all the clinics involved. 

Train the Trainer Flipcharts, Site Visits, and Newborn Resuscitation

A newly developed maternal and newborn health training flipchart was developed through input by the TBRA leadership during the previous visit to Uganda in October 2017.   Presentation of this newly developed 24 page training program was presented to the leadership and used during the site visits in May 2017.

The site visits included 6 of the 13 surrounding Health Units and one remote village with challenging access to a health center.  These site visits reinforced the understanding of the challenges faced by these remote communities in accessing health centers.  Flooding causing a washout of the road and the use of alternate methods for crossing and a long walk back to the convent/clinic facilities.

Patrick, program director for the TBRA program, standing 
in front of the washed out road caused by extensive rains and flooding.  

At each site a program was conduced for training of TBRAs and midwives with the newly developed training guide for maternal and newborn health.  Newborn resuscitation programs were conducted with health center nurses and midwives.  In addition, permanently mountable BP Monitors/Cuffs and newborn manikins were presented to the 6 health clinics.  Seven more BP monitors were left for the leadership to deliver to the remaining health units.

Future Plans 

1.  Ugandan BETBRA Trainers are planning to continue with the trainings all 13 Manafwa Clinics using the flipcharts developed in conjunction with USA based GHE.
2.  Development of Ugandan leadership groups in the communities served by each of the 13 health clinics to .  These groups, in collaboration with BETBRA, will focus on major challenges faces by these communities in accessing health care including communication, patient transportation.   BETBRA leadership will facilitate  with local leadership the prospect of the pooling of community resources to address major concerns including the purchase phones for communications, and stretchers for patient transport.
3.  Continued performance assessments of TBRAs at all of the 13 association health clinics with quarterly data collections for each of the 13 health units.
4.  Continued accountability of donated funds with management of funds carefully monitored  by at least 3 members.
5.  Continue to encourage referral to health centers rather than deliver at home
6.  Encourage income generating activities among groups of TBRAs

Ronald
Follow-up Success Story

We met Ronald as a 12 year-old orphan with osteomyelelitis, a chronic infection of an exposed bone fracture of his left leg.  In March 2015 Dr. Drougas performed the necessary amputation of his left leg above the knee.  Since the amputation Ronald has grown out of one prosthesis and is having a new device constructed in May 2017. He is enrolled at the St. Angela’s Convent Boarding School where he is able to enjoy being a student for the first time.  His clothing and school fees are made  possible through generous donations from friends in the U.S.

Ronald age 12 

Surgery/amputation March 2015

Ronald age 14 in May 2107.  Donated clothing, student at St. Angela's boarding school.  

Newsletter for October 2016 trip to Uganda

October 2016 

Ugandan Trip Report - Global Health Educators

Travelers to Uganda in October 2016:  Steve Hill MD, Susan Hill RN, Wilton  Kennedy DHSc., PA-C, Mark Gustafson MD, MPH, Judy Gustafson MD, MPH.   Physician Assistant students from Jefferson College of Health Sciences:  Laura Cunningham, Ashylnn Baird, Kristen Peansky, and Alyssa Shroeder.

Programs Addressed

1.  Traditional Birth Referral Agent Program

2.  Surgical and Anesthesia Mentoring Progam

3.  Albinism Program

3.  Maternal/Newborn Health Teaching Programs - Ultrasound, Management of Maternal Emergencies, Breast Feeding, Newborn Resuscitation, Repair of birth lacerations and suture training

4.  Convent School Volleyball and Vision Programs

Traditional Birth Referral Agent Program (TBRA)

  Reducing Maternal/Infant Mortality Through Community Involvement

The Challenge:  Maternal and infant mortality rate is 10 times greater in Uganda than in the US.  More than 50% of mothers still deliver outside the Ugandan Health Centers by men and women  called “Traditional Birth Attendants (TBAs).”  Some caring for Ugandan mothers may have little or no medical training.

A Promising Solution:  The TBRA program was initiated in October 2014 following focus group meetings with the medical staff at Magale Health Center and Traditional Birth Attendants (TBAs) within the community.  Since 2014, the TBRA program has become a grassroots movement spreading to 14 health centers and villages throughout the Manafwa District in Eastern Uganda.  A core of 15 Ugandans comprised of physicians, midwives, and community members lead the educational programs, encourage membership, and collect data on maternal referrals to antenatal clinics and health centers for delivery.  To celebrate their success, we were invited to their gala event on October 19th that included 500 TBRAs, Midwives, and political leaders.  In addition, 5 representatives from the Kitgum area in Northern Uganda attended the TBRA and midwife training programs to learn how a similar program could be initiated in their area.

A Better Understanding of the Challenges in Caring for Mothers/Newborns in Uganda

A trek to the highest village, Bukomi Village (shown in terrain map above), showed representatives of GHE the access challenges facing local TBRAs and their mothers to obtain needed medical care.  “Dramas” were performed along the 2 hour hike to the top and an afternoon rainstorm extended the return trip back down an additional 3 hours.  The experience underscored the need for further education of the entire community and desperately needed rain gear including rubber boots for TBRAs to help transport mothers walk to the clinics during the rainy season.

A "dramatization" of trying to bring mothers down the mountains from the high villages.

Clinic and Village Visits

Other site visits included meeting with TBRAs, Village Leaders, and interviews with mothers at Bubuto HC3 and at Bumwoni village with a high maternal/infant mortality - noted the importance of including village leaders and fathers in maternal health education programs.  The albinism program was discussed at each of these visits as well.

Lessons Learned

There has been a dramatic improvement in the relationship between TBRA members and health workers at the 14 health centers in the Manafwa District as reported by individual interviews of the TBRA leadership.  It is now common to see mothers being brought to the health centers by TBRA members wearing their green t-shirt uniforms. 

Several obstacles that keep mothers from the recommended 4 antenatal visits and delivering at a health centers include: lack of financial support by their husbands to obtain transportation, lack of education, fear of abuse by health workers, fear of testing positive for HIV or other diseases with resultant stigma, and family obligations at home.

“The Way Forward” for the TBRA Program

Educational Support

The most requested topics obtained through leadership interviews include:  Nutrition, HIV testing/couseling, financial preparation for birth, importance of antenatal visits, family planning, danger signs during pregnancy, malaria prevention, breast feeding, newborn childcare,  dangers of herbal medicine, and importance of delivery by qualified medical personnel.  The Ugandan TBRA leadership requested help in the development of these educational programs to be presented in a “Flip Chart” format since electricity is a problem at all health centers.  

Financial Support

Operating expenses for the TBRA program have been helped through the donation of green T-shirts and subsequent selling the TBRA uniform (green T-shirts) to the TBRA membership.  During this visit, a financial donation (from GHE and supporters from the US) was made in order to purchase more uniforms as well as rubber mud boots. 

Data Collection

Monthly data has been collected since January 2016 showing a general positive trend in more antenatal visits and referrals of mothers to the health centers for delivery.   

Surgery and Anesthesia

Steve Hill, MD in Magale OR with Laura Cunningham, Mary Nakye, and Susan Hill, CRNA

Susan Hill, CRNA, names the baby “Grace.”

Over 45 surgical cases were done at Magale Health Center Level 4 despite challenges with limited medical supplies, anesthetics, and oxygen.  The majority of surgical cases were able to be performed under local or spinal anesthesia including a c-section where there had been a question if the infant was still viable prior to surgery.  The mother was so grateful, she requested Susan Hill to name her baby girl. 

Albinism Program

The Challenge:  Albinism is still considered a “curse” with resultant ostracism and illness.  The Traditional Birth Referral Agent leadership has taken over the training and delivery of supplies for the albinism project.  

During the visits to outlying clinics, Ugandans with albinism were encouraged to attend meetings and the communities received education regarding genetic transmission and sun protection for people with albinism.   The TBRA program will continue with trainings and outreach to other organizations in Uganda working with Albinism.

Maternal/Newborn Health Teaching Programs

Ultrasound, Management of Maternal Emergencies, Breast Feeding, Newborn Resuscitation, and Hands-on Suture Training

Each PA student helped develop and present topics on the use of the ultrasound, maternal emergencies, and breast feeding.  Subsequent to the trainings, the ultrasound was used to help in the diagnosis and treatment of more than 15 patients.

Susan Hill, RN teaching newborn resuscitation

Mark Gustafson MD, MPH teaching Ultrasound with Dr. Lukia of Magale HC4

Convent School Soccer Ball and Vision Programs

The Physician Assistant Program of Jefferson College of Health Sciences was successful in a soccer ball drive that resulted in twenty soccer balls being donated to the students at St. Angela’s Convent primary and secondary schools.  

Wilton and students present soccer balls to St. Angela’s primary and seconday schools.

Vision Program

The program began in October 2015 with the first group of PA students from Jefferson College. 

The Vision Committee, consisting of teachers at St. Angela’s primary school, continues to test vision.  Of note was the significant improvement in vision for students with albinism using readers of 3.0 and greater.  Donations for this program continue to be appreciated!

A Final Word of Thanks

Thank you to all our families and supporters in the US for encouraging us to continue to return to Eastern Magale and be witnesses to the continual progress being made by these committed Ugandans. A sincere thanks also to St. Angela’s Convent for providing our travelers with a convenient, safe, and loving place to stay.

From Left to right:  Susan, Steve, Sister Immaculate and Judy

From Left to right:  Laura, Kristen, Ashlynn, Aly, and Sister Symphrose