Ugandan Sexual Health and Pastoral Education (USHAPE)

USHAPE is an initiative between UK GPs and Bwindi Community Hospital run in conjunction with the Royal College of General Practitioners delivering Family Planning and Sexual Health Training and Education in Uganda. Our work began at Bwindi Community Hospital and is rapidly spreading to other hospitals and districts across Uganda. We are honoured to currently receive funding and support from the Tropical Health & Education Trust (THET) Health Partnership Scheme (funded by UKAID/DfiD), which has been a huge help in advancing our programs.

Train one, train all: the cascade training model

The challenge:

How does one tackle family planning educational needs at both service provider and community levels with limited human and financial resources?

The solution: Cascade training!

The USHAPE (Ugandan Sexual Health and Pastoral Education) project faced an all too familiar global health challenge in rural remote South West Uganda. Unwanted teenage pregnancies, large family size, maternal mortality, HIV and other sexual health issues present major health problems for the local population. Unfortunately, access to proper family planning training for healthcare staff is limited and the community is rife with misinformation and cultural misconceptions.

Presented with a multi-level educational deficit, the USHAPE team set about designing a solution. A solution that could be both cost-effective and sustainable.They came up with the Cascade Training Model. 

Figure 1: USHAPE Training Cascade Model: training figures as of Feb 2017

Cascade training is not an entirely new concept, and has been utilized through train the trainer programs in other fields. USHAPE has adapted the model and expanded it to apply to the challenge of multi-level health education in resource poor settings. Our graduates at every stage go on to consolidate their learning through becoming teachers themselves. This helps to enhance the adult learning process for them as individuals, as well as build their motivation and sense of achievement.

 Skills Exchange

UK GPs and Ugandan Family Planning Providers work together to develop the training program. This allows quality family planning training methods to be combined with local cultural context. By providing high quality dynamic workshops, we not only deliver training. We introduce new methods of interactive teaching which our colleagues and graduates enjoy and emulate.

Figure 2 UK GPs assist local staff in developing and delivering the Family Planning Provider Training

The Whole Institution Approach

We deliver 2 levels of training for both in-service staff and pre-service nursing students. Family Planning Advocate or Level 1 training is a 4-5 hour program, targeted at ALL staff, that aims to emphasise:

• emphasise the importance of family planning in preventing maternal and child mortality and morbidity
• highlight the positive impact of smaller family sizes and birth spacing on personal and community economics
• correct myths and misconceptions about family planning methods and side effects
• encourage all staff to screen for and when appropriate refer those with unmet need for family planning

Family Planning Provider or Level 2 training is a 25-30 hour program with one to one follow up, targeted at selected clinical staff. The program aims to:

Figure 3: Nurses and midwives develop practical skills on the Family Planning Provider (Level 2) Training Program

• ensure in depth knowledge and understanding of unmet need, different methods, and sensitive groups (such as men, adolescents, HIV/AIDs, post-partum)
• increase confidence and skill in family planning counselling
• increase confidence and skill in delivering methods, including IUDs and implants
• build teaching skills to enable graduates to engage in health promotion and outreach activities

Institution wide training to increase advocacy and provision combined with routine point of care screening for unmet need and community outreach fosters a widespread positive attitude towards family planning. Horizontal integration into all programs and departments increases screening, opportunities for counseling and method initiation and a greater rate of attitudinal and cultural shift.

Creating community level demand for family planning

Figure 4: USHAPE Graduate educating local Community Health Volunteers

Our Family Planning Provider graduates in turn go on to train and support generic health workers, teachers and village health teams. It is vital that these valuable and respected members of the community are able to explore and resolve any misinformation and cultural misconceptions prevalent in their communities.

Figure 5: USHAPE Graduate delivers community outreach to ante and postnatal mothers

The process comes full circle when these respected community members and health workers go on to talk to their communities, including engaging males and adolescents. They are also able to screen and refer women who have unmet family planning needs.Wherever possible we advocate for these activities to be built into our graduates work plans and integrated with other important outreach work, such as HIV screening and childhood vaccinations. As the demand for family planning goes up, our healthcare workers gain experience and motivation and a growing cycle of supply and demand develops.

Invest in One, Invest in All!

Figure 6: USHAPE Family Planning Provider graduate and Childrens Nurse Ephraim returns regularly to help teach on the Provider course and conduct community outreach

Thus far the cascade approach has been a huge success for USHAPE. Utilising just a handful of Ugandan and UK Family Planning trainers hundreds of healthcare staff, village health workers and adolescents have received high quality health educational messages in interactive environments which leads to proven increases in knowledge and skills. It will take more time to see how this will effect behavioural change and subsequent health outcomes, but we have high hopes!

We have presented our work at RCGP and at the Ugandan Ministries of Health and Education where we received a lot of interest from other projects and institutions. We will continue to engage with the Ugandan Maternal Child Health Cluster and the Tropical Health Education Trust to disseminate our progress.

Sustain & Diversify

The next step is developing and delivering Train The Trainers programs to build local capacity to sustainably deliver and expand the program. The first TTT was launched in January 2017, and was a great success with 12 Ugandan and 2 UK USHAPE trainers completing the course.  These graduates are now continuing to implement the program in our 2 existing sites at Bwindi and Kizzisi Hospitals, as well as enabling expansions to Rugarama Hospital and Katate Health Centre IV. Meetings have been held with the Uganda Nursing and Midwifery Council to plan to gain CPD accreditation for the Level 1 (Advocate) and Level 2 (Provider) so that our graduates have their training recognised as they move on to work elsewhere.

Figure 7: Nursing students learn the important art of counselling through observed role playing

In addition, we are working with  Bwindi, Kizzisi and Rugarama Nursing Schools to align the program for pre-service nursing students with the Ugandan Nursing Curriculum, to seek accreditation and sustainable integration of the program into Nursing education pathways.

It doesn’t stop with family planning! This model can be applied to other health educational needs, such as alcohol and motor vehicle safety (two of the leading causes of morbidity and mortality in Uganda). We are working with Bwindi Community Hospital to seek funding to develop similar programs in these important areas.

Through the dissemination and further development of the cascade model and the whole institution approach we believe that multiple health educational needs, at both healthcare provider and community beneficiary levels, can be tackled cost effectively and sustainably.