EKFS Center of Excellence in Non Communicable Diseases Management in Rural Uganda

2ND YEAR ANNUAL REPORT

2 Issue 30th September 2018 From right to left: Dr. Robert Kalyesubula, Trishul Siddharthan, Prof Moses Kamya, Prof Felix Knauf, and Nora Anton PREFACE CONTENT

Message from the CONTENT Principal Investigators

2 3 3 Preface 18 Global Health Education t gives us immense Berlin, Yale University, Johns We thank the Else Kröner pleasure to share Hopkins University and Fresenius-Stiftung for 4 Executive Summary 19 Research fellows for EKFS project Iwith you our progress Makerere University. supporting this vision and during the second year of contribute to efforts that 5 Introduction operations since we received We have been able to follow have enabled us to reach OUR STORIES a three-year grant support up the patients screened out a great number of 8 Building Capacities from your foundation. Non- from the NCD survey in community members with 22 Our People communicable diseases year 1 and have gone ahead health services. 10 WHO PEN II Protocol remain a major cause of to work with the Ministry Training Workshop 24 Grassroots Champion Award 2018 morbidity and mortality of Health and Nakaseke Happy reading!! which mostly affects low Hospital to set up the first 12 Building a Network 26 EKFS support at ACCESS income countries such integrated Clinic for NCD Felix Knauf as Uganda. Therefore, we care in the district. Trishul Siddharthan 13 NCD-training curriculum 28 Conference Calls are most grateful for the Robert Kalyesubula support we have received. Alongside, we have been 15 NCD census 29 Thank you! This year’s report summa­r­ able to train 20 community izes the achievements of the health workers as well as 27 ACCESS Uganda partnership Health professionals who with colleagues from have multiplied our impact Charité Universitätsmedizin in the community. INTRODUCTION INTRODUCTION EXECUTIVE SUMMARY EXECUTIVE EXECUTIVE SUMMARY INTRODUCTION

4 5 he EKFS (Else Kröner- Major events in the past We have developed, We continue to offer scholar­ Recently we hosted three he Rural NCD project Our goal is to contribute to 3. Global Health Education. Fresenius Stiftung) year have been the training translated and field-tested ships to nursing students with medical students from is a strategic initiative the realization of this vision In this document we T medical-humanitarian of 27 health care workers PocketDoktor booklets 3 new candidates selected for Makerere University College T designed to establish in rural Uganda. provide an update using funding was established in (HCWs); establishment for hypertension, diabetes the awards. of Health Sciences through a center of excellence in the three theme headings, September 2016 in Nakaseke of a rural NCD clinic at mellitus and chronic kidney Makerere University-Yale the care and management Since its inception in with particular attention district of Uganda to promote Nakaseke General Hospital; disease. We currently provide As a way of reaching out to University collaboration of non-communicable September 2016, our work to the work that has been patient-centered care for development of NCD charts chronic care to over 300 the community, we have (MUYU) programme. We also diseases in rural Uganda. has progressed in three accomplished in the second non-communicable diseases approved by the Uganda patients through the newly adopted this CHW model hosted one student from Yale We envision enhanced main themes: year of the programme. (NCDs), in order to foster the Ministry of Health (MoH), established NCD clinics to disseminate NCD-related School of Medicine, USA and clinical capacities and development of a Center of training of 20 Community at Nakaseke and Life care health education, screen for one student from Germany.. improved patient- 1. Enhancing clinical Excellence for NCDs in rural Health Workers (CHWs), center. We have trained 7 NCDs and refer community centered care for NCDs in capacities and establishing Uganda. A full report of our integration of CHW model students in global health members diagnosed with rural Uganda; improved patient-centered care for activities from September into NCD care program; from Uganda, USA and NCDs to Nakaseke NCD clinic knowledge on feasibility NCDs. 2017 to September 2018 testing the feasibility of NCD Germany. We set up the and ACCESS life care center. and effectiveness of has been compiled and PocketDoktor booklets on NCD fellowship program In addition, the program patient-centered care in 2. Improving knowledge presented separately. 100 selected participants with in collaboration with the has also strengthened NCD resource-limited settings on the feasibility and NCDs in Nakaseke. Uganda Ministry of Health global health education and promoting collaborative effectiveness of patient- and our first candidate is component through global health training centered care. finishing in this year. supporting both local and platforms for local scholars international fellows. with interest in NCD health. Enhancing clinical capacities and establishing Clinical characteristics of patients patient-centered care for NCDs recruited from NCD clinic Other NCDs

Patients at the NCD Sex HTN DM CKD Cancer Clinic funded through (N=301) EKFS awaiting to be seen by the health workers.

191 110 177 103 177 103 1 1 1 1 63.5 % 36.5 % 69 % 31 % 63.2 % 36.8 % INTRODUCTION INTRODUCTION

6 7 Improving infrastructure, n addition to the achieve­ment In addition, to simplify data Developing Luganda Pocket transport and medical of obtaining a vehicle for the collection in the clinic, the Doktor tools for management uganda is the These booklets are currently I programme in the first year, programme developed patient NCD language spoken being distributed to patients equipment at ACCESS for we have been able to establish charts which were approved by the of HTN, DM and CKD: Lin the district of attending the Nakaseke district-wide NCD health ACCESS-EKFS-Nakaseke NCD clinic Uganda Ministry of Health (MoH). Nakaseke. In the second NCD clinic. at Nakaseke General Hospital. The The clinic officially opened in January year of the programme management: clinic runs every Friday of the week 2018. Since then, we have been able PocketDoktor booklets by a qualified programme physician to attend to over 300 NCD patients. in the language Luganda who is employed fulltime thanks the ACCESS Nursing school while were developed, reviewed to the EKFS funding to see NCD 46 community healthworkers have by experts in NCDs and patients. He is supported by a team been trained and commissioned to tested on NCD patients of nurses who were trained to use support the community. at Nakaseke NCD clinic. WHO pen protocol. A total of 200 copies of The third strategic pillar is about PocketDoktor booklets economic empowerment where the for hypertension, diabetes target beneficiaries are the elderly mellitus and kidney disease and adolescent youth who are have been printed in provided with small start-up grants Luganda version. to generate income for sustainable improvements in their lives. Ms. Faith Nassali listens to a CHW consent another CHW during role plays

The number of CHWs who attended the workshop (left) and percentage gain in knowledge of CHWs about NCD care and management (right)..

11 9 53,9% pretest 54,3% 82,9% post test 82,1% BUILDING CAPACITIES BUILDING CAPACITIES

8 9 Community ver 20 CHWs (55% The training followed two In module 2, we provided Health Worker Male, 45% Female) main modules. trainees with knowledge NCD The CHW Training Workshop with the Owere trained in NCD about NCD health promotion health promotion Modules 1 & 2 Training care and management. This In module 1, we provided and education. We skills & knowledge and education Workshop: was a three-day workshop trainees with knowledge conducted pre- and post- to teach the pre- and post- which took place at ACCESS and skills required to teach workshop assessments community workshop2 life care center in Nakaseke the community on the to document gain in 1 from Wednesday 30th significance of change knowledge about NCDs. May to Friday 1st June in life style in prevention 2018. The main objective of and control of Diabetes, the workshop was to train Hypertension and Chronic CHWs in NCD management Kidney Disease. In addition, and equip them with we provided trainees with basic research skills. We knowledge and skills selected 20 CHWs from rural required to detect NCDs. communities of Nakaseke. SCHOLARSHIPS Nakaseke Hospital nurses taking pre- Dr Ben Bodnar and Dr. Munana Richard conducting the Nakaseke Hospital staff taking a workshop test HEARTS protocol training at Nakaseke hospital post-workshop test WHO PEN II PROTOCOL

10 11 WHO PEN II Protocol e conducted a The workshop was Training Workshop two-day WHO moderated by Dr. Benjamin W pen II protocol Bodnar from Johns Hopkins training workshop at University, an expert in HCW Gain in knowledge Nakaseke General Hospital the field of NCDs. He was Attendance of HCW from 8th to 9th Febraury assisted by Dr. Richard 2018. The main objective Munana from ACCESS, of the training was to train Nakaseke. nurses, clinical officers and Medical officers into HEARTS, a technical 39% pre-test 71,1% package for cardiovascular 4 23 36% post test 80,6% disease management in primary health care. Over 27 participants from ACCESS NCD clinic and ACCESS- EKFS-Nakaseke hospital The pie chart represents the number of health care workers who NCD clinic attended the attended the HEARTS protocol training. The bar graph shows the training. gain in knowledge of participants after being trained in the use of the HEARTS protocol. One of our trained CHW (left) teaching about hypertension to a client (right) using pocket doktor booklet for hypertension.

27% HTN only

DM only 48%

23% HTN and DTM

2% NCD-TRAINING Building a network of The NCD-training other CKDs

BUILDING A BUILDING A NETWORK Community Health Workers curriculum for Community Selected NCDs at the clinic in Nakaseke district Healthy Workers:

12 13 network of 20 These selected patients ith support of NCDs screening tools a certificate in Community well trained have been followed-up on from EKFS, our and to acquire health NCD Practice. This certificate A and competent a monthly basis to monitor W programme promotion and education allows them to mobilize CHWs who have been their hard outcomes like developed an NCD skills. The curriculum and educate communities utilized to conduct NCD blood pressure profiles curriculum. It consists targets candidates who on prevention, control and patient education using in order to assess for of two modules i.e. NCD are citizens of either management of NCDs PocketDoktor booklets control. We have employed prevention and control Nakaseke Town Council, at household level. The for hypertension, diabetes this model to design a (module 1), a taught course Kasangombe Sub County curriculum implores the mellitus and kidney disease community base programme for seven and half hours or Nakaseke Sub County, trainers to use interactive at ACCESS-EKFS-Nakaseke through which our team and health promotion and are willing to work in these and learner centered NCD clinic. Our CHW team of CHWs will conduct education (module 2) a, sub counties, are 18-40 methods to stimulate active has been able to reach out NCD patient education, taught course for 20 hours. years old, have a minimum participation and ensure to 100 patients diagnosed screening and referral of The curriculum is designed qualification of Uganda that learning objectives with selected NCDs as patients to ACCESS-EKFS- to provide VHTs with basic Certificate of Education are met. Competence is illustrated in the graph Nakaseke NCD clinic for understanding of NCDs, (ordinary level) and are able assessed through practical below. NCD management by our increase capacity for disease to communicate in both assessment, written exam/ physicians. surveillance, prevention, local language (Luganda) test, oral questioning and management and control and English. On completion project work. at the community level, of the basic training, the train CHWs into the use successful CHWs is awarded Overall satisfaction 22% Hypertension with NCD education 100 Received no education Patients at the clinic

30% Figure 8. The pocketdoktor booklets Diabetes 70% Satisfied with Diabetes, Hypertension & CKD Mellus management plan 68 32 48%

Were educated about their condition at the clinic Participation in

NCD research NCD CENSUS Theme 2: Improving knowledge Satisfied with nature of my condition

IMPROVING KNOWLEDGE IMPROVING on the feasibility and effectiveness Publishing NCD Community Census of patient-centered care conducted during year 1

14 15 ince August 2018, The PocketDoktor booklets We administered a PAM-13 e have been able acknowledgment that we have been are being administered questionnaire at baseline to complete one existing studies provide an S conducting a by our team of trained and measured clinical W manuscript from incomplete understanding Satisified with being informed prospective cohort study CHWs on these selected and sociodemographic the NCD census which was of the burden of NCDs. We about treatment options designed to run for 6 patients. Our study characteristics of these conducted in year 1 of the demonstrated successful months. In this study, we outcomes include patient individuals. In three months programme. The manuscript enrollment of 16,272 rural are implementing and satisfaction measured by time post recruitment, we is titled “The Rural Uganda Ugandan residents at a evaluating the impact of a patient activation measure will assess the PAM-13 score Non-Communicable Disease response rate of 99.2%. And validated patient-centered (using PAM-13 tool) and and clinical parameters like (RUNCD) Study: design, these participants were education tool (PocketDoktor health outcomes measured blood pressure in these methods, and self-reported systematically captured booklets) among 100 by hard outcomes such individuals to determine if disease”. In this write up, from three sub-counties of Satisified with being informed patients diagnosed with as systolic and diastolic there has been any impact we have described a rural the larger Nakaseke Health about disease prevention hypertension and/or blood pressure. We have by our intervention. cohort of individuals with District representative of the diabetes in a rural outpatient recruited 100 patients (68% self-reported NCDs. We have Ugandan rural setting. setup of Nakaseke NCD females) diagnosed with presented the establishment clinic. either hypertension (22%) or of the RUNCD study in diabetes mellitus (48%). response to the epidemic of Extremely dissatisfied NCDs in low- and middle- Moderately dissatisfied income countries and the Moderately satisified Extremely satisfied Community Health Workers posing a question to global health students from Makerere University.

GLOBAL HEALTH EDUCATION Theme 3 Research fellows for EKFS project

Dr Munana Richard attending to a patient at the NCD clinic RESEARCH FELLOWS RESEARCH

GLOBAL HEALTH EDUCATION HEALTH GLOBAL GLOBAL HEALTH FELLOWS FROM UGANDA

18 19

EDUCATION ur program He has been key in care cadres. It consists of in rural settings, the recruited Dr. documenting patients modules developed under impact of WHO HEARTS O Richard Munana, seen at the clinic. He has the auspices of the Global protocol driven care for e successfully The students appreciated a fulltime research established a database Hearts Initiative, led by hypertension and diabetes hosted two our CHW model in delivering fellow based at ACCESS of patients with NCDs. WHO and the US Centers on patient outcomes and W female and NCD care at Nakaseke Uganda and mentored Currently, his research for Disease Control and the barriers and enablers two male 4th year medical hospital, participated in by experts in the field of area focuses on the Prevention. The fellow to implementing protocol students from Makerere patient care through bedside NCDs from Johns Hopkins implementation and has participated in the based non-communicable University College of teachings and ward rounds. University, USA. His dream assessment of the impact of initial training of 18 nurses disease care. We hope that Health Sciences for a three At the end of the visit, is to become a master of the WHO HEARTS protocol at Nakaseke General during the 3rd year of the days placement. The main students had a general protocol driven care of among hypertensive and Hospital with the Johns programme, our fellow will objective of the visit was picture of NCD management NCDs in rural Ugandan diabetic patients of rural Hopkins NCD expert on gain a deeper appreciation to expose these selected program at ACCESS, the role settings like Nakaseke. He communities of Nakaseke. the use of the HEARTS of the HEARTS protocol students to research Community Health Workers has played a critical role in Briefly, the HEARTS protocol protocol in NCD care. He and its impact on the rural opportunities in NCDs at (CHWs) and the community the establishment of the is a technical package for has further developed community. ACCESS and familiarize in championing NCDs care Nakaseke NCD clinic. He cardiovascular disease a protocol to assess the them with community based and management. runs the clinic every Friday management and care in level of awareness and Richard Munana solutions to medical care. screening and treating for the community, hospitals fidelity to implementation NCDs. and by low level health of WHO HEARTS protocol Research fellows for EKFS project

Dr. Kast shares a light while Theresa takes the CHWs attending to a client in the through diabetes and the NCD clinic diabetic booklet during the CHW training. RESEARCH FELLOWS RESEARCH FELLOWS RESEARCH FELLOWS FROM GERMANY

20 21 e hosted Dr. In addition, she visited heresa is a German She interacted with the EKFS Katarina Kast, Global Health Uganda, medical student Yale sponsored students W one of the team which currently assists in the T that visited ACCESS who visited ACCESS during members on the EKFS ACCESS-EKFS NCD center of for a four weeks’ period. her rotation. She participated project based in Germany for excellence. Dr. Kast received During her stay at ACCESS, in the training of the NCD a week’s rotation from 19th- various HEARTS materials she rotated with four other CHWs that took place at 24th February. The main and the Uganda clinical global health students the ACCESS premises in aim of her visit was to get guidelines. On 23rd February from the USA. She received Nakaseke. acquainted with the works 2018, she ran the Nakaseke various lectures in NCDs, of ACCESS and explore hospital based NCD clinic tropical medicine and possible areas of future and gave a teaching to reproductive health. These collaborations. During her global health students were provided by the team visit, she was part of various Jamon and Stephanie from at ACCESS and Nakaseke ACCESS activities such as Touro University, USA. hospital. She also received visiting some of the Health training in HEARTS materials Centers that ACCESS works and was involved in caring hand in hand with to extend for the NCD patients in both reproductive health services the Nakaseke based and in Nakaseke. ACCESS based NCD clinics. OUR STORIES ACCESS UGANDA ACCESS OUR STORIES

22 23 Miss Estherloy Katali James Ssewanyana Alex Kayongo Mrs. Faith Nassali Kyanzi Taddeo

She is the managing director He is a clinical officer by He is a postgraduate our NCD Project Coordinator, Meet Mr. Kyanzi Taddeo, the of ACCESS since January training, co-founder and research fellow serving as who is currently pursuing driver for the EKFS-ACCESS 2018. She has been keen in deputy executive Director a research scientist under a Master’s degree in Public NCD program. He has been OUR PEOPLE

ACCESS UGANDA ACCESS supporting implementation of ACCESS Uganda. He the EKFS funded Center Health at Makerere University key in ensuring that our staff the EKFS-NCD program is known in Nakaseke as of Excellence for NCDs in School of Public Health. are transported for outreach activities and overseeing the Musawo (doctor). Nakaseke district. She has played a significant programs. OUR PEOPLE overall management of role in implementing the

24 the program. In addition, she He lives and works with He is a medical doctor and NCD project. Faith has He has also been helpful 25 has been key in coordinating ACCESS in Nakaseke. currently a master’s student been key in organizing in picking and dropping off visiting fellows at ACCESS. James serves as the primary in Immunology and Clinical protocol training sessions, visiting scientists from the Estherloy earned her clinician at Life Care Center, Microbiology at Makerere good clinical practice airport. Master’s Degree in Computer and oversees ACCESS University College of Health (GCP), protection of human Technology at Makerere programs in Nakaseke. sciences. His passion is to research participants University. understand the interaction (PHRP) workshops for between NCDs and HIV in Community Health Workers rural Uganda. He has been (CHWs) implementing very key in designing and the PocketDoktor study. implementing protocols In addition, she has been in the program including conducting quality assurance hospital and community (QA) sessions for the project, components of the holding monthly meetings PocketDoktor study. He has with CHWs to go over SOPs also played a key role in for the project. She has teaching visiting fellows from also assisted in preparing Germany and the United monetary reports and states. working on requisitions to ensure smooth running the program activities. Dr. Robert Kalyesubula — Winner of the 2018 Grassroots Champion Award! OUR HONOR

OUR HONOR 2018 AWARD GRASSROOTS

26 27 he Segal Family They are building an equit­ e’s a doctor, a Please congratulate Foundation believes able community of visionary senior lecturer, a Dr. Robert Kalyesubula, T in a world where organizations—both doers “H PhD candidate, and who has maintained development is steered and donors—across Sub- the founder of our partner deep connections with by grassroots leaders and Saharan Africa so that African Community Center his community in Uganda power is shifted into the together they can improve for Social-Sustainability through establishing a hands of communities. the lives of millions. (ACCESS). nursing school, a clinic, and And now he’s the winner a network of community The Foundation works Outstanding leaders are at of our 2018 Grassroots health workers, as well as across Sub-Saharan Africa the helm of the exemplary Champion Award! supporting orphans and and strive to be true partners partner organizations. vulnerable children through to our grantees. They want to Each year the Segal Family scholarships.” change the power dynamics Foundation recognize these inherent in traditional hard-working leaders during philanthropy and prove that their Annual Meeting. a new, more equitable, and responsive approach is not only more fair, but more effective. Hope of a heart diseased patient Musawo Sewannyana restored through generous holistic care assessing Janet. Photo taken with Janet’s permission and support by Else Kröner-Fresenius- Stiftung. SHARING THE IMPACT EKFS SUPPORT AT ACCESS AT EKFS SUPPORT SHARING THE IMPACT OF EKFS SUPPORT AT ACCESS

28 29 eet Janet, a 65 year old protocol received Janet and In addition he performed an ECG Four of five people who die from Many thanks to Else Kröner- We hope that our efforts will curb female peasant from assessed her condition. He found which revealed atrial fibrillation, a CVD are killed by either a heart Fresenius-Stiftung which the raising prevalence of CVDs in M Kyanika Bamunanika out that Janet’s condition was heart rhythm disorder affecting attack or a stroke according to sponsored the pilot phase of the rural communities of Nakaseke. in Luwero. She was diagnosed indeed more than hypertension the upper chambers of the heart World Health Organization. When HEARTS protocol training in 2017 Let us all work together to achieve with high blood pressure 5 years and malaria. “Janet had a low and left ventricular hypertrophy. the community is empowered at Nakaseke General Hospital. the 25 by 25 goal of reducing ago. Despite the effort to look grade fever” he reported. What He wasn’t in position to do further through taking charge of their Through continued support, premature mortality from NCDs for blood pressure medications was astonishing was a finding of a tests given the lack of capacity health, the impact can be we plan on continuing with by 25% by 2025. from different health Centers in systolic murmur and an irregular at the clinic. He instead instituted enormous. This story illustrates the HEARTS training targeting Nakaseke and medical camps, heartbeat. Musawo Sewannyana treatment for high blood pressure, how learning and putting into low cadre health workers and sometimes she could go without measured her blood pressure gave an antibiotic and counselled practice skills of assessing Village health Team (VHTs) to taking any medications to control and random blood glucose the patient on healthy lifestyle patients with suspected increase awareness of CVD in the her blood pressure. Six months which he found at 140/80 and including reduction on salt intake. cardiovascular diseases (CVD) by community. ago, adding to the already 6.5mg/dl respectively. He also Janet has been attending care at lower health care workers can complicated health of Janet, she measured her weight, height and ACCESS for the last six months. have long lasting impact on the developed relentless on and waist circumference. With the She reports that her general health status of peasants who off fevers and joint pains which newly developed NCD charts at health has improved significantly can not afford care from tertiary she initially thought was malaria. the clinic, Musawo Ssewanyana thanks to the care at the NCD centers or highly specialized Musawo Ssewanyana, a health was able to perform a relevant clinic. personnel (cardiologists). care worker based at ACCESS assessment of the patient. NCD clinic and trained in HEARTS 30 CONFERENCE CALLS FOR CAPACITY BUILDING CONFERENCE CALLS T of theprogram director, weekly conference calls we have beenhaving two- Germany, USA andUganda, administrator, andresearch attended by theproject fellows. the implementation team in Uganda comprised principal investigators from o monitor project rigor of theprogram, progress andincrease challenges faced during we discuss weeklywe supporting theprogram. applications to continue During theseconferences, from our current research team, troubleshoot updates from theassigned through data collected implementation, go publications andgrant projects, discusspossible

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