https://orcid.org/0009-0004-3797-317X
Figures
Abstract
Introduction
Uganda has a high demand for neurosurgical and neurological care. 78% of the over 50 million population reside in rural and remote communities where access to neurosurgical and neurological services is lacking. This study aimed to determine the feasibility, appropriateness, and usability of mobile neuro clinics (MNCs) in providing neurological care to rural and remote Ugandan populations.
Methods
Neurosurgery, neurology, and mobile health clinic providers participated in an education and interview session to assess the feasibility, appropriateness, and usability of the MNC intervention. A qualitative analysis of the interview responses using the constructs in the updated Consolidated Framework for Implementation Research was performed. Providers’ opinions were weighted using average sentiment scores on a novel sentiment-weighted scale adapted from the CFIR. A stakeholder analysis was also performed to assess the power and interest of the actors described by the participants.
Results
Twenty-one healthcare providers completed the study. Participants discussed the potential benefits and concerns of MNCs as well as potential barriers and critical incidents that could jeopardize the intervention. Of the five CFIR domains evaluated, variables in the implementation process domain showed the highest average sentiment scores, followed by the implementation climate constructs, inner setting, innovation, and outer setting domains. Furthermore, many interested stakeholders were identified with diverse roles and responsibilities for implementing MNCs. These findings demonstrate that MNC innovation is feasible, appropriate, and usable.
Citation: Mukumbya B, Kitya D, Trillo-Ordonez Y, Sun K, Obiga O, Deng DD, et al. (2024) The feasibility, appropriateness, and usability of mobile neuro clinics in addressing the neurosurgical and neurological demand in Uganda. PLoS ONE 19(6): e0305382. https://doi.org/10.1371/journal.pone.0305382
Editor: Nicholas Aderinto Oluwaseyi, Ladoke Akintola University of Technology Teaching Hospital: LAUTECH Teaching Hospital, NIGERIA
Received: January 2, 2024; Accepted: May 28, 2024; Published: June 24, 2024
Copyright: © 2024 Mukumbya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are included within the manuscript and its supporting information files. In addition, relevant deidentified data files containing all coded interviews, domain analysis, and data analysis codes are available from the Duke University Research Data Repository, and are accessible via the DOI: https://doi.org/10.7924/r4m90f080 (plain text: 10.7924/r4m90f080).
Funding: BM received funding from the Duke Global Health Institute (DGHI), [website: [https://globalhealth.duke.edu].
Competing interests: The authors have declared that no competing interests exist.
Introduction
Neurological disorders are among the leading causes of death and disability worldwide, with over 22 million people living with these disorders and 5 million deaths attributed to them annually [1, 2]. Access to neurological (synonymous with neurosurgical and neurological) care is disproportionately low in rural and remote settings, where healthcare barriers are prominent. Uganda is a low-income country (LIC), home to more than 50 million people and 1.5 million refugees [3, 4]. Furthermore, the World Poverty Clock (2023) estimates that 16% of Uganda’s population is impoverished, and 78% live in rural and remote communities where access to essential health care is limited or non-existent due to a variety of existing barriers [5, 6]. Given that Uganda only has four neurological hospitals, providing neurological care across the country is impossible [7–12]. Uganda’s demand for specialized neurological services exceeds its supply due to inadequate infrastructure and workforce [13, 14]. The aforementioned barriers lead to disparities in the quality of neurological care for people in rural and remote communities, signifying an urgent need for innovative approaches to neurological service delivery. These approaches should transcend geographical isolation and socioeconomic factors to address challenges such as limited access to neurological care, shortage of trained healthcare professionals, and inadequate infrastructure.
Mobile health clinics (MHCs) provide healthcare services in remote communities using customized vehicles or mobile units [15]. They are staffed by healthcare professionals who offer a variety of medical services and are used in many settings globally to meet the demand for healthcare, especially in resource-limited settings [16–18]. MHCs have been used to bring essential medical services to underserved populations worldwide, including in the United States (US) [16, 17, 19] and Uganda, where Jatho and colleagues used MHCs to provide cancer management to patients [20]. MHCs can significantly improve patient outcomes by providing patient education, early screening, identification, follow-up, and rehabilitation services [16, 17, 20–23]. Qureshi and colleagues successfully implemented mobile neuroendoscopy in East Africa, which treated hydrocephalus patients and trained a neurological workforce [24, 25]. Therefore, implementing well-designed MNCs can enhance healthcare equity by eliminating barriers that hinder rural and remote communities from accessing neurological care [26].
Given the evident neurological burden, constrained resources, and the potential effectiveness of MHCs in addressing Uganda’s challenges, the adaptation of MNCs becomes imperative [27, 28]. A pediatric neurosurgical MHC successfully designed and implemented by Owler and colleagues in rural and remote Australia improved neurosurgical outcomes for patients by decreasing the delays to definitive neurological care [21]. Some facilities in Uganda, such as CURE Children’s Hospital of Uganda (CCHU), have integrated mobile clinic models into neurosurgery practices, incorporating tools such as mobile endoscopy [25, 29–32]. The purpose of this study was to comprehensively analyze the potential and practicality of MNCs as a strategic intervention for improving neurological care, particularly in Uganda’s constrained remote and rural areas.
Methods
Study participants were interviewed after attending an educational session introducing the Mobile Neuro Clinics (MNCs) concept. The Consolidated Framework for Implementation Research (CFIR) domains and background literature from MHCs, neurosurgery, and neurology were used to design the educational content and interview guides [33–37]. Our approach aimed to align the study with a strong theoretical framework while ensuring the relevance and contextual applicability of the educational content (https://youtu.be/55fRRXSyMks) and (S1 File). The CFIR framework comprehensively evaluates innovations and their implementation in specific contexts [38–40]. As such the CFIR framework enables a holistic examination of the complex interplay of factors influencing MNCs and their successful implementation. Furthermore, the study included healthcare providers with varying experience levels, the CFIR framework was ideal for thoroughly evaluating the participants’ perspectives. By applying the CFIR guidelines, the study identified potential barriers and facilitators to innovation and further assessed Uganda’s current neurological services. This evaluation further identified whether MNCs are feasible, appropriate, and usable (S1 Table).
Setting and participants
The study was conducted at Mulago National Referral Hospital (MNRH), Mbarara Regional Referral Hospital (MRRH), and other locations chosen by MHC providers in Uganda. MNRH is Uganda’s largest public hospital, located in Kampala, with established neurological departments, and is affiliated with Makerere University. MRRH is a teaching hospital in western Uganda offering clinical services in mental health care, neurology, and neurosurgery. Mobile healthcare providers who were unable or preferred not to participate in the study at MNRH or MRRH were interviewed at a location of their choice.
Between July 27, 2022, and October 5, 2022, neurological specialists (neurosurgeons, neurologists, and residents) involved in patient care at MNRH and MRRH were recruited in the study. MHC administrators and healthcare professionals with at least one year of experience were also enrolled, within the same period, due to their understanding of how mobile health services operate in the country. All study participants were required to be competent in English. Participants who did not meet the above criteria were excluded.
Purposive sampling was used to select neurological and MHC providers for the study. Healthcare providers were contacted via phone, email, and in-person interactions and invited to attend an education session. Participants who attended the in-person education sessions at MNRH and MRRH were contacted to schedule interviews. Other participants who watched the YouTube education session (https://youtu.be/55fRRXSyMks) were also contacted for follow-up interviews. Prior research indicates that 12–16 interviews may provide at least 90% saturation; [41–43] however, the expected sample size for the recruitment pool of this study was 24 individuals.
Ethics statement
The study received ethical approval from the Duke Health Institutional Review Board (IRB) (Pro00110750) and from the Mulago Hospital Research Ethics Committee (MHREC 2317). Both verbal and written informed consent were obtained from study participants and documented on a pre-specified consent form approved by the two institutional ethical review boards. Study participants were compensated $35–52 USD upon their completion of the education session and interviews.
Data collection
Data were collected from consenting participants using secure recording devices provided by Duke Global Neurosurgery and Neurology (DGNN). All interviews were conducted in English by a single researcher (B.M.) to ensure consistency. The interview audio was securely stored on a secure Duke Box cloud, with access restricted to approved team members for transcription. Three team members (B.M., Y.T.O., and K.S.) transcribed the recordings independently. The transcripts were then thoroughly verified for accuracy by the investigator (B.M.) who conducted the interviews in the field, and any important revisions were performed to ensure high-quality transcriptions.
We conducted in-depth face-to-face interviews in which participants answered open-ended questions before being probed to clarify any additional information. Interview guides collected demographic information, and also had four different sections. The four sections collected information related to the understanding of healthcare, MHCs and their application in neurological care and other general medical specialties, and the barriers and facilitators to designing and implementing MNCs. The first part of the interview guide for MHC providers assessed their general understanding of neurosurgery and neurology, while that of neurological specialists assessed their general understanding of mobile clinics. The remaining three parts of both interview guides followed the same structure.
Data coding and analysis
We created two distinct codebooks from 5 sampled neurological and 4 sampled MHC providers’ interviews, respectively. These two codebooks were subsequently combined to form a single comprehensive codebook (S2 File and S2 Table). We used applied thematic analysis to build these codebooks, integrating inductive and deductive reasoning [43–45]. We guided our deductive approach with the CFIR-assigned constructs while allowing the inductive approach to help identify any new and emergent themes that the CFIR constructs had not previously considered [31, 32, 44, 45]. After B.M. developed the codes, the group provided feedback on what needed to be improved. A team of four individuals (B.M., Y.T.O., K.S., and A.T.F.) utilized Microsoft Excel to formulate and refine the codes and themes for analysis. The team thoroughly examined the codes, their meanings, and how they related to the study’s aims. After completing the full codebook, three team members (B.M., Y.T.O., and K.S.) individually coded the transcripts that were assigned to them. During team meetings, all four members reviewed the coded content to ensure the codes were correctly applied using the comprehensive codebook shown in Fig 1 and S2 File.
A detailed description of the themes, codes, and sub-child codes is in S1 and S2 Tables. The Innovation Domain describes all the characteristics of Mobile Neuro Clinics or Mobile Health Clinics and then goes on to explain how the intervention can be used to meet the demand for local neuro care. The Outer Setting Domain is the setting in which the Inner Setting exists: Uganda, international communities, and any other Communities. The Inner Setting Domain is the setting in which the innovation (MNCs) is intended to be implemented: rural and remote communities in Uganda. Implementation Climate Constructs characterize the ability to absorb change, the providers’ shared openness to MNCs, and the degree to which MNC use will be rewarded, encouraged, and anticipated. Individuals Domain describes the roles and characteristics of individuals. The Characteristics subdomain describes the MNC characteristics applicable to the roles in the MNC project. The Implementation Process Domain explains the procedures and strategies used to put the innovation into practice. The domain recorded the activities and strategies that would be used to implement the innovation, as well as the implementation process framework.
Sentiment weighted scale
Once the interviews had been transcribed, our team analyzed the data using a modified version of the sentiment-weighted scale (SWS) based on CFIR [33, 34, 46]. We adopted the SWS to assign sentiment ratings (SR) to the codes and themes that emerged from the interviews, considering the magnitude of each construct and its valence (positive or negative influence), [33, 34, 47] as shown in Table 1.
To evaluate the MNC concept’s feasibility, appropriateness, and usability, we compared log-transformed average sentiment scores (ASS) across five CFIR areas. Analyzed CFIR domains include the innovation domain, implementation climate construct, outer setting domain, inner setting domain, and implementation process domain. The ASS was defined as the average SR for the participants that responded to that theme or code. Computation and visualization were performed in R (The R Foundation for Statistical Computing, Vienna, Austria).
Stakeholder analysis
The team further determined the identified stakeholders’ power, interest, and roles based on the CFIR guidelines for the Individuals domain and the Characteristics subdomain [47–49]. Interviews with participants led to the identification of four major stakeholder types. High-level Leaders were defined as important decision-makers, executive leaders, directors, or government figures who have the power to influence the adoption of innovations [33, 34, 46–50]. Mid-level Leaders were managers responsible for supervising subordinates and were managed by high-level leaders [33, 34, 46–50]. Opinion Leaders describe stakeholders as those who exert subtle influence on the actions and thoughts of others [33, 34, 46–50]. Leaders in this category include religious leaders, local leaders, and traditional and cultural leaders. Implementation Facilitators described field experts who would provide guidance, coaching, or support during the implementation process [33, 34, 46–50]. This category included community health workers (CHWs), village health teams (VHTs), and medical officers.
The combination of sentiment and stakeholder analysis provides a comprehensive understanding of the challenges and opportunities faced by innovations while identifying key players that are critical to their successful establishment and operations.
Inclusivity in global research
Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S3 File).
Results
Demographics
A total of 21 healthcare professionals were interviewed. Twenty in-depth face-to-face interviews ranging from 20 minutes to 1 hour and 30 minutes were conducted, excluding the educational session components. Nineteen (95%) of the 20 interviews comprised distinct, in-depth face-to-face interviews, with two participants (5%) interviewed in the same session. Seven (33.3%) MHC providers and 14 (66.7%) neurological providers were interviewed.
The participants were between the ages of 25 and 65, with a mean age of 37.9 years and a median age of 35 years. Only three participants (14.3%) were female. Ten (47.6%) of the participants had only neurological care experience; eight (38.1%) had both neurological and MHC experience; and three (14.3%) had only MHC experience. Additionally, two neurological specialists and six MHC providers had administrative authority. The time in the profession ranged from 8 months to 25 years, with a mean of 6·3 years and a median of 5 years (Table 2).
Sentiment weighted scale results
We evaluated the sentiment ratings for five CFIR domains based on healthcare providers’ perceptions in our study. The implementation process domain variables had the highest ASS. The implementation climate constructs, inner setting domain, outer setting domain, and innovation domain ASSs followed sequentially. The perspectives of healthcare practitioners across all CFIR domains had a stronger positive valence, as observed in the boxplot in (Fig 2A). The positive valence of the SWS describes the significance of MNCs in terms of feasibility, appropriateness, and usability.
Fig 2A, the Domain Favorability, succinctly encapsulates providers’ enthusiastic embrace of innovative MNCs. The findings indicate a significant support for the MNC idea in the analyzed setting. Fig 2B, the Innovation Domain, delineates critical features of concern and facilitators pertaining to both MNCs and MHCs. Providers further elucidate how the intervention would address local neurological care demand. The Implementation Climate Constructs in Fig 2C demonstrate the high flexibility to change, providers’ collective receptivity to MNCs, and the level to which MNC adoption would be acknowledged, promoted, and anticipated. Fig 2D, the Outer Setting Domain, depicts Uganda’s, foreign communities’, and other locations’ roles in assisting MNCs. While impediments exist, various facilitators were identified that could support MNCs. In the Inner Setting Domain (Fig 2E), the focus was on the specific implementation setting, namely rural and remote communities in Uganda. Providers exhibit an exceptionally optimistic view in this domain regarding the MNC concept. Finally, Fig 2F, the Implementation Process Domain, delineates the procedural and strategic aspects of introducing the innovation. Providers discussed key activities and strategies essential for successful implementation, alongside an overarching implementation process framework.
Innovation domain
Innovation domain findings identified substantial insights into the fundamental components of MNCs from the perspective of providers. Six themes/codes (54.5%) scored high positive valency, while five (45.5%) scored negative valency (Fig 2B). Opinions from both providers show that there are numerous perceived benefits to the innovation (Fig 3). Additionally, ASS findings suggest that the providers support the idea that the innovation can be designed with numerous central, adaptable components in an appropriate amount of time to address neurological demands. The ASS, however, shows that the providers have numerous concerns, including the MNCs’ cost, disruptiveness, radicality, and intricacy. Fig 3 classifies the aspects of the relative advantage theme, including perceived benefits and concerns. Considering all factors, providers understand how critical it is to modify and rethink current mobile clinic models for neurological treatment to create superior MNCs. With thoughtful designs and implementation strategies, these MNCs have the potential to significantly improve access to critical neurological care and meet the current demand for neurological services. A neurologist emphasized that:
“Mobile neuro clinics might not be as good as being in a hospital. However, they may go a long way toward alleviating some of the community’s common conditions. Because [they] can treat and, more importantly, recognize the conditions… Then, because [they] identify cases and refer them to the center, [they] can undoubtedly improve referrals. In some ways, [they] also assist the staff and health care providers in rural areas. You also educate them on each condition. Teach them how to treat these conditions. As a result, it will greatly benefit the community.” (Neurologist).
Fig 3 unveils the relative advantages associated with MNC innovation as described by healthcare providers. The findings highlight the positive aspects of MNCs, demonstrating how the perceived benefits far surpass any perceived concerns. This illustrative diagram meticulously delineates the key perceived benefits that can be attained through carefully designing and implementing MNCs.
Implementation climate constructs
The implementation climate constructs explain how receptive healthcare providers are towards MNCs and how such innovation would be rewarded, supported, and expected. The research examined the implementation climate themes/codes and how participants anticipated how Ugandan communities and the government would respond to the intervention. Nine themes/codes (90%) scored a high positive valence, while only non-compatible aspects (10%) scored a negative valence. (Fig 2C). Respondents recognized the potential of MNCs as a two-pronged approach to alleviating shortages in neurological services. By delivering essential care directly to communities and emphasizing preventive measures, MNCs could benefit Ugandans at all levels of society. Nevertheless, providers expressed concerns about limited access to neuroscience knowledge, insufficient government support, and potential incompatibilities in the components essential for developing and implementing MNCs. Fig 4 summarizes the variables in the compatibility theme. One neurosurgery resident explained that:
“Outside of Kampala, you will only see Mbarara and CURE in Mbale, and that’s it… As a result, there is a significant deficit…” (Neurosurgery Resident).
Fig 4 presents a nuanced examination of the compatibility of mobile neuro clinics based on insights shared by healthcare providers. The research findings accentuate a comprehensive and notable summary, revealing that the compatible aspects of MNCs significantly outweigh the incompatible aspects. This visual representation offers a valuable perspective for actors, suggesting that Uganda possesses numerous quantifiable aspects that can be utilized during the integration of MNCs.
Outer setting domain
Healthcare providers assessed Uganda’s current condition and described potential unforeseen incidents related to the efficient implementation of MNC healthcare practices within the outer setting domain. Fig 2D shows nine (69.2%) themes/codes scored highly on the positive valence SWS for MHC providers and six (46.1%) for neurological specialists. Four (30.8%) themes/codes scored negatively on the valence SWS. The participants reinforced the need to recognize that, despite commendable efforts, the present neurological care initiatives are not up to standard with the expanding demands. Numerous determinants of neurological disorders are on the rise, necessitating continuous collaboration, innovation, and resource allocation to address the evolving healthcare needs of the Ugandan population. Most of the themes/codes in the outer setting domain support the successful implementation of the innovation concept, while the others describe aspects to be cautious about. A neurosurgeon explained that:
“We must ascertain how we fall under the legal purview of medical practice and which laws apply to mobile clinics. You are aware that any clinic operating within the nation is subject to some type of legal regulation… Because you need a license to register as a clinic right now. These licenses are now linked to URSB registration, which is one of the rules. You must register, and your clinic must be registered as a company with an address, so those are some of the problems you’ll encounter. What’s going to be the address of the mobile clinic?” (Neurosurgeon).
Inner setting domain
The inner setting domain examined healthcare providers’ perspectives on Uganda’s rural and remote communities. The domain evaluated providers’ opinions on local communities and how they considered innovation could be beneficial to these regions. All the themes and codes scored highly in the positive valence on the SWS. Based on the ASS scores, the providers’ opinions indicate that MNCs are culturally appropriate, and as such, strategies to allow MNCs to operate can be developed, as shown in Fig 2E. As a result, the providers emphasized the collaboration of MNCs and health centers.
“Collaboration with the health system, I believe, is an important factor. The current structure of the health-care system includes either a health center III or a health center IV. That could be useful. It would be extremely beneficial. And then train the health center I in the village; there are village health teams (VHTs) to try to identify those other people in the community who need help but are unwilling to go to the hospital or change their attitude. As a result, VHTs are being incorporated. It would be ideal.” (Neurologist).
Implementation process domain
The implementation process domain findings described potential barriers, efficient strategies, and the resources required for successful MNC implementation. Eleven (73.3%) themes or codes scored on the positive valence of the SWS, and only four (26.7%) scored on the negative valence. (Fig 2F). According to the ASS, interviewees expressed numerous aspects that can be utilized to overcome the existing barriers. Fig 5 depicts the barriers that might be encountered in the Ugandan context when MNC innovation is designed and implemented, while Fig 6 summarizes the planning and strategies the providers suggested to utilize the limited resources to implement MNCs efficiently. Providers also recognize that part of the MNC intervention would involve community outreach and campaigns, among other activities.
“So those people who have an influence on the population, the local citizens, have to be really educated, so there are going to be massive community awareness exercises and campaigns for long, protracted times to get these people to understand the neurosurgical problems that need intervention.” (Neurosurgeon).
Providers described barriers at the individual level, community level, hospital level, and hospital level. These identified barriers collectively prevent neurological patients from initiating, accessing, and receiving necessary neurological care. Such impediments have the potential to harm one’s health and incur severe financial burdens.
Insights from healthcare providers delve into the realm of planning and tailoring strategies, emphasizing the essential elements required for the successful implementation of MNCs. This diagram outlines key planning considerations that, if carefully executed, have the potential to facilitate widespread adoption by MNCs.
Stakeholder analysis from individuals domain and sub-characteristics
The stakeholder analysis interpretations integrate perspectives based on individuals and sub-characteristic domains to examine the power and interests of key actors critical to the innovation. Fig 7 presents numerous actors along with their respective roles and responsibilities essential for the implementation of MNCs in Uganda’s communities. Providers encourage engaging stakeholders from the start, which is of prime importance.
“Involving the Ministry of Health is critical. Mobilizing the community and then identifying these mobile providers, of which there are many: nurses and doctors who want to join and sensitizing them. That, I believe, is significant.” (MHC Provider).
A power vs. interest analysis of high-level, middle-level, opinion leaders, and implementation facilitators. High-level leaders were identified as decision-makers, executive leaders, or directors with the authority to influence the innovation process. Mid-level leaders, on the other hand, include managers who supervise subordinates and are managed by high-level managers. Their powers are modest, and they play an important role in implementing innovations. Opinion leaders were described as having a subtle influence on the behavior and thinking of others. Religious leaders, local leaders, traditional/cultural leaders, and others are examples of opinion leaders. These actors were described as able to influence the acceptance and implementation of innovations in their communities. Implementation facilitators were identified as on-site experts who provide guidance, coaching, or support during the implementation phase. They include community health workers and medical personnel, who ensure that innovations are effectively implemented and utilized.
Discussion
This qualitative study evaluated the feasibility, appropriateness, and usability of mobile neuro clinics (MNCs) to provide neurological care to Uganda’s remote and rural populations. Our findings indicate that MNCs were considered feasible, appropriate, and usable for rural and remote communities in Uganda. Respondents emphasized numerous advantages, including demystifying neuroscience; early diagnosis and initiation of neurological care; providing patient follow-up; strengthening referral networks; and, most importantly, improving the country’s overall quality of neurological care. In addition to the discerned advantages, healthcare providers also outline strategies for leveraging facilitators while carefully overcoming barriers and engaging stakeholders at every stage of the process.
Our findings further provide additional clarification on the multifaceted substantive design and implementation challenges MNCs could face during the delivery of neurological care. These challenges encompass a spectrum of concerns, barriers, and critical incidents, the origins of which could be attributed to the prevailing context in Uganda. Additionally, providers repeatedly conveyed the intricate nature of neurological care and the absence of explicit policies and regulations governing the activities of MHC providers. However, despite these challenges, MNCs have the potential to improve neurological care by reducing the time, distance, and delay between patients and neurological interventions.
Feasibility, appropriateness and usability assessed by the sentiment weighted scale
According to the ASS, it was evident that the findings supported the positive valence in all the domains. Consequently, this suggests that MNCs are feasible, appropriate, and usable. Furthermore, the participants identified numerous stakeholders and their roles in the individual domains and characteristics subdomains. The findings suggest that existing facilitators can be leveraged to ensure MNCs’ effective design and implementation. Fig 8 summarizes the concept ideas of the MNC from the providers’ suggestions.
(left, MNC unadapted; right, Adapted). Findings improve our understanding of the potential impact of MNCs on neurological care. The innovation, when adapted, could meet numerous expectations. It is evident that emphasis must be placed on engaging stakeholders who operate in all domains. “Numerous Challenges exist, but planning, tailoring strategies, and doing are the steps that can get the innovation operational. Evaluating and Reflecting can be the aspects that ensure that the innovation continues to operate efficiently”.
Innovation domain
Most participants were optimistic about the potential benefits that MNCs could provide to the general community, despite several concerns surrounding their adoption. The providers’ enthusiastic perspective originates from their previous experiences with mobile health services, recognizing the potential advantages introduced by such advancements. However, the intricate nature of neurological specialties introduces an additional layer of complexity to the design of MNCs. Providers believe that this high level of complexity could hinder the seamless adoption of MNCs in neurological care. As a result, MNC integration necessitates a tailored approach that addresses the complexities specific to neurological care and Uganda. Recognizing and proactively addressing these difficulties is critical to the effective design of MNCs.
Shrime and colleagues (2016) notably advocated developing and deploying mobile surgical units (MSUs) in Uganda [51]. In their research, they explain how MSUs could help Uganda achieve its sustainable development goals (SDGs) and could significantly enhance access to critical surgical procedures. Based on this precedent, MSUs were introduced in Sudan, thereby improving patient access to critical surgical procedures [52]. Furthermore, Qureshi and colleagues’ research signifies the safety, convenience, and cost-effectiveness of mobile endoscopic procedures, providing credibility to MNC’s practicality [24, 25, 53]. Similarly, the implementation of mobile clinics in healthcare settings has demonstrated favorable results. For instance, in order to enable follow-up visits and prompt referral of potential clinical issues, BethanyKids, a Christian service provision organization at Kijabe Hospital, set up mobile clinics at 15 locations throughout Kenya [54]. These projects demonstrated the potential of mobile clinics while emphasizing the importance of tailored strategies for the successful development and use of innovative medical treatments. By leveraging the collective expertise accrued from a variety of evidence and real-world applications, there is an opportunity to build high-quality MNCs that effectively address the complexities inherent in the delivery of neurological care.
Implementation climate constructs
Healthcare providers emphasized the need for change to address the urgent demand for enhanced neurological services while acknowledging that MNCs could fill gaps in the current neurological care system. According to the providers, Uganda’s main objective of advancing public health is in line with the proposed MNC concept. Participants acknowledged that MNCs could serve as a long-term factor in the advancement of neurological care. This collective perspective emphasizes MNCs’ perceived value and prospective impact, conveying their role as a dynamic and developing part of the larger healthcare framework.
Uganda began its pursuit of neurosurgery in the late 1960s, with groundbreaking work done at Kampala’s Mulago Hospital [55]. The practice has grown in scope and spread to CCHU in Mbale, Eastern Uganda and MRRH in Western Uganda [56–58]. Regardless of these establishments, neurological services are still in deficit and are unevenly dispersed. In Uganda’s situation, a number of issues include poor access, a high surgical volume, a sparse workforce, and a lack of vital resources in the healthcare system [59, 60]. Addressing this challenge necessitates both innovative curative interventions and preventive measures.
Our study highlights the potential of MNCs as a two-pronged approach to alleviate deficits in neurological care. By delivering essential care directly to communities and emphasizing preventive measures, MNCs have the ability to benefit Ugandans at all levels of society [20, 24, 25, 61]. However, providers expressed multifarious concerns about limited access to neuroscience knowledge, minimal government support, and potential incompatibilities in the components essential for developing and implementing this innovation.
Outer setting domain
Healthcare providers highlighted a substantial demand for neurological services in Uganda, exacerbated by challenging economic and technological conditions [5, 62]. Additionally, the local attitudes towards neuroscience remain distinctly unfavorable. Given these challenges, providers recognize that the strategic implementation of MNCs could substantially ameliorate the situation. Honoring the importance of collaboration, providers highlighted existing partnerships and underscored the potential for additional cooperation, emphasizing the pivotal role these alliances play in making the vision of MNCs a reality. Nonetheless, participants raised legitimate concerns about potential challenges, with particular emphasis on unforeseen incidents, such as medical errors that could significantly impact the practice of MNCs. Furthermore, the lack of well-established norms and laws for MNCs poses a significant obstacle, highlighting the need for a comprehensive regulatory framework.
Regardless of the uncertainties, global and national initiatives have been launched to improve neurological capacity. Notably, the "4 T’s Paradigm" established through Duke and Uganda’s collaborative efforts has significantly increased training and technological capacity [55, 63, 64]. The neurological providers expressed gratitude to Duke University, DGNN, CURE International, and numerous other supporters for their ongoing efforts to improve neurosurgery practice. The College of Surgeons of East, Central, and Southern Africa (COSECSA) and the DGNN collaborate to provide specialized neurosurgery training, nurturing a group of practitioners who actively support the nation’s neurological care capability [55, 63, 65, 66]. The locally trained Ugandan neurosurgeons could help operate MNCs. In addition, Makerere University, Mbarara University, and some private institutions in Uganda offer the Master of Medicine (MMed) program aimed at improving the neurosurgical workforce [56, 67, 68].
Inner setting domain
Opinions in the inner setting domain were overwhelmingly positive because providers explained that MNCs that are well-designed and effectively implemented have the potential to integrate seamlessly with the communities and cultures they serve. The findings further emphasized the significance of effective communication and establishing meaningful connections with local populations and healthcare facilities. Successful MNCs, as demonstrated by previous research, [20, 61] hinge on the ability to foster trust and rapport within communities, thus enhancing the acceptance and uptake of neurological services.
Respondents advocated the significance of various structural characteristics in fulfilling the neurological demands of Uganda’s rural and remote locations. These include robust physical infrastructure, advanced information technology systems, and a skilled workforce [51, 69]. It is widely recognized that many parts of Uganda face limitations in these structural aspects of health care delivery. MNCs, with their flexibility and adaptability, [70] have the potential to fill these gaps and enhance healthcare support in areas with limited infrastructure in a cost-effective manner. The NeuroPIPES survey corroborates the challenges faced by hospitals across Uganda, indicating shortages in personnel, infrastructure, equipment, and supplies [36]. These shortages directly impact the number of neurosurgery procedures that can be performed, emphasizing the urgent need for innovative solutions such as those from MNCs to bridge these gaps [24, 25, 36, 51, 52, 70].
An informative example pertaining to the impact of MNCs comes from a neurosurgeon with MHC experience. Based on their experience in Ruharo, southwestern Uganda, MHCs deliver service to more than 400 neurosurgery cases annually. Additionally, CCHU in Mbale is successfully operating mobile neurological services in many parts of Uganda [71]. The firsthand testimony and the evidence from practical implementation demonstrate the concrete role that MNCs could play in providing crucial neurological management to marginalized populations.
Implementation process domain
The landscape of neurological care in Uganda is suffused with a myriad of barriers, spanning individual, community, hospital, and systemic levels [72, 73]. Providers, in particular, described the systemic issues that exist, where a plethora of parties with opposing agendas compete for limited resources [74]. Kapiriri and colleagues (2007) described the contention that Uganda has to consider international interests when setting health priorities, unlike many high-income countries [75]. Consequently, MNCs face stiff competition for resources, similar to other healthcare initiatives in the country, demanding careful strategic planning.
Providers further referenced the intricacy of neurological care as a significant barrier that transcends pure resource allocation challenges. Several researchers have noted that neurological care is multidisciplinary and highly specialized, with unique complexities [76, 77]. This multidisciplinary nature poses challenges in designing and implementing MNCs effectively. The ethical considerations are paramount, given that many neurological conditions necessitate collaboration among multiple healthcare professionals to ensure definitive and quality care [37]. Ford and Kubu (2006) assert that neurological care holds the potential to significantly alter various facets of a patient’s personhood, including mood, personality, and cognitive abilities—attributes highly esteemed in patient well-being [78]. As a result, before investing in the design and implementation of MNCs, innovations in neurological care must be carefully planned.
Concerns about the high level of technical specialization in neurological care should also be considered before designing MNCs. Cobb and colleagues (2016) emphasize that quality is more important than quantity in neurological care. As a result, a high level of technical expertise is required to avoid more than 75% of preventable and technical neurological errors [79]. Therefore, ensuring successful neurological care outcomes requires highly skilled care providers, specialized environments, and equipment. When determining the scope of MNCs, both the interdisciplinary nature and the highly specialized nature of neurological care should be evaluated.
Stakeholder analysis from individuals domain and sub-characteristics
The study’s comprehensive analysis identified four pivotal stakeholder categories in the innovation process: high-level leaders, mid-level leaders, opinion leaders, and implementation facilitators. This comprehensive evaluation elucidates the unique roles and responsibilities inherent to each stakeholder group, providing a solid foundation for a strategic approach designed to ensure optimal design, implementation, and adoption by MNCs. Central to this analysis was the assessment of the stakeholders’ varying levels of interest in innovation and health, revealing a spectrum of engagement across the stakeholder landscape.
The Neurosurgical Society of Uganda (NSU), founded in 2017, [80, 81] is a notable example of this. This dynamic organization, comprising prominent neurosurgeons committed to providing high-quality medical care, stands as a beacon of progress in the Ugandan healthcare landscape. The NSU, driven by key neurosurgeons deeply entrenched in the evolution of neurosurgical practices, has taken proactive measures [82]. These dedicated providers have integrated mobile services into their healthcare approaches, recognizing the transformative potential of such initiatives. Their proactive engagement underscores the tangible benefits of adopting mobile services in the country, offering valuable insights into how partnerships can be forged to sustainably support the development and operation of MNCs. This response exemplifies a collaborative approach within the healthcare sector, highlighting the essential role of stakeholder buy-in in driving innovation and fostering sustainability.
Global health actors would also be crucial in influencing the planning and implementation of MNCs in Uganda, in addition to the local stakeholders. Prominent global health organizations, such as the conjoined effort between Duke Global Health Institute (DGHI) and DGNN, [36, 55, 83] Duke University Medical Center, [84] Global Partners in Anesthesia and Surgery (GPAS), [85] Stanford Global Health Neurosurgery, [86] and others, have all shown a dedication to strengthening Uganda’s surgical and neurological care infrastructure. To address and raise the caliber of neurological care delivery in the area, a comprehensive strategy should be implemented through the collaboration and active participation of these numerous stakeholders.
Feasibility, appropriateness, and usability findings
The findings of our study hold significant implications for the successful implementation of MNCs in Uganda. While the innovation concept demonstrates feasibility, appropriateness, and usability, it is essential to acknowledge and address potential concerns and barriers to its effective deployment. Our research underscores the importance of exercising caution throughout the implementation process, emphasizing the need for a meticulous approach to realize the intended benefits. Moreover, the identification of facilitators that can be leveraged to overcome obstacles is crucial. Additionally, the active involvement of stakeholders at all levels is paramount for the sustained success of MNCs in Uganda.
These insights contribute to the development of a comprehensive framework that aligns MNCs with Uganda’s unique healthcare landscape, paving the way for improved neurological care delivery. The implications derived from this study reinforce the critical role of strategic and collaborative approaches in guiding MNCs on their trajectory toward conceptual integration into the Ugandan healthcare system. Strategic planning and collaboration emerge as necessities for the successful integration of MNCs into the existing healthcare system considering the recognized potential and envisaged outcomes.
Limitations and study strengths
In this study, we employed rigorous inclusion and exclusion criteria for the participants, excluding many healthcare workers, including nurses and anesthesiologists, among others. However, it is important to note that neurological services are multidisciplinary fields that rely on collaboration with various medical specialties and professionals. Hence, gathering insights from other medical specialties involved in neurological care could have added valuable perspectives to the study. Unfortunately, two important healthcare facilities, BNRMH and CCHU, were administratively censored from participating in the study due to logistical and time constraints. BNRMH is known for its expertise in treating epileptic patients, and their inclusion in the study could have provided further enriching insights into neurological care. Similarly, CCHU, a private hospital that incorporates mobile clinic aspects into its services, may have provided greater insight into existing mobile neurological care practices and contributed to a more thorough knowledge of the innovation’s design and implementation. Also, the perspectives of other stakeholders, such as policy makers and health sector leaders were not captured, further adding to the limitations of the study.
Additionally, potential bias could have been introduced by basing the calculation of average sentiment scores solely on respondents related to a specific theme or code. As a result, the sentiment analysis might not be representative of the interviewed respondents in a few domains with low response rate from the participants.
Despite these limitations, the study benefited from a robust methodological framework, utilizing the Consolidated Framework for Implementation Research (CFIR). This framework facilitated a comprehensive exploration of key domains and ensured consistency and reliability in data collection. Utilizing the sentiment-weighted scale derived from the CFIR provided a refined dimension to the analysis, ensuring a more precise evaluation of aspects essential to the innovation concept’s feasibility, appropriateness, and usability. Moreover, the study maintained a coherent structure with consistent formats for the education and interview sessions, ensuring a seamless transition that enhanced participant understanding and engagement.
A Ugandan expert (B.M.) monitored the study’s design and implementation. This method was crucial in maintaining cultural relevance, local context sensitivity, and a comprehensive awareness of the Ugandan healthcare system’s complexities. The participation of a Ugandan supervisor provides a dimension of authenticity to the study, improving its quality and contributing to the findings’ credibility in the local context.
Future implications
Our findings provide a suggestive model for designing and implementing MNCs successfully. Based on the suggested model, strategic considerations include completing a needs assessment, engaging stakeholders, and leveraging facilitators. Conducting a detailed needs assessment would provide insight into the community’s distinct neurological issues. The strategy will enable MNCs to tailor responses to the specific needs of local populations, thereby increasing the effectiveness and relevance of neurology services. Collaborative efforts at global and national levels will result in a holistic approach that considers different perspectives, resources, and skills, providing a more robust and long-term framework for implementation by MNCs. Finally, by leveraging facilitators, any barriers can be proactively addressed to facilitate the seamless integration of MNCs into the healthcare landscape while improving the overall quality of neurological care delivery. Future steps include developing a logical conceptual MNC framework, finding funding sources to design and implement MNCs through grants and other sources, and engaging local and global collaborators [87–90].
While MNCs remain feasible, appropriate and usable for enhancing and strengthening neurological care in Uganda, practical alternatives such as telemedicine, community outreach, and awareness campaigns have the ability to supplement MNCs in the short term to strengthen neurological care [20, 91–94]. Long-term planning for neurological care necessitates capacity building at all levels, neurological workforce training, and collaboration with a wide range of stakeholders [55, 63–66] This comprehensive and sustainable healthcare model would provide holistic neurological care while also tailoring it to Uganda’s context and challenges.
Conclusion
In this study, we assessed the feasibility, appropriateness, and usability of MNC’s concept in Uganda using the CFIR framework. We discovered that the five CFIR domains demonstrated high positive valence, and the overall ASS was similarly high. Since the average sentiment scores favored positive valence, the MNC’s concept was considered feasible, appropriate, and usable. Additionally, the results of the stakeholder analysis examined the power and interests of several stakeholders who ought to be involved in different significant capacities during the establishment and operation of MNCs.
By comprehensively elucidating the barriers and facilitators influencing the feasibility, appropriateness, and usability of Mobile Neuro Clinics (MNCs), as well as delineating the roles of various actors, our study not only provides essential guidelines for the MNC intervention concept but also elucidates the actors who should be engaged throughout the process. Despite several barriers, concerns, and critical incidents, healthcare providers continually emphasized the need for change. They considered the MNC intervention to be aligned with the mission of delivering healthcare to all. As a result, providers developed ways to overcome these limitations to provide quality neurological care through MNCs.
Finally, additional efforts should focus on establishing the specific parameters of MNCs, as well as engaging multiple actors, acknowledging that this endeavor cannot be handled by a single stakeholder. Active participation and transparency should be prioritized throughout the process since they are crucial for designing and putting into practice an innovation that truly benefits all stakeholders. In doing so, stakeholders at the national and global levels will be able to collaborate and develop an innovative MNC.
Supporting information
S3 File. Inclusivity in global health research.
https://doi.org/10.1371/journal.pone.0305382.s003
(DOCX)
Acknowledgments
The authors would like to thank Mulago National Referral Hospital and Mbarara Regional Referral Hospital for being supportive of this research. Special appreciation is extended to Dr. Michael Muhumuza, and Dr. Oscar Obiga for their support with data collection. We would like to appreciate the health care providers who participated in this study. We also thank the DGHI Research Design and Analysis Core (RDAC) for their insightful criticism and assistance during the study’s design and analysis stages. We are particularly grateful to Jennifer Headley, Catherine Staton, Joao Ricardo Nickenig Vissoci, and Anna Tuptez. Their perceptive viewpoints and helpful criticisms significantly improved the robustness of our study. We also want to thank the Duke Center for Data and Visualization Sciences. Specifically, Lauren Nichols offered invaluable perspectives into the nuances of our data, which improved the accuracy and depth of our conclusions.
References
- 1. Morris K, Nami M, Bolanos JF, Lobo MA, Sadri-Naini M, Fiallos J, et al. Neuroscience20 (BRAIN20, SPINE20, and MENTAL20) Health Initiative: A Global Consortium Addressing the Human and Economic Burden of Brain, Spine, and Mental Disorders Through Neurotech Innovations and Policies. J Alzheimers Dis. 2021 Jan 1;83(4):1563–601. pmid:34487051
- 2.
Organization WH. Neurological disorders: public health challenges [Internet]. World Health Organization; 2006 [cited 2023 Mar 10]. Available from: https://apps.who.int/iris/handle/10665/43605
- 3.
Refugee population by country or territory of asylum | Data [Internet]. [cited 2023 Feb 3]. Available from: https://data.worldbank.org/indicator/SM.POP.REFG
- 4.
Uganda. In: The World Factbook [Internet]. Central Intelligence Agency; 2023 [cited 2023 Feb 3]. Available from: https://www.cia.gov/the-world-factbook/countries/uganda/
- 5. Fuller A, Tran T, Muhumuza M, Haglund MM. Building neurosurgical capacity in low and middle income countries. eNeurologicalSci. 2016 Jun;3:1–6. pmid:29430527
- 6.
World Poverty Clock [Internet]. [cited 2023 Feb 3]. Available from: https://worldpoverty.io
- 7.
Mulago National Referral Hospital [Internet]. Ministry of Health | Government of Uganda. [cited 2023 Feb 3]. Available from: https://www.health.go.ug/sermon/mulago-national-referral-hospital/
- 8.
Mulago National Referral Hospital | Life is Precious [Internet]. [cited 2023 Feb 3]. Available from: https://mulagohospital.go.ug/
- 9.
Mbarara Regional Referral Hospital [Internet]. Ministry of Health | Government of Uganda. [cited 2023 Feb 3]. Available from: https://www.health.go.ug/sermon/mbarara-regional-referral-hospital/
- 10.
Mbarara Regional Referral Hospital [Internet]. [cited 2023 Feb 3]. MRRH. Available from: https://mbararahospital.go.ug/
- 11.
Butabika Hospital [Internet]. [cited 2022 Oct 13]. Butabika National Referral Mental Hospital. Available from: https://www.butabikahospital.go.ug/
- 12.
CURE International | [Internet]. 2020 [cited 2023 Feb 3]. Uganda | CURE International Mbale pediatric neurosurgery. Available from: https://cure.org/hospitals/uganda/
- 13. Sader E, Yee P, Hodaie M. Assessing Barriers to Neurosurgical Care in Sub-Saharan Africa: The Role of Resources and Infrastructure. World Neurosurg. 2017 Feb;98:682-688.e3. pmid:27506409
- 14. Ukachukwu AEK, Still MEH, Seas A, Von Isenburg M, Fieggen G, Malomo AO, et al. Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030. J Neurosurg. 2022 Aug 1;1–12. pmid:35962968
- 15. Malone NC, Williams MM, Smith Fawzi MC, Bennet J, Hill C, Katz JN, et al. Mobile health clinics in the United States. Int J Equity Health. 2020 Dec;19(1):40. pmid:32197637
- 16. Coaston A, Lee SJ, Johnson J, Hardy-Peterson M, Weiss S, Stephens C. Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review. Popul Health Manag. 2022 Apr 1;25(2):264–79. pmid:35442787
- 17. Yu SWY, Hill C, Ricks ML, Bennet J, Oriol NE. The scope and impact of mobile health clinics in the United States: a literature review. Int J Equity Health. 2017 Dec;16(1):178. pmid:28982362
- 18. Awuah WA, Adebusoye FT, Tenkorang PO, Mehta A, Mustapha MJ, Debrah AF, et al. Ailing neurosurgical services in rural Africa. Int J Surg Lond Engl. 2023 Mar 3;109(3):227–9. pmid:36906787
- 19. Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg. 2018 Apr 1;1–10. pmid:29701548
- 20. Jatho A, Mugisha NM, Kafeero J, Holoya G, Okuku F, Niyonzima N. Mobile cancer prevention and early detection outreach in Uganda: Partnering with communities toward bridging the cancer health disparities through “asset-based community development model”. Cancer Med. 2020 Oct;9(19):7317–29.
- 21. Owler BK, Browning Carmo KA, Bladwell W, Fa’asalele TA, Roxburgh J, Kendrick T, et al. Mobile pediatric neurosurgery: rapid response neurosurgery for remote or urgent pediatric patients. J Neurosurg Pediatr. 2015 Sep;16(3):340–5. pmid:26090548
- 22. Gillispie M, Mobley C, Gibson LM, Moore de Peralta A. Perceptions of and Preferences for a Mobile Health Clinic for Underserved Populations. 99 [Internet]. 2016; Available from: https://tigerprints.clemson.edu/languages_pubs/99
- 23. Stasinaki A, Büchter D, Shih CHI, Heldt K, Güsewell S, Brogle B, et al. Effects of a novel mobile health intervention compared to a multi-component behaviour changing program on body mass index, physical capacities and stress parameters in adolescents with obesity: a randomized controlled trial. BMC Pediatr. 2021 Jul 9;21(1):308. pmid:34243738
- 24. Qureshi MM, Piquer J, Young PH. Mobile endoscopy: a treatment and training model for childhood hydrocephalus. World Neurosurg. 2013 Feb;79(2 Suppl):S24.e1-4. pmid:22381851
- 25. Piquer J, Qureshi MM, Young PH. Impact of mobile endoscopy on neurosurgical development in East Africa. World Neurosurg. 2010 Apr;73(4):280–4. pmid:20849778
- 26. Cheyuo C, Hodaie M. Editorial. Neurosurgical capacity-building in Africa: how do we build an equitable future? J Neurosurg. 2022 Aug 12;138(4):1098–9.
- 27. Upadhyayula PS, Yue JK, Yang J, Birk HS, Ciacci JD. The Current State of Rural Neurosurgical Practice: An International Perspective. J Neurosci Rural Pract. 2018 Jan;09(01):123–31. pmid:29456356
- 28. Punchak M, Mukhopadhyay S, Sachdev S, Hung YC, Peeters S, Rattani A, et al. Neurosurgical Care: Availability and Access in Low-Income and Middle-Income Countries. World Neurosurg. 2018 Apr;112:e240–54. pmid:29325943
- 29. Stagno V, Mugamba J, Ssenyonga P, Kaaya BN, Warf BC. Presentation, pathology, and treatment outcome of brain tumors in 172 consecutive children at CURE Children’s Hospital of Uganda. The predominance of the visible diagnosis and the uncertainties of epidemiology in sub-Saharan Africa. Childs Nerv Syst. 2014 Jan 1;30(1):137–46. pmid:24132516
- 30. Onweni CL, Venegas-Borsellino CP, Treece J, Turnbull MT, Ritchie C, Freeman WD. The Power of Mobile Health. Mayo Clin Proc Innov Qual Outcomes. 2021 Apr 23;5(2):486–94.
- 31. Baker DE, Nolting L, Brown HA. Sci-Hub | Impact of point-of-care ultrasound on the diagnosis and treatment of patients in rural Uganda. Tropical Doctor, 51(3), 291–296 | [Internet]. 2021 [cited 2023 Jan 22]. Available from: https://sci-hub.st/10.1177/0049475520986425
- 32. Budohoski KP, Ngerageza JG, Austard B, Fuller A, Galler R, Haglund M, et al. Neurosurgery in East Africa: Innovations. World Neurosurg. 2018 May;113:436–52. pmid:29702967
- 33. Damschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022 Oct 29;17(1):75. pmid:36309746
- 34. Damschroder LJ, Reardon CM, Opra Widerquist MA, Lowery J. Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): the CFIR Outcomes Addendum. Implement Sci. 2022 Dec;17(1):7. pmid:35065675
- 35. Kiryabwire JW. Neurosurgery in Uganda. Neurosurgery. 1987 Apr;20(4):664–5. pmid:3587563
- 36. Ploss B, Abdelgadir J, Smith ER, Fuller A, Nickenig Vissoci JR, Muhindo A, et al. Pilot Use of a Novel Tool to Assess Neurosurgical Capacity in Uganda. World Neurosurg. 2017 Dec;108:844–849.e4. pmid:28826868
- 37. Koltai DC, Kakooza-Mwesige A, Haglund MM. Understanding the cultural context of epilepsy care in Uganda: Introduction to this special issue. Epilepsy Behav EB. 2021 Jan;114(Pt B):107293. pmid:32943332
- 38. Komatsu R. A practical framework for evaluating innovation projects [Internet]. Open Science Framework; 2021 Jun [cited 2023 Jun 15]. Available from: https://osf.io/uhzsk
- 39. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Dec;4(1):50.
- 40. Dobni C B., Klassen M. Linking Innovation Measurement to an Implementation Framework: A Case Study of a Financial Services Organization at the Front End of Innovation. J Innov Manag. 2018 May 8;6(1):80–110.
- 41. Hennink MM, Kaiser BN, Marconi VC. Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough? Qual Health Res. 2017 Mar;27(4):591–608. pmid:27670770
- 42. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field Methods. 2006 Feb;18(1):59–82.
- 43. Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. Soundy A, editor. PLOS ONE. 2020 May 5;15(5):e0232076. pmid:32369511
- 44.
Guest G, MacQueen KM, Namey EE. Applied thematic analysis. Thousand Oaks, California: SAGE Publications; 2012.
- 45. Javadi M, Zarea K. Understanding thematic analysis and its pitfall. J Client Care. 2016;1(1):33–9.
- 46. Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci. 2013 May 10;8(1):51. pmid:23663819
- 47. Breimaier HE, Heckemann B, Halfens RJG, Lohrmann C. The Consolidated Framework for Implementation Research (CFIR): a useful theoretical framework for guiding and evaluating a guideline implementation process in a hospital-based nursing practice. BMC Nurs. 2015 Aug 12;14(1):43.
- 48. Depla AL, Crombag NM, Franx A, Bekker MN. Implementation of a standard outcome set in perinatal care: a qualitative analysis of barriers and facilitators from all stakeholder perspectives. BMC Health Serv Res. 2021 Feb 2;21(1):113. pmid:33530989
- 49. Michel DE, Tonna AP, Dartsch DC, Weidmann AE. Experiences of key stakeholders with the implementation of medication reviews in community pharmacies: A systematic review using the Consolidated Framework for Implementation Research (CFIR). Res Soc Adm Pharm. 2022 Jun;18(6):2944–61. pmid:34420864
- 50. Robinson CH, Damschroder LJ. A pragmatic context assessment tool (pCAT): using a Think Aloud method to develop an assessment of contextual barriers to change. Implement Sci Commun. 2023 Jan 11;4(1):3. pmid:36631914
- 51. Shrime MG, Sekidde S, Linden A, Cohen JL, Weinstein MC, Salomon JA. Sustainable Development in Surgery: The Health, Poverty, and Equity Impacts of Charitable Surgery in Uganda. PloS One. 2016;11(12):e0168867. pmid:28036357
- 52.
International Committee of the Red Cross [Internet]. 2015 [cited 2022 Oct 20]. Mobile surgical teams bring emergency medical care throughout South Sudan. Available from: https://www.icrc.org/en/document/mobile-surgical-teams-bring-emergency-medical-care-throughout-south-sudan
- 53. Piquer J, Qureshi MM, Young PH, Dempsey RJ. Neurosurgery Education and Development program to treat hydrocephalus and to develop neurosurgery in Africa using mobile neuroendoscopic training. J Neurosurg Pediatr. 2015 Jun;15(6):552–9. pmid:25745948
- 54. Gathura E, Poenaru D, Bransford R, Albright AL. Outcomes of ventriculoperitoneal shunt insertion in Sub-Saharan Africa: Clinical article. J Neurosurg Pediatr. 2010 Oct;6(4):329–35.
- 55. Haglund MM, Warf B, Fuller A, Freischlag K, Muhumuza M, Ssenyonjo H, et al. Past, Present, and Future of Neurosurgery in Uganda. Neurosurgery. 2017 Apr 1;80(4):656–61. pmid:28362930
- 56. Mangat HS, Schöller K, Budohoski KP, Ngerageza JG, Qureshi M, Santos MM, et al. Neurosurgery in East Africa: Foundations. World Neurosurg. 2018 May;113:411–24. pmid:29702965
- 57. Prabhu VC. Neurosurgery Initiatives in Global Health. World Neurosurg. 2015 Dec;84(6):1544–6. pmid:26265303
- 58. Paradie E, Warman PI, Waguia-Kouam R, Seas A, Qiu L, Shlobin NA, et al. The Scope, Growth, and Inequities of the Global Neurosurgery Literature: A Bibliometric Analysis. World Neurosurg. 2022 Aug;S1878875022011846. pmid:36028109
- 59. Ozgediz D, Galukande M, Mabweijano J, Kijjambu S, Mijumbi C, Dubowitz G, et al. The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda. World J Surg. 2008 Jun;32(6):1208–15. pmid:18299920
- 60. Albutt K, Punchak M, Kayima P, Namanya DB, Anderson GA, Shrime MG. Access to Safe, Timely, and Affordable Surgical Care in Uganda: A Stratified Randomized Evaluation of Nationwide Public Sector Surgical Capacity and Core Surgical Indicators. World J Surg. 2018 Aug;42(8):2303–13. pmid:29368021
- 61. Kamulegey L, Ssebwana J, Abigaba W, Bwanika J, Musinguzi D. Mobile Health in Uganda: A Case Study of the Medical Concierge Group. East Afr Sci. 2019 Mar 25;1(1):9–14.
- 62. Fuller AT, Corley J, Tran TM, Butler EK, Vissoci JR, Andrade L, et al. Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey. World Neurosurg. 2018 Feb;110:e747–54. pmid:29180091
- 63. Veerappan VR, Gabriel PJ, Shlobin NA, Marks K, Ooi SZY, Aukrust CG, et al. Global Neurosurgery in the Context of Global Public Health Practice–A Literature Review of Case Studies. World Neurosurg. 2022 Sep 1;165:20–6. pmid:35697226
- 64. Haglund MM, Kiryabwire J, Parker S, Zomorodi A, MacLeod D, Schroeder R, et al. Surgical capacity building in Uganda through twinning, technology, and training camps. World J Surg. 2011 Jun;35(6):1175–82. pmid:21487850
- 65. Henderson FJ, Abdifatah K, Qureshi M, Perry A, Graffeo CS, Haglund MM, et al. The College of Surgeons of East, Central, and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training. World Neurosurg. 2020 Apr;136:172–7. pmid:31958592
- 66. Ukachukwu AEK, Seas A, Petitt Z, Dai KZ, Shlobin NA, Khalafallah AM, et al. Assessing the Success and Sustainability of Global Neurosurgery Collaborations: Systematic Review and Adaptation of the Framework for Assessment of InteRNational Surgical Success Criteria. World Neurosurg. 2022 Nov;167:111–21. pmid:36058483
- 67. Dewan MC, Onen J, Bow H, Ssenyonga P, Howard C, Warf BC. Subspecialty pediatric neurosurgery training: a skill-based training model for neurosurgeons in low-resourced health systems. Neurosurg Focus. 2018 Oct;45(4):E2. pmid:30269595
- 68.
UNAS | UNIVERSITIES IN UGANDA ACADEMIA [Internet]. 2015 [cited 2023 Nov 5]. Available from: https://web.archive.org/web/20150303102213/ http://ugandanationalacademy.org/universities.php
- 69. Luboga S, Galukande M, Mabweijano J, Ozgediz D, Jayaraman S. Key Aspects of Health Policy Development to Improve Surgical Services in Uganda. World J Surg. 2010 Nov;34(11):2511–7. pmid:20730430
- 70. Budde-Schwartzman B, Shwarzman O, Lakhoo K, Owusu F. Bringing specialist paediatric surgical care to the doorstep in rural Ghana: A mobile paediatric surgery clinic. Afr J Paediatr Surg AJPS. 2021 Dec;18(4):195–200. pmid:34341302
- 71. Lepard JR, Dewan MC, Chen SH, Bankole OB, Mugamba J, Ssenyonga P, et al. The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings. BMJ Glob Health. 2020;5(2):e002100. pmid:32133193
- 72. Kapiriri L, Ekochu EA, Nabudere H. Health Research Priority Setting in Uganda: A Qualitative Study Describing and Evaluating the Processes [Internet]. In Review; 2020 Oct [cited 2023 Nov 5]. Available from: https://www.researchsquare.com/article/rs-90818/v1
- 73. Kapiriri L, Arnesen T, Norheim OF. Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings? The case of Uganda. Cost Eff Resour Alloc CE. 2004 Jan 8;2:1. pmid:14711374
- 74. Colenbrander S, Birungi C, Mbonye AK. Consensus and contention in the priority setting process: examining the health sector in Uganda. Health Policy Plan. 2015 Jun 1;30(5):555–65. pmid:24846947
- 75. Kapiriri L, Norheim OF, Martin DK. Priority setting at the micro-, meso- and macro-levels in Canada, Norway and Uganda. Health Policy. 2007 Jun;82(1):78–94. pmid:17034898
- 76. Schmidt RF, Vibbert MD, Vernick CA, Mendelson AM, Harley C, Labella G, et al. Standardizing postoperative handoffs using the evidence-based IPASS framework through a multidisciplinary initiative improves handoff communication for neurosurgical patients in the neuro-intensive care unit. J Clin Neurosci. 2021 Oct;92:67–74. pmid:34509265
- 77. Servadei F, Rossini Z, Nicolosi F, Morselli C, Park KB. The Role of Neurosurgery in Countries with Limited Facilities: Facts and Challenges. World Neurosurg. 2018 Apr;112:315–21. pmid:29366998
- 78. Ford PJ, Kubu CS. Stimulating debate: ethics in a multidisciplinary functional neurosurgery committee. J Med Ethics. 2006;32(2):106–9. pmid:16446416
- 79. Cobb MIPH, Taekman JM, Zomorodi AR, Gonzalez LF, Turner DA. Simulation in Neurosurgery—A Brief Review and Commentary. World Neurosurg. 2016 May;89:583–6. pmid:26704209
- 80.
Neurosurgical society of Uganda [Internet]. [cited 2023 Nov 5]. Available from: https://nsu-ug.org/
- 81.
Women In Neurosurgery [Internet]. [cited 2023 Nov 5]. Available from: https://nsu-ug.org/women-in-neurosurgery/
- 82.
The NSU Team [Internet]. [cited 2023 Nov 5]. Available from: https://nsu-ug.org/the-nsu-team/
- 83.
Duke Global Neurosurgery & Neurology [Internet]. [cited 2023 Nov 16]. Home page. Available from: https://www.dukeglobalneurosurgery.com/
- 84. Lartigue JW, Dada OE, Haq M, Rapaport S, Sebopelo LA, Ooi SZY, et al. Emphasizing the Role of Neurosurgery Within Global Health and National Health Systems: A Call to Action. Front Surg [Internet]. 2021 [cited 2022 Oct 14];8. Available from: https://www.frontiersin.org/articles/10.3389/fsurg.2021.690735 pmid:34708069
- 85. Lipnick M, Mijumbi C, Dubowitz G, Kaggwa S, Goetz L, Mabweijano J, et al. Surgery and Anesthesia Capacity-Building in Resource-Poor Settings: Description of an Ongoing Academic Partnership in Uganda. World J Surg. 2013 Mar 1;37(3):488–97. pmid:23192167
- 86.
Neurosurgery [Internet]. [cited 2023 Nov 16]. Global Health Neurosurgery. Available from: https://www.med.stanford.edu/neurosurgery/divisions/globalhealth.html
- 87. Barrie U, Detchou D. Letter: Commentary: The Importance of Increased Funding Opportunities to Empower Global Neurosurgeons from Low-Middle Income Countries. Neurosurgery. 2022 Jul;91(1):e35–6. pmid:35532176
- 88. Rolle ML, Garba DL, Kerry VB, Nahed BV. Commentary: The Importance of Increased Funding Opportunities to Empower Global Neurosurgeons from Low-Middle Income Countries. Neurosurgery. 2021 Sep 15;89(4):E235–6. pmid:34333647
- 89. Rosseau G, Johnson WD, Park KB, Arráez Sánchez M, Servadei F, Vaughan KA. Global neurosurgery: current and potential impact of neurosurgeons at the World Health Organization and the World Health Assembly. Executive summary of the World Federation of Neurosurgical Societies–World Health Organization Liaison Committee at the 71st World Health Assembly. Neurosurg Focus. 2018 Oct;45(4):E18. pmid:30269578
- 90. Lu Z, Tshimbombu TN, Abu-Bonsrah N, Kanmouyne US, Hesson D, Edward A, et al. Transnational Capacity Building Efforts in Global Neurosurgery: A Review and Analysis of Their Impact and Determinants of Success. World Neurosurg. 2023 May;173:188-198.e3. pmid:36746238
- 91. Owolabi EO, Quene TM, Louw J, Davies JI, Chu KM. Telemedicine in Surgical Care in Low- and Middle-Income Countries: A Scoping Review. World J Surg. 2022;46: 1855–1869. pmid:35428920
- 92. Sarfo FS, Adamu S, Awuah DO, Ovbiagele B. Tele-neurology in sub-Saharan Africa: A systematic review of the literature. J Neurol Sci. 2017;380: 196–199. pmid:28870567
- 93. Dadlani R, Ganesh J, Mohan MBAD, Niranjana , Rajgopalan , Thakar BSS, et al. The impact of telemedicine in the post-operative care of the neurosurgery patient in an outpatient clinic: A Unique perspective of non-exigent utilization of this valuable resource in the developing world, an experience of over 3000 tele-consultations. 2014. Available: https://api.semanticscholar.org/CorpusID:263598678
- 94. Dorsey ER, Glidden A, Holloway M, Birbeck GL, Schwamm LH. Teleneurology and mobile technologies: the future of neurological care. Nat Rev Neurol. 2018;14: 285–297. pmid:29623949