Article 3 December 2010, Vol. 2, No. 2 AJHPE Introduction The number of older adults (OAs) is increasing worldwide, and as the life expectancy in developing countries improves their populations will grow faster than in developed countries. Worldwide there are approximately 600 million OAs, of whom 370 million (60%) live in developing countries. By 2050, this proportion is estimated to increase to 80%.1 In Uganda, the population of OAs (people ≥65 years) was estimated at 5% of the coun- try’s population of 30 million in 2002.2 This has been brought about by the increase in life expectancy from 46.5 years to 48.1 years to the current 51 - 52 years for men and women, respectively.3 Although the current life expectancy in Uganda is still below 65 years, projections indicate that in the next five decades the number of OAs and therefore potential geriatric patients in Uganda will be nine times greater than currently.2 The demographic transition from a young to an older population is usually accompanied by increased prevalence of chronic diseases, both physical and psychological.4,5 Reports from developed countries show that as people become older, they experience more chronic and multiple health problems due to lowered immunity, existing medical conditions and difficulty in accessing health care services.6 Other risks include ac- cidents such as falls and fractures.7 The increased risk of health prob- lems is also associated with an increased risk of disability among OAs. In Uganda, 40% of OAs have a disability and as a group they are among those most affected by poverty, malaria, HIV/AIDS, poor housing, mal- nutrition, and poor access to health care and water.8,9 The two trends of increasing numbers of OAs and increased chronic health problems or disability are enormous challenges to health care systems, health professional training institutions and policy makers who are required to meet the changing and complex needs of OAs. The response to the chal- lenges has generally been minimal because in developing countries the focus is mostly on infectious diseases, paediatrics and maternal health, and most curricula to train and educate health professionals currently do not include geriatrics.1 As a result most health professionals are not formally trained to address health care problems specific to OAs.10 Training in geriatrics (sci- entific study of the effects of ageing and age-related diseases on humans, including the biological, physiological, psychosocial, and spiritual aspects of ageing) is essential to address the health care needs of OAs. Lack of geriatric knowledge and skills has significant implications for health care providers (HCPs) working in rural areas of developing countries because this is where most AOs live. Additionally, these ar- eas are characterised by poor access to health care services and a wide gap between the health care needs of OAs and treatment skills of HCPs who serve them.11 Some of the strategies suggested to address the lack of geriatric skills among HCPs include integration of geriatric content in training curricula and geriatrics continuing education programmes.11,12 However, before undertaking curricula revisions or continuing education programmes it is important to establish existing geriatric knowledge and attitudes of currently practising HCPs. Negative attitudes towards OAs are one of the critical factors that impede provision of proper health care by health professionals.12 Abstract Population trends in developing countries show an increasing popula- tion of older adults (OAs), especially in rural areas. The purpose of this study was to explore the geriatrics continuing education needs of health care providers (HCPs) working in rural Uganda. The study employed a descriptive design to collect data from HCPs working in Apac district, a rural district in northern Uganda. The 240 HCPs (mean age 33.8±10.5 years) from whom data were collected were nurses (52%), physician assistants (17%), social workers (12%), laboratory technologists (10%) and physicians (10%). Self-adminis- tered questionnaires composed of the Palmore’s Facts on Aging Quiz (FAQ1) and Kogan’s attitude towards old people (KAOP) scale were used for data collection. Results. Most HCPs (63%) regularly cared for OAs but their pro- fessional education did not include geriatric-specific courses (69%). The majority of HCPs had a poor or fair geriatric knowledge (88%) (FAQ1 mean score 11.6±2.3), but had a positive attitude towards OAs (80%) (KOAP mean score 115.9±11.5). Positive attitude was associ- ated with personal experiences with OAs and a desire for a future career in geriatrics (p≤0.05). Conclusion. In Uganda training curricula for health professionals have not evolved to address the changing demographic trends show- ing increasing numbers of OAs. Consequently, there is a significant knowledge gap in certain aspects of health care, such as geriatrics, among currently practising HCPs. There is need for tailored geriatrics continuing education programmes to bridge the knowledge and skill gaps to ensure quality health care for OAs. Continuing education in geriatrics for rural health care providers in Uganda: A needs assessment Mary Ajwang, BSN, RN Nursing Officer, Continuing Professional Development, Mulago National Referral and Teaching Hospital, Uganda Joshua K Muliira, DNP, MSN, MA, BSN, RN Lecturer of Nursing and Geriatric Nurse Practitioner, Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda Ziadah Nankinga, MSc, BSN, RN Lecturer of Nursing and Clinical Epidemiology, Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda Correspondence to: J K Muliira (jkmuliira@gmail.com) Article Article 4 December 2010, Vol. 2, No. 2 AJHPE OAs in developing countries are at a disadvantage because as urbani- sation and modernisation set in they become more socially isolated and economically vulnerable.13 In developed countries other concerns such as abuse and neglect have also been highlighted as major problems, with health implications among OAs.14 A combination of diminished vitality due to ageing, increased risk of poor health, and social and economic depriva- tion means that when OAs seek health care they present with more than one health problem. Therefore, if HCPs are not specifically trained in caring for geriatric patients, they are bound to face a major challenge and eventually provide inadequate care.15 The unique characteristics and health care needs of OAs have to be specifically addressed to optimise health outcomes and quality of life.16 Therefore, to achieve optimal health and quality of life for OAs, the HCPs must be knowledgeable and skilled in geriatrics.17 In several countries geriatrics or gerontological content is not em- phasised in entry-level training programmes for health professionals,18 and this gap in the curricula can lead to negative attitudes towards ageing and geriatrics by HCPs.19 The attitudes of HCPs are important because unfavourable attitudes hinder delivery of quality health care.20 Studies of students in health care disciplines, such as physiotherapy, have also shown that they often lack geriatric knowledge and require planned learning opportunities to develop positive attitudes towards OAs.21 Train- ing in geriatrics has also been shown to be the most effective approach to changing HCPs attitudes towards OAs.22,23 The purpose of this study was to explore geriatrics continuing education needs of HCPs working in rural areas of Uganda. Study setting The study was conducted among HCPs working in rural health facili- ties in Apac, a rural district in northern Uganda. The two health facilities (Apac Hospital and Aduku Health Center) are both in Apac district. Ac- cording to Uganda’s 2002 Population Census, Apac district is estimated to have a population of 12 400. Apac Hospital, the only hospital in the district, is staffed by 264 health professionals (nurses, physicians, physi- cian assistants, social workers, laboratory technologists, dentists, dental assistants, physiotherapists and occupational therapists), and has a capac- ity of 120 beds. Aduku Health Center is a 50-bed facility located 25 miles from Apac Hospital and is staffed by 48 health professionals, including physicians, nurses, laboratory technologists, optometrists and dental as- sistants. The health centre provides mostly primary care services and in-patient care for patients with uncomplicated conditions. Apac Hos- pital and Aduku Health Center were selected because they are the larg- est health facilities in the district and regularly receive geriatric patients, both as in-patients and out-patients. Methods A descriptive quantitative design was used to explore the need for geri- atrics continuing education among HCPs working in rural health facili- ties. After obtaining approval from the Institutional Review Board of the College of Health Sciences at Makerere University, meetings were held with administrators of Apac Hospital and Aduku Health Center. At the two facilities the study was publicised and advertised on notice boards, by word of mouth, and during meetings a week before data collection. To participate in the study, participants had to be qualified health profes- sionals registered by their relevant professional bodies, legally employed by the health facility, directly involved in patient care and not currently a student in any health profession training institution or programme. A convenience sampling technique was used to access the 257 participants in Apac Hospital and 48 participants at Aduku Health Center. The inves- tigators went to each clinical unit or ward in the two facilities during day, evening and night shifts to explain the study purpose to HCPs on duty. The HCPs were approached during their shift break in the break room. Those who agreed to participate in the study signed a consent form before they were given self-administered questionnaires in English, the official language in Uganda. Participants were given 2 hours to complete the questionnaire and to drop it off in the receiving box in the break room or lobby of the unit. Data were collected over 3 weeks in April 2010. Of the 305 participants who consented and received a self-administered questionnaire at the two facilities, 240 returned the completed form at the designated centres. Therefore the response rate for this study was 79%. Instruments The self-administered questionnaire used for data collection had four sections, i.e. demographic characteristics, experiences with OAs, geriat- ric knowledge and geriatric attitude. In this study the need for geriatrics continuing education was determined by measuring rural HCPs’ geriatric knowledge and attitude towards OAs. The section on experience with OAs generated data about prior personal and clinical experiences with OAs and was comprised of items such as: ‘Have you ever lived with a relative of age 65 years and above?’; ‘How often do you take care of patients older than 65 years?’; ‘How comfortable are you with the knowl- edge and skills required to take care of OAs?’ Living with a relative of age 65 years and above was emphasised because such experience gives a person close interaction with OAs, and an understanding of lifestyles and the social aspects of ageing. The section on geriatric knowledge was composed of a standardised scale called the Palmore’s Facts on Aging Quiz (FAQ1). The FAQ1 was de- veloped by Erdman Palmore in 197724 and has been found to be a reliable measure of geriatric knowledge in a variety of cultures.25 The FAQ1 has reliability values ranging from Cronbach’s alpha of 0.66 - 0.68 and content validity of up to 0.82.26,27 The FAQ1 is composed of 25 statements focus- ing on different aspects of ageing and OAs. The participants responded by stating whether a statement is true (T) or false (F). The FAQ1 include statements such as: ‘Old people tend to react slower than young people’; and ‘Lung vital capacity tends to decline with old age’. The statements that are answered correctly are assigned a score of 1 and the wrong ones a score of 0. The final scores for each participant are interpreted as follows: poor knowledge for scores of less than 10; fair knowledge for scores of 10 - 14; good knowledge for scores of 15 - 19; very good knowledge for scores of 20 - 24; and excellent knowledge for scores of 25. The section on attitude towards OAs was composed of the Kogan’s attitude towards old people (KOAP) scale. The KOAP measures attitude towards geriatric patients and has been used in several studies.28 The reli- ability of the KOAP has been reported at Cronbach’s alpha ranging from 0.79 to 0.82.29,30 The KOAP is a 34-item tool with a 6-point Likert scale (strongly disagree = 1, disagree = 2, slightly disagree = 3, slightly agree = 5, and strongly agree = 6). The tool contains 17 positively rated and 17 negatively rated statements about OAs. For instance, the participants responded to items such as: ‘Most OAs get set in their ways and are un- able to change’; and ‘Most OAs tend to let their homes become shabby and unattractive’. The range of scores for the KOAP is from 34 to 204, with higher scores representing positive attitude. The participants’ scores on the KOAP are categorised as: poor attitude for a score of less than 103; neutral attitude for a score of 104; and positive attitude for scores greater than 105. The two standardised scales (KOAP and FAQ1) are tested and proven measures that have been used in several cultures, and when closely examined by the researchers their items were found to be culturally neutral and focused on general aspects of ageing and OAs. The details of the two scales are published in other studies.24-30 Article 5 December 2010, Vol. 2, No. 2 AJHPE Although this is the first time the KOAP and FAQ1 are being used in Uganda, considering the above characteristics and that they were to be used to collect data from English-speaking participants, pilot testing was done on only six HCPs working in another rural health centre (nurse, doctor, dental assistant, social worker, laboratory technologist and den- tist). The results of the pilot testing showed that the questionnaire was understandable, with no cultural biases or ambiguities, and required on average 60 minutes to complete because the HCP stayed on the ward/unit performing other routine duties. Results Demographic characteristics of participants The sample was composed of 240 participants representing five different health professions. As shown in Table I, 51% of participants were male, and 43% qualified with associate degrees and 42% with professional cer- tificate-level education. The mean (+SD) age and years of clinical experi- ence for the sample was 32 (±10.5) and 4 (±1.9) years, respectively. Participants’ experience with OAs during professional practice As shown in Table II, most participants had lived with a relative of age 65 years or older (85%), and during clinical practice they took care of OAs every day or regularly (63%). When participants were asked to list the five most common health problems among OAs, they reported depression (58%), hypertension and cardiovascular diseases (54%), diabetes (38%), arthritis (28%) and dementia (28%). Most participants (71%) agreed that they needed training in geriatrics to provide better care to OAs. Table I. Demographic characteristics of participants Variable Frequency (N=240) percentage (%) Gender Male 122 (50.8) Female 118 (49.2) Age (yrs) (M=33.8, SD=10.5) 20 - 30 132 (55.0) 31 - 40 54 (22.5) 41 - 50 32 (13.3) 51 - 60 20 (8.4) ≥60 2 (0.8) Profession of health care provider Doctor or physician 24 (10.0) Nurse 124 (51.7) Laboratory technologist 24 (10.0) Physician assistant 40 (16.7) Social worker 28 (11.7) Years of clinical experience (M=4.0, SD=1.9) <1 20 (8.3) 1 - 3 92 (38.3) 4 - 5 34 (14.2) ≥5 94 (39.2) Level of education Certificate 100 (41.7) Diploma level or associate degree 104 (43.3) Bachelor’s degree 30 (12.5) Master’s degree 6 (2.5) Table II. Participants’ personal and professional experience with OAs Variable Frequency (N=240) percentage (%) Experience with OAs in personal life Has ever lived with a relative of ≥65 years 204 (85.0) Has never lived with a relative of ≥65 years 36 (15.0) Takes care of patients of ≥65 years during clinical practice Every day 64 (26.7) Regularly 88 (36.7) Rarely 76 (31.6) Not at all 12 (5.0) Five most common health conditions seen among patients of ≥65 years (multiple responses from health care providers) Hypertension and other heart diseases 130 (54.2) Diabetes mellitus 90 (37.5) Arthritis 68 (28.3) Dementia 68 (28.3) Cataracts 36 (15.0) Deafness 10 (4.2) Depression 140 (58.3) Fractures 16 (6.7) Cancer 44 (22.0) Benign prostatic hyperplasia 24 (10.0) I need special training in geriatrics to provide better care Strongly agree 50 (20.8) Agree 120 (50.0) Neutral 46 (19.2) Disagree 18 (7.5) Strongly disagree 6 (2.5) Article Article 6 December 2010, Vol. 2, No. 2 AJHPE Participants’ geriatric knowledge The knowledge of participants about geriatrics and care of OAs was meas- ured using the FAQ1. Results presented in Fig. 1 and Table III show that most participants (88%) scored below 14. The majority of HCPs (69%) were in the score range of 10 - 14, while others (19%) had scores of less than 10, representing fair and poor geriatric knowledge, respectively. The mean score for the sample on the FAQ1 was 11.6 (±2.3), which indicates poor knowledge. Results in Table III also show that the majority of par- ticipants (69%) reported that they were educated and trained on curricula that did not include geriatric-specific content or courses. However, de- spite the poor scores on the FAQ1 and lack of formal professional educa- tion focusing on geriatrics, some participants felt very confident (26%) or somewhat confident (46%) about their geriatric skills and knowledge levels. Participants’ attitude towards OAs The attitude of rural HCPs towards OAs was measured using the KOAP and results in Table III show that a significant percentage (80%) of partici pants attained scores representing a positive attitude. The highest score attained by participants was 145 out of 170 and the mean for the sample score was 115.9 (±11.5). Results in Table IV highlight some of the fac- tors associated with HCPs’ attitude towards OAs. The findings show that a positive attitude towards OAs is significantly associated with having lived with an OA relative (r=0.207, p≤0.05), desire for a future career in geriatrics (r=0.206, p≤0.05) and feeling comfortable with current geriat- ric knowledge and skills (r=0.207, p≤0.05). On the other hand, as years of clinical experience increase among rural HCPs their participation in caring for OAs diminishes (r=-0.416, p≤ 0.01) and the desire for a career in geriatrics depreciates (r=-0.286, p≤0.01). These factors are important to consider when planning implementation of tailored geriatrics continu- ing education programmes for rural HCPs. HCPs’ geriatric knowledge was not significantly associated with any factors. Discussion The participants in this study were mostly mid-career health profession- als as indicated by the mean age (33.8±10.5 years) and years of clini- cal experience (4±1.9 years). The findings show that they had very good personal and professional experience with OAs, and therefore were able to identify the common medical problems that affect OAs. The common health problems identified, such as hypertension and heart diseases, dia- Table III. Geriatric knowledge and attitudes of rural health care providers in Uganda Variable Frequency (N=120) percentage (%) Underwent professional training curriculum that included geriatric-specific courses Yes 60 (25.0) No 166 (69.0) Don’t remember 14 (6.0) Confident about knowledge and skills neces- sary for quality care of geriatric patients Very confident 62 (25.8) Somewhat confident 102 (42.5) Not confident 76 (31.7) Definition of a person considered an OA Person of ≥45 years 20 (8.3) Person of ≥50 years 38 (15.8) Person of ≥65 yars 128 (53.3) Person of ≥75 years 54 (25.5) Health care providers’ knowledge about geriatric care as measured by FAQ1 (M=11.6, SD=2.3) Poor knowledge (score of <10) 46 (19.2) Fair knowledge (scores = 10 - 14) 166 (69.1) Good knowledge (scores = 15 - 19) 28 (11.7) Health care providers’ attitudes towards OAs as measured by Kogan’s attitude towards old people (KOAP) scale (M=115.9, SD=11.5) 91 - 99 14 (5.8) 100 - 109 66 (27.5) 110 - 119 68 (28.4) 120 - 129 64 (26.6) 130 - 139 26 (10.9) ≥145 2 (0.8) Categorisation of participants’ attitudes Poor attitude (KOAP score <103) 36 (15.0) Neutral attitude (KOAP score = 104) 12 (5.0) Positive attitude (KOAP score ≥105) 192 (80.0) Fig. 1. Bar graph showing distribution of participants by scores on the FAQ1. Article 7 December 2010, Vol. 2, No. 2 AJHPE betes mellitus, arthritis, dementia, cataracts, deafness, cancer, and benign prostatic hyperplasia, are all chronic and, without adequate care, may lead to other chronic complications and disability. When complications and disability occur there is a need for interdisciplinary teams of HCPs who are knowledgeable and skilled in geriatrics to provide quality health care. Similar health problems are common among OAs in Kenya and the rest of sub-Saharan Africa.31,32 Currently, good health care for OAs living in rural Uganda is difficult to achieve because, as shown by the findings of this study, the majority of HCPs who take care of OAs have a poor or fair geriatric knowledge and were educated on curricula that did not include geriatric content. How- ever, the future is promising because most HCPs recognise their geriatric knowledge and skills deficits and are interested in attaining special training in geriatrics to provide better care to OAs. The lack of geriatric knowledge and skills is not unique to HCPs in Uganda. Other studies in countries such as Australia and Saudi Arabia show that HCPs in rural settings commonly have significant deficits in geriatric knowledge and skills.33,34 The geriatric knowledge and skills deficits have been mostly blamed on lack of geriatric content in curricula to train and educate health pro- fessionals before they enter into professional practice. The response to this problem has been mainly inclusion of geriatric content in training curricula for future health professionals. Although this is important in en- suring geriatric competencies of future health professionals, it is a partial response to the problem and only caters for the geriatric knowledge and skills of those who are yet to join professional practice, and neglects the needs of those who are already in clinical practice. In this study we have been able to emphasise the extent of the geriatric knowledge and skills gaps of HCPs working in a rural health facility in Uganda. These results will be used to inform the planning and implementation of a pilot pro- gramme to enhance geriatric competencies through a tailored continuing education programme. The costs and details will be developed by a team of local and international experts in geriatrics and continuing education for health professionals. However, even before implementation of the pilot programme, in this study there are significant results which show that the continuing edu- cation programme has a very good chance of being successful. For in- stance, the majority of rural HCPs had a positive attitude towards OAs. This study also revealed that in rural areas of developing countries like Uganda there are still some competent health professionals with good clinical experience (mid-career) who can be trained through continuing education to improve their care of geriatric patients. The viability of a continuing education programme in geriatrics is also further enhanced by the fact that most of the participants had personal experiences with OAs. This is very important, especially for adult learners, because it facilitates easy understanding of psychosocial problems of OAs. The other geriatric competencies commonly recommended for all health care disciplines in- clude understanding age-related changes, risk assessment and health pro- motion, and mental, physical, affective, psychosocial and environmental aspects of health problems experienced by OAs.12 All these aspects are easier to understand when you have lived with and later alone taken care of OAs.35,36 Another general but important lesson from this study is that as years of clinical experience increase, HCPs become less interested in geriatrics as a specialty and are less likely to be working in clinical units where OAs are admitted. This finding suggests a need for balance when recruiting participants in continuing education programmes in geriatrics to ensure that there is good representation of junior to mid-career HCPs. The factors highlighted above and the other findings of this study provide some baseline information on which to build a continuing edu- cation programme in geriatrics in a country where there are no data on geriatric competencies and where geriatrics has not yet been introduced as a specialty. In the immediate term a tailored continuing education programme in geriatrics is the most cost-effective approach to ensuring knowledge and skills acquisition by rural HCPs, because they are able to enhance their competencies without leaving the work station. This point is especially important in Uganda and other sub-Saharan countries which are currently experiencing shortages and migration of HCPs to developed countries. Limitations The sample for this study was recruited using a convenience sampling technique from a rural district in Uganda which is mostly settled by peo- ple with limited incomes. This decision was taken because the current study was undertaken as a baseline assessment in preparation for the im- plementation of the pilot continuing education programme. Therefore, as the results are based on a sample obtained from a specific setting, the findings have limited generalisability. However, despite its limita- tions, this study is the first to focus on geriatrics and health professionals in Uganda and it highlights the gaps in geriatric knowledge and skills among rural HCPs. Furthermore, the results of this study have the poten- tial to stimulate debate about curriculum revision in health professional training institutions to address the geriatric knowledge and skills gaps in preparation for the changing health care needs of the population of Uganda and other countries with similar characteristics. Table IV. Factors associated with participants’ attitude towards OAs Factor (N=240) ATOAs LIVED CARE GERO COMF EXP Attitude towards older adults (ATOAs) 1 Ever lived with relative of ≥65 years (LIVED) 0.207* 1 Cares for patients ≥65 years (CARE) 0.058 0.302† 1 Would like a future career in geriatrics (GERO) 0.206* 0.205* 0.430† 1 Comfortable with current geriatric knowledge and skills (COMF) 0.207* 0.287† 0.286† -0.059 1 Years of clini- cal experience (EXP) 0.114 -0.206* - 0.416† -0.286† -0.149 1 * Correlation is significant at the 0.05 level (2-tailed). † Correlation is significant at the 0.01 level (2-tailed). Article 8 December 2010, Vol. 2, No. 2 AJHPE Conclusion HCPs working in the rural Apac district of Uganda have deficits in geri- atric knowledge and skills, and underwent professional training that did not emphasise geriatrics. The HCPs recognise this knowledge and skills gap and voiced a need for tailored continuing education programmes to be able to provide quality health care to OAs. 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