Setting

Data were collected in the Busoga sub-region, located in the central eastern part of Uganda. According to the latest report published in 2021 by the Uganda Bureau of Statistics, the Busoga sub-region was ranked as the poorest in the country. An estimated 4 million people live in Busoga, with a significant proportion being children and adolescents. The under-five mortality rate in the sub-region is higher compared to the country’s average, reaching 84 deaths per 1,000 live births [21]. Data were collected from all public and private not-for-profit (PNFP) health facilities providing inpatient paediatric care in Busoga, including one regional referral hospital, four general hospitals, two PNFP hospitals, and seven level IV healthcare centres (14 total).

Data collection and selection of participants

The study data consisted of 14 facility inventories, 100 individual surveys with health workers, and 14 FGDs with healthcare staff of different cadres providing emergency paediatric care at various facilities within the sub-region. The inventory questions were derived from selected sections of the WHO’s Hospital Care for Children: Quality Assessment and Improvement Tool, focusing on required items to adhere to ETAT+ guidelines [22]. They covered availability of infrastructure, drug stocks, equipment availability, staffing and referral capacity. The survey was based on questions used in ETAT+ training materials and covered participants’ experience, training, knowledge of ETAT/ETAT+, and current clinical practice, including referrals. The survey included 14 knowledge questions, with 0–2 points assigned to each question.

The inventories, FGDs, and initial surveys were conducted over one week from the 31^st of January to the 5^th of February, 2023, with additional surveys completed in April 2023. A team of data collectors visited one facility at a time, completing the inventory, surveys, and FGDs before moving on to the next facility. The facility in charge was chosen to respond to the inventory questions. The surveys were conducted with HCWs who regularly manage children, capturing individual experiences and knowledge in managing severely sick children. Quantitative data were collected using RedCap on handheld mobile devices, with data uploaded to the server at the end of each workday [23, 24].

The FGD tool was developed to cover aspects of emergency care that are not easily quantified, such as feelings of support, motivation, and confidence. The topic guide was developed using results from previous work on health workers’ experiences and perceptions of emergency care delivery [25, 26]. FGDs lasted approximately 30–45 minutes. For logistical reasons, i.e. the shortage of staff and time constraints, one discussion per facility was conducted with four to eight HCWs of different cadres per discussion. For participant recruitment, purposeful sampling was used, including healthcare providers who regularly care for children to yield the most relevant information. The approach was also pragmatic, selecting all staff members managing severely sick children available for discussion during the study period. The FGDs were facilitated by a moderator, a Ugandan social scientist with prior experience in qualitative data collection. In addition to the moderator, a note taker captured the verbal and non-verbal interactions of participants in the discussions. The language used was either English or the local language Lusoga, as preferred by the participants. The discussions were recorded, transcribed by the social scientist fluent in both Lusoga and English, translated into English when needed, and anonymised before sharing with the rest of the study team.

Analysis

Quantitative data were transferred to STATA v.16 (StataCorp LLC, College Station, TX) for analysis, then summarized using proportion percentages, and medians [27]. The data was categorized based on facility category and healthcare provider classification, as applicable. The responses from 14 survey questions related to knowledge were combined into an overall knowledge score, with a maximum total score of 28 points. This score was used for a linear regression analysis to assess links between HCWs’ knowledge scores and their training history, years of experience and professional category. P-values less than 0.05 were considered statistically significant.

The FGDs data were analysed using NVivo version 14.0 (Release 1.7.1) software, employing thematic analysis with a pragmatic framework approach [28, 29]. This systematic yet flexible method enables the identification of patterns in the data and generation of the framework matrix [29]. The content was analysed inductively, with codes and categories formed during the coding process. Analysis involved following these consecutive steps: 1) transcription, 2) familiarisation, 3) coding, 4) developing an analytical framework, 5) applying the analytical framework, 6) charting data into the framework matrix, and 7) interpreting the data [29]. Initial coding of five FGDs was done by GL. The codebook was then shared and discussed with HH and DA, codes were updated accordingly, and applied. Themes were then developed and discussed with a wider study team, several of whom are working within the study facilities, to agree on the final interpretations.

Ethical considerations

This study has been reviewed by the Higher Degrees Research and Ethics Committee of Uganda Christian University, Mukono (UCUREC-2022-397). All the participants were provided with comprehensive information about the study prior to obtaining the written consent from each. Participants were given the option to skip questions if they did not want to address them or withdraw from the discussion entirely if they felt uncomfortable at any time. All the data were kept confidential, and only anonymised versions were shared with other members of the research team. Moreover, the audio recordings and the transcriptions were encrypted and held on study laptops protected with a password, whereas all paper consent forms were stored in a locked room accessible only to members of the study team.

1. Paediatric emergency care in current practice

All facilities reported shortages of supplies needed for emergency care, with only 33% of public facilities reporting the availability of IV Artesunate and Ceftriaxone at the time of data collection. Table 2 provides an overview of the available equipment and drugs by facility ownership.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Equipment and drug availability across different types of institutions.

https://doi.org/10.1371/journal.pgph.0003666.t002

The qualitative discussions revealed that in addition to the lack of equipment, dysfunctional items were sometimes provided, and these challenges were reported across all facility levels.

• “Our pulse oximeter sometimes it is on and off, sometimes it gives good results other times wrong results because it is faulty.”—General Hospital.

Four of the facilities (29%) were staffed with at least one paediatrician. Due to insufficient staffing HCWs were forced to work beyond their assigned roles.

• “Limitations of health workers is the biggest issue in Uganda. You find that you are the midwife, you are the counsellor, doctor, health educator but the beauty is if you are doing things to save life, everyone joins in, even the cleaners are part of the emergencies.”—General Hospital.

Referrals posed a major challenge to successful management. Children were referred due to facility limitations like a lack of specialized doctors (specifically, a paediatrician), supply shortages, or the need for higher-level care. Incomplete referrals were mainly due to transportation issues or fuel shortages. Notably, only 25% of public facilities had access to a fuelled ambulance.

• “They didn’t have transport to Jinja, and, in the ambulance, there was no fuel. We were stuck there; we were looking at each other with nothing to do and the child was in a critical condition.”—General Hospital.

All but two staff (98%) reported that their facility used some sort of triage, most commonly the general appearance of the child (35%) but Integrated Management of Childhood Illness (IMCI) (32%) and ETAT (24%) were also reportedly used. Among benefits of triaging, the ability to deal with patients with critical conditions quicker and appreciation from the community were mentioned.

• “I appreciate because at times there are emergencies like in [Outpatient Department] they have gone as far as getting different [colour coded] stamp, like for a seriously ill child, they use a red stamp, and you are able to identify that this patient needs serious attention.”—General Hospital.

67% of HCWs reported managing an emergency case within the last week. 76% managed with 2–3 people, and 31% had all necessary items available.

2. Communication as a part of management

All respondents reported that they had someone to consult when handling paediatric emergency cases. Of these, 53% responded that consultations were always possible, 19% reported "most of the time," and 28% said "sometimes." As a benefit of discussing with superiors, the HCWs mentioned the ability to improve and make positive changes in clinical practices.

In the qualitative interviews, receiving feedback from supervisors was mostly perceived as the supervisor’s ability to respond to HCWs requests in terms of tools, equipment, or additional staffing.

• “So, when we need to be supplied with power, we call the administration and when they respond it is positive feedback from the administration.”— General Hospital.

According to the participants, flaws of communication between facilities and scarcity of feedback resulted in compromised management, not being updated about their patients’ conditions, and a feeling of stagnation in professional development.

• Then too we have a challenge with feedback, we don’t get feedback from the referred points, we refer but getting feedback is still <…>, I don’t know whether my patient improved or not.”— Health Centre IV.

A third (32%) of respondents reported having debriefings after managing emergency cases. This was reportedly done during department meetings, continuous medical education (CME) meetings, quality improvement committee meetings, or audits.

• “We tend to have meetings with our departmental in-charges where we are able to raise our concerns that we are facing. When they can, we get the solutions and when they can’t, that is the situation, we are in.”—Health Centre IV.

3. Interaction with guardians

A total of 66% of respondents reported receiving regular appreciation. The primary sources of appreciation were patients (54%) and the general community (25%), with additional acknowledgment from colleagues (38%) and superiors (41%). In some facilities, village health teams worked as communicators between HCWs and the community, holding regular meetings and reporting feedback.

• “Yes, we get, there are those ones who appreciate, they come back and tell us that the services have improved compared to those days.”—Health Centre IV.

HCWs were forced to ask caregivers to contribute financially, thus the ability to provide care was oftentimes dependent on the financial situation of the caregiver, which in turn had an impact on the outcome.

• ”We want to help the patient, we have to talk to care takers and see if they can buy so that we are able to so that we are able manage the child and if they refuse still, we have nothing much to do.”—Health Centre IV.

4. Professional development

Of the participants, 47% had undergone any paediatric emergency care focused training, including ETAT, Advanced Paediatric Life Support (APLS), or Paediatric Advanced Life Support (PALS). Additionally, 29% had received refresher training, and 42% had engaged in simulation training.

Familiarity with the ETAT guidelines varied both across different facilities and within individual facilities. Participants who were familiar with the ETAT guidelines cited benefits such as reduced referrals, minimised delays, improved healthcare skills, and saved lives. They identified obstacles like shortages of critical supplies and suggested solutions such as ensuring availability of equipment and drugs, along with continuous training and supervision.

• “We would advocate more for refresher training, supplies and space because some things are out of our hands and also motivation for the people who are implementing.”—Regional Referral Hospital.

Notably, 51% health workers reported never receiving any form of training in paediatric emergency care. Another issue identified during qualitative interviews was the frequent turnover or relocation of trained staff.

Among all included HCWs, the median knowledge score was 10 (IQR 2–18). Knowledge scores were primarily increased with received training and refresher trainings (Table 3). Healthcare professionals who had undergone emergency management training and participated in refresher courses had a mean score of 13.2 (95% CI 11.6–14.8), compared to 9.2 (95% CI 8.0–10.3) among HCWs without emergency care training. The full results of regression analysis can be found in the supplementary file (S4 File).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Linear regression analysis of ETAT knowledge.

https://doi.org/10.1371/journal.pgph.0003666.t003

5. Healthcare workers’ motivation

Overall, the interviews revealed that having what was needed to deal with a paediatric emergency case led to better care, fewer referrals and HCWs’ contentment and self-satisfaction. On the contrary, inability to provide care due to limitations of equipment and medicines resulted in frustration and despair among health workers. HCWs expressed their effort to do whatever was possible despite the limitations using phrases such as “did my best”, “we tried our level best”, “it is not our fault”.

• “Ok I did my best but only that some of the things were not around like cannulas, syringes and some antibiotics.”—Health Centre IV.

The median self-reported work satisfaction among HCWs, was 6 (IQR 4–9) on a scale of 0–10. 51% of participants reported feeling prepared or well-prepared to manage paediatric emergency cases, and this feeling was associated with a higher self-scoring of work satisfaction (mean 6.9, 95% CI 6.5–7.2 versus mean 6.0, 95% CI 5.7–6.4). To add more, participants who felt well-prepared (51%) scored higher on the knowledge survey (mean 12.2 (95% CI 11.2–13.1) than those responding negatively (49%) (mean 8.5 (95% CI 7.3–9.7).

• “Yes, I was telling you that the benefits are on both sides of the patient and the health worker. When the patient gets the services, it will save life and also if I see my patient getting better, I feel good.”—Health Centre IV.

While not statistically significant, health workers who reported they felt appreciated had a median knowledge score of 11 (IQR 4–18), whereas those who did not feel appreciated had a median knowledge score of 10 (IQR 3–15). Additionally, no discernible differences were observed in work satisfaction based on whether respondents felt appreciated or not, or from whom the appreciation originated.

Organisational factors

Institutional limitations, such as shortage of medicines, equipment, and medical supply, along with understaffing, hinder the provision of quality care and jeopardize the successful implementation of ETAT+. These constraints are prevalent in low-resource settings and have been identified as demotivating factors in other studies [30–32]. Our findings also support previous reports of equipment and drug shortages [25, 26, 33]. A survey by Ugandan authorities highlighted significant lack of material and drugs, particularly in eastern Uganda [34]. Working without basic equipment not only demotivates HCWs but also contributes to HCW turnover [35] and deters young medical professionals from working in rural areas [36]. These challenges impact HCWs’ morale [37], leading to dissatisfaction [38] and increased workload [39].

Aside from the material shortages, insufficient human resources were also recognized as a challenge, leading to heavy workloads and negatively impacting worker motivation [40]. Among the 14 facilities in our study, only four had a paediatrician on their team. The lack of specialized medical workers is a global challenge, with LMICs bearing the greatest burden of understaffing [41].

Referring a child to another facility, when necessary, proved challenging, with only a quarter of the public facilities having access to a fuelled ambulance. Previous studies have demonstrated the high cost of referrals and transportation challenges as some of the weakest parts of emergency care in low-resource settings [26, 42]. Unreliable communication between facilities for organising referrals and underdeveloped referral systems were additional challenges. A qualitative study in rural Uganda revealed that guardians perceive ambulances as unreliable due to poor communication between the vehicle driver, healthcare centre and caregivers [42].

Efficient communication between colleagues and supervisors was not always reported. Lack of communication is a known precursor to medical errors [43]. Supervision and audits with constructive feedback can enhance worker performance, whereas poor communication between HCWs and managers negatively impacts worker motivation [44, 45]. We found no difference in workers’ satisfaction levels based on whether appreciation was felt even though it is consistently described in previous studies [46–49]. Improving teamwork, fostering debriefing practices, and conducting regular meetings can enhance worker performance without significant expense.

As feedback loops were ineffective, participants in our study sought alternative ways to stay updated on referred patients’ conditions. The desire for feedback resonates with findings from previous research where HCWs saw it as necessary for their professional development, even if 79% of them did not actively follow up with patients [26]. Comparably, a study in Tanzania revealed frustration when subsequent feedback after a referral was lacking, resulting in missed learning opportunities [50]. Developing referral networks and creating effective feedback loops are essential reforms for facilitating management and promoting learning opportunities.

Community and clients

The community context is critical to health workers’ motivational processes through its impact on worker experience of outcomes [51]. Strengthened connections with communities lead to increased feedback, enhancing worker performance [47]. Being appreciated by the community serves as a significant motivator, as found in studies in Tanzania and western Nigeria [52, 53]. A systematic review identified twelve studies confirming that good community relations increase motivation, underscoring the importance of social factors [30]. Caregivers are not only expected to but also directly contribute to the management of critically ill children, particularly in referrals. Lack of funds and transportation difficulties were significant barriers for caregivers to complete referrals in rural Uganda [42]. As emphasised in a study conducted in Kampala, high out-of-pocket expenditures serve as another barrier to accessing emergency care services [5].

Organisational efforts to improve workers capability

The evidence illustrates that HCWs value training opportunities and knowledge acquisition, consistent with prior studies [30, 31, 50, 54]. A comprehensive systematic review on HCWs motivation in the East African community highlights the importance of continuous education and training throughout one’s career [32]. In our study, health workers acknowledged the significance of training refreshment in enhancing performance on ETAT knowledge. However, HCWs also expressed frustration over possessing knowledge but being unable to utilize it due to material shortages required to adhere to guidelines [25, 55]. Inadequate organisation can exacerbate staff shortages and create workload imbalances, generating excessive workloads [37]. Disparities in training accessibility exist across healthcare cadres and sectors with workers from private sectors having fewer opportunities [37, 39, 45, 52]. Ensuring dissemination of knowledge is crucial for the successful adoption of new guidelines.