Studyreportofaperceptionsurveyamongtrainedmedicalstaffin

Uzbekistan

GIZproject“Advancedtrainingofmedicalandtechnicalprofessionalstoworkwithmodernhightechnologyequipmentin

Uzbekistan

Author:JunuHada

StudentofMasterofScienceinInternationalHealth

InstituteofPublicHealthRUPRECHT-KARLSUNIVERSITÄTHEIDELBERG

Supervisor:Dr.OlafHorstick

InstituteofPublicHealthRUPRECHT-KARLSUNIVERSITÄTHEIDELBERG

Co-supervisor:Dr.GunnarStrote

GIZUzbekistan

August2016

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TableofContentsTableofContents...............................................................................................................i

Listoffigures.....................................................................................................................ii

Listoftables......................................................................................................................ii

Listofabbreviations.........................................................................................................iii

Executivesummary..........................................................................................................iv

Introduction......................................................................................................................6

1.1. HealthsysteminUzbekistan.....................................................................................6

1.2. Healthstatus.............................................................................................................6

1.3. Backgroundoftheproject........................................................................................8

1.4. CurrentstateoftheoverallGIZproject....................................................................9

1.5. Researchquestion.....................................................................................................9

1.6. Generalobjective......................................................................................................9

1.7. Specificobjectives.....................................................................................................9

1.8. Conceptsoftrainingevaluation..............................................................................10

1.9. Conceptualframework...........................................................................................10

1.10. Rationaleforthestudy........................................................................................12

Methods..........................................................................................................................13

2.1. Studydesign............................................................................................................13

2.2. Studyarea................................................................................................................13

2.3. Studypopulation.....................................................................................................13

2.4. Datacollectiontools...............................................................................................13

2.4.1. Self-administeredquestionnaires......................................................................................14

2.4.2. Focusgroupdiscussionandin-depthinterviews..............................................................14

2.5. Dataanalysis...........................................................................................................15

2.6. Ethicalapproval.......................................................................................................15

Studyresults....................................................................................................................17

3.1. Self-administeredquestionnaire............................................................................17

3.1.1. Characteristicsoftherespondents....................................................................................17

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3.1.2. Knowledgeandskillsonuseandbasiccareofequipment...............................................18

3.1.3. Trainingreflectiontoactualworksetting.........................................................................19

3.1.4. Confidenceusingequipment.............................................................................................19

3.1.5. Needofsupervision...........................................................................................................19

3.1.6. Clinicalerrors......................................................................................................................19

3.1.7. Patientcareandworkload................................................................................................19

3.1.8. Hindrances..........................................................................................................................19

ListoffiguresFigure1:Conceptualframeworkofthestudy..............................................................................................10Figure2:Professionbysexoftheonlineplatformrespondents..................................................................17

ListoftablesTable1:Agebyprofessionofonlineplatformrespondents.........................................................................17Table2:Numberoftrainingsreceivedbyprofession...................................................................................18

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Listofabbreviations

ALOS AverageLengthofStay

BIRADS BreastImaging-ReportingandDataSystem

CD CompactDisk

CT ComputerizedTomography

CVDs CardioVascularDiseases

EBM EvidenceBasedMedicine

FAPs Feldshermidwifepoints

FGDs FocusGroupDiscussions

GIZ GesellschaftfürInternationaleZusammenarbeit

HIV HumanImmunodeficiencyVirus

HU HeidelbergUniversity

LMICs LowandMiddleIncomeCountries

MCH MotherandChildHealth

MoH MinistryofHealth

MRI MagneticResonanceImaging

MS Microsoft

MSCT Multi-slicecomputertomography

NCDs non-communicablediseases

PHC PrimaryHealthCare

Rayons/Tumans District

RMO RayonMedicalOrganization

RRCEM RepublicanResearchCenterofEmergencyMedicine

SUBs Ruralcommunityhospitals

SVAs Ruralambulatoryfacilities

SVPs Ruralphysicianpoints

TIAME TashkentInstituteofPostgraduateMedicalEducation

TOT TrainingofTrainers

USB UniversalSerialBus

Viyolats Region

WHO WorldHealthOrganization

ZRB Centralrayonhospitals

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Executivesummary

Background

Uzbekistan’s health care system was highly impacted after its independence in 1991. Adramatic rise in the prevalence and incidence of Non-Communicable Diseases (NCDs),includingCardioVascularDiseases(CVDs),cancers,diabetes,andtraumatologycasesintherecent years has brought several major health care reforms in the country, aiming todecentralizeand improveefficiencyof thehealthcareservices.Theavailabilityofmodernhealthcare technology isoneexample,where thegovernmenthas invested in toaddressthe demand of rising patients in the last 15 years. Despite the availability of high-techmedical equipment, shortage of skilled health workforce resulted in insufficient andcompromisedservicedelivery.Toaddressthisissue,theGermanDevelopmentAgency(GIZfor its acronyms in German) and the Ministry of Health (MoH) in Uzbekistan initiated aproject “Use of modern advanced medical technology in Uzbekistan” in 2001. The mainobjectiveof theprojectwas to trainmedicalandtechnicalprofessionals touseadvanced,modernhealthtechnologyefficiently.

Kirkpatrick'strainingevaluationmodelevaluatestraininginfourdimensionswhichincludesreaction (measures reaction to the training, experience), learning (measures increase inknowledge,skills,confidenceasaresultofthetraining),behavior(measuresapplicationoftheinformation),andresults(analysestheoutcomeoftraining).Thelastlevelwasalreadymeasuredbytheprojectwhichshowedapositiveresultwithareductioninaveragelengthof stay (ALOS), early diagnosis of diseases and an increased proportion of diagnosis andsurgeriesinselectedhealthfacilities.Butthefirstthreephaseshadnotbeenevaluatedsofarandthisstudyisanattempttoevaluatefirstthreephases.Thisstudyaimedtoexplorereaction, learningandbehavioroftrainingparticipantsfromtheirperception,underbroadcategoriesoftraining influenceontheirknowledge, improvedskills,personalcompetency,satisfactionandaccountability towards their job.Thestudyalsoexploresexperiencesandfurther areas of improvement for the advancedmedical equipment training programandproposesrecommendationsbasedontrainees’expectations.

Methods

This study used a mixed methods approach with qualitative and quantitative tools. Itgatheredinformationtoreachwiderparticipantsthroughquantitativemethodsanddeeperdescriptiveinformationviaqualitativemethods.

The self- administered questionnaire used rating scales and semi-structured questions,whereasaguidedframeworkwasusedforFocusGroupDiscussions(FGDs)andinterviews.Total respondents for self-administered questionnaires were 240 out of 489 initiallyexpected participants trained by the project, and 12 FGDs and 12 interviews wereconductedbyvisitingtheselectedhealthfacilitiesofUzbekistan.

Findings

All the participants appreciated the training and perceived that their knowledge, skills,confidence inusing theequipmenthas improvedandproficiency inhandling complicatedemergencycaseshasenhanced.

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Someofthepositiveaspectsexploredincludedearlydiagnosisinrelationtodecreasedpostsurgeries complications, increased use of modern surgical methods, doctors and nursesbeing able to synchronize during surgeries, improved public awareness of the availableservices, raised interest and willingness to learnmore on the equipment by themedicalstaff,andperceivedincreaseinthequalityofcare.

Meanwhile, the study was also able to gather some experiences that were hinderingimplementation of the learning. The common experiences included lack of consumables,shortageof spareparts,noequipmentat someworkstations,non-functioningequipmentduetolackofmaintenanceservices.

Oneofthesurprisingfindingswasthatalltheparticipantsseemtobesatisfiedandproudofworkinspiteofsubstantialincreaseinworkload,feelingofstressatworkandlimitedworkautonomyfornurses.

Recommendations and support requested from the participants mainly included regularrefresher trainings, trainings from international experts, use of the local language fortraining,provisionofup-to-date trainingmaterials, regularpreventivemaintenanceof theequipment, provision of additional laparoscopic units both at training center and workstations, adequate supply of the spares and consumables, establishment of a knowledgeandskillssharingplatform,andfuturetrainingtopicsasperparticipantsinterest.

Conclusion

Theprojectoverall illustratesnoticeablepositiveeffects.Training isextremelyappreciatedand perceived to enhance knowledge, skills, confidence and competency by themajorityparticipants. The study revealed that, though the participants perceived an increasedworkload, complained about the same, but they seem to be satisfied with the recentimprovement inthehealthcaresystem.Participantsexpectedcontinuoussupportbothforthetrainingandtoimplementlearningsatwork.

The studyconcludes that several actors (government,donors,health care staff, financing,trainingcenter,supplychainmanagement)needtoworktogethertokeepthespirithighofcurrentlysatisfiedandmotivatedhealthworkforce,byaddressingtheobstaclesfacedbytheparticipantsinwork.

Recommendation

Theneedsmentionedbyhealthcarestaffarediverse,thusitneedsprioritizationandinputfrommultipleactors.Thestudyrecommendsfurtherstudiestoassessthepracticabilityandrequirementsofnewtrainingtopics, refreshertrainings,andnewtrainingequipment.Themajorrecommendationincludes,addressingthepreferredlanguageofdeliveryfortraining,timely supply of equipment and consumables, strengthening supply management, evendistribution ofworkload from central to peripheral facilities by reinforcing the peripheralfacilities,andcreatingaconduciveplatformforknowledgeandexperiencesharing.

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Introduction

1.1. HealthsysteminUzbekistan

After Uzbekistan became independent in 1991, the health care system was dramaticallyimpacted (Ahmedov M, Azimov R et al. 2014). Several major health care reforms wereundertaken in the country aiming to decentralize and improve efficiency of the health careservices. At present, the health system is organized on three hierarchical levels: national(republican);viyolat(regional);andtuman(districtorcity)(AhmedovM,AzimovRetal.2014).

Figure1:ThehealthcarestructureinUzbekistan

Source:Hanser2015,Baselinestudyreport ‘AdvancedtrainingformedicaldoctorsandhealthworkersfortheuseofmodernhealthtechnologyinUzbekistan’

Health care in Uzbekistan is primarily public sector driven with the private sector mainlycomprising of pharmacies, small institutions involved in service delivery or pharmaceuticalmanufacturing (Petrosyan and Rai 2015). The basic benefit package provided by theGovernment includes free of charge services in the field of emergency care, communicablediseases,mentalhealthcareandoncology(PetrosyanandRai2015).

1.2. HealthstatusUzbekistanpopulationhasbeengrowingcontinuouslyinrecentdecades,reaching30.75millionin2014(TheWorldBank2014)ofwhich51%arefemale(PetrosyanandRai2015).Althoughthepopulationisstillyoung,with28.2%ofthepopulationaged0-14yearsin2013,thisproportion

Nakonallevel

• RepublicanResearchCenterofEmergencyMedicine(RRCEM)inTashkent

• SpecialisedterkarycarehospitalssuchastheRepublicanPerinatalCenterinTashkent,theCenterofEndovisualandMinimal-invasiveSurgeryofChildren,theSurgicalCenteroftheAcademy,clinicalfacilikesofMedicalAcademyinTashkent,SamarqandandAndijon

Oblast(region)

• Oblastmulk-profilehospitals

• 13affiliatesofRepublicanResearchCenterofEmergencyMedicine(RRCEM)

• PerinatalCentersandpaediatrichospitals

Rayon(district)

• RayonMedicalOrganisakons(RMO)comprisingrayonhospitals,policlinicsandperinatalCenters

• 172affiliatesofRepublicanResearchCenterofEmergencyMedicine(RRCEM)

Ruralcommunik

es

• Ruralphysicianpoints(SVPs)andsomefewsmallruralcommunityhospitals(SUBs)

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has been decreasing since 1980 (Ahmedov M, Azimov R et al. 2014). The majority of thepopulationlivesintheruralarea(64%)(PetrosyanandRai2015).

Thelifeexpectancyatbirthformaleis70.7yearsandfemaleis75.5years(StateCommitteeOnStatistics2013).ThematernalmortalityrateinUzbekistanhasbeendecliningtoanofficialrateof 20.2 maternal deaths per 100 000 live births in 2012. However, a maternal death isconsideredtohavearisen fromacriminaloffenceand is subject tocriminal investigationsbytheprosecutor’soffice,creatinganincentiveforunder-reportinginofficialstatistics(AhmedovM,AzimovRetal.2014).WHOestimatedmaternalmortalityratioat36per100000livebirthsin2015.RechalandRichardsoetalsaysthatInfantandchildmortalityratesrecordedinofficialstatistics are under estimated than actual mortality and the average life expectancy rate isconsequentlyhigherthanactuallifeexpectancy(Rechel,Richardsonetal.2014).

Diseases of the circulatory system (in particular ischemic heart disease and cerebrovasculardisease)arethemostcommoncausesofdeathinUzbekistan.ThemortalityratefromdiseasesofthecirculatorysystemhasincreasedinUzbekistansincethe1980s(AhmedovM,AzimovRetal.2014).Theage-standardizeddeathratefromnon-communicablediseasesin2012amountedto810.9per100000population,withalargeproportionofdeaths(48.34%amongmalesand37.56%forfemales)occurringundertheageof70years(WorldHealthOrganization2014).Outof all deaths due to non-communicable diseases in 2014, about 54% were attributed tocardiovascular diseases, 8% to cancers, and 3% to respiratory diseases (World HealthOrganization2014).Atthesametime,mortalityfromdigestivediseaseshasincreasednotablyinthecountry,muchofwhichisduetochronicliverdiseaseandcirrhosis(AhmedovM,AzimovRetal.2014).

ThisNCDsreflectschallengestothepublichealthsystemwithlimitedresources.However,theUzbekhealthsystemhasundergonenumerouscomprehensivereformswithasystemapproachinresponsetoimprovetheprimaryhealthcare(PHC)systematalllevels.

Modern health care technologies have changed the face of healthcare delivery around theworld. Today's health care delivery systems have been influenced by and are dependent onstate of the arts technologies. In this regard, the health care systemofUzbekistan is not anexception.Thegeneralgovernmentexpenditureonhealthasapercentageoftotalexpenditureon health has increased considerably from around 40% in 2007 to more than 50% in 2013(WorldHealthOrganization2016).Approximately60millionUSDwereinvestedinnewmedicalequipment at both secondary and tertiary health care levels in past 15 years (Khodjibaev,Anvarovetal. 2014). Theabove-mentioned fundwasmostlyallocatedon the investments indiagnostic and therapeutic technologies in order to address the demand of patients inUzbekistan. A considerable amount of modern high-tech medical equipment has beenpurchased through donor-funded programs since 2001 (Hanser 2015). The new equipmentincludes some of the latest high-tech medical devices for imaging, laboratory diagnostics,anesthetics, intensive care and endoscopy (Hanser 2015). That fund allocation shows thathealthservicedeliveryisinatransitionphaseinthiscountry.However,duetotheshortageofqualified technical personnel, there has been an obstruction to efficient and effective use,

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management, and maintenance of the existing equipment (Hanser 2015). Anecdotal lack ofskillful staffmembers results in insufficientandcompromisedhealth servicedelivery,despitetheavailabilityofhigh-techmedicalequipment(Hanser2015).

1.3. BackgroundoftheprojectTakingaboveissuesintoaccount,GIZUzbekistanandtheMinistryofHealth(MoH)initiatedaprojectin2001,“UseofmodernadvancedmedicaltechnologyinUzbekistan”.Theactivitiestoreachtheprojectobjectivesinclude:

1) Capacity building of medical and technical professionals for the use of Advanced,ModernHealthTechnology;

2) Quality assurance and management improvement within procurement, logistic andmaintenanceintheselectedclinicalareas;

3) Improvementofprocurementandfinancingplanninginselectedclinicalareas,4) Public Private Partnerships in centers specialized in advanced training for health

professionalsandtechnicians

“AdvancedtrainingformedicaldoctorsandhealthworkersfortheuseofmoderntechnologyinUzbekistan”,isoneofthecomponentoftheproject.Theprojectisimplementedincooperationwith other related structures like the Institute of Postgraduate Education of Doctors, theRepublican Research Centre of Emergency Medicine (RRCEM) and the privately organized“Uztibtechnika”inchargeformaintenance(Horneber2012).Theselectedclinicalareasare:(i)imagingsystems/CTandMRIEquipmentand(ii)Endoscopyequipment/less-invasiveSurgery(Horneber2012).

Theprojectalsosupportedcontinuousprofessionaleducation.Therequirementsforphysiciansareasfollows:

• Within 5 years, any physician - whether working in a healthcare organization, ahealthcare administration or ministerial structure - has to undergo 288 hours ofcontinuouseducation,whichistypicallyorganizedintwoslotsofonemonth.

• PhysicianswhoworkintheMinistryofHealth(MoH)healthcaresystemhavetoundergoaregularcheckanddeterminationoftheir‘category’.

• PhysicianswhoworkintheprivatesectorhavetogetalicensefromtheMoHtopractice(this is not the case for the above mentioned physicians who work in the MoHstructure).Thelicenseneedstoberenewedafter5years.

Nurses with a higher education have to undergo 144 hours of continuous professionaleducationduring3yearsoftime.

The Tashkent Institute of Postgraduate Medical Education (TIAME) holds the exclusiveresponsibility for the postgraduate education, specialization and retraining of medicalpersonnel (AhmedovM,AzimovRetal.2014).Besidestheheadoffice inTashkent,therearetworegionalbranches,onelocatedinSamarqand,theotherintheprojectpilotregionAndijon(Hanser2015).AccordingtoTIAME,thereareapproximately75,000physicianstrainedduringoneyear,outofwhichabout15,000physiciansaretrainedeveryyearbyTIAME(Hanser2015).

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TrainingforMoHphysicianstomaintainorimprovetheirprofessionalcategoryisprovidedfreeofcharge(Hanser2015).

The GIZ project cooperation and support is appreciated by TIAME for continuous training,organizing technical consultations with international and regional experts, and promotinginternational partnership (Khodjibaev, Anvarov et al. 2014). Study tours were organized forTIAME’seducationalstafftocooperatingpartnersof internationalclinics, informationvisitstomedicalmanufacturersincountriessuchasAustria,Belarus,GermanyandRussia(Khodjibaev,Anvarovetal.2014).Moreover,internationalexpertsandprofessorshavecometoTIAMEfromabroad(mainlySt.PetersburgandBelarus)toteachandtrainTIAME’seducationalstaff(Hanser2015).

Thetrainingthatthesurgeonsundergoinlaparoscopydoesnotconstituteonlyanewmedicalspecialty,butwiththetrainingcertificate,thesesurgeonsgettheofficialpermissiontoconductsurgicaloperationswith laparoscopes(Hanser2015).Thetrainingaimedto increasetechnicalcapacityofhealthprofessionals in theeffectiveandefficientuseofadvancedtechnologies inselectedclinicalareas.Atotalof489medicalstaff(whichincluded207surgeons,156radiologyspecialists, and106 theaternurses) received specialized training (Hanser 2015). Theultimatebeneficiariesare thepeopleofUzbekistanaswellashealthprofessionalsusing theadvancedmoderntechnologiesasspecified(Horneber2012).

1.4. CurrentstateoftheoverallGIZprojectThe project has so far shown positive outcomes with a reduction in average length of stay(ALOS),earlydiagnosisofdiseaseslikebraintumors,trauma,ischemicstrokeandhemorrhagicstroke (GIZ2014).There isalsoan increasedproportionofdiagnosisandsurgeries inselectedhealth facilities (GIZ 2014).According to theproject baseline study report byHanserA.C, theproject expected that the doctors’ trained in laparoscopy accomplish 90% of gynecologicalstandardinterventionsbyminimal-invasiveinterventions.

1.5. ResearchquestionThisstudywasadvancedtoanswerthefollowingquestion:Whatistheperceptionoftrainees(doctorsandmedicalstaff)ofthetrainingontheuseofmodern,advancedmedicaltechnology,implemented in selectedhealth facilities from13 regionsandTashkentCityofUzbekistan? Itattemptstoinvestigateanychangeintheperceptionsofknowledgeandskills,andtopersonalcompetencyandprofessionalaccountabilityafterthetraining.

1.6. GeneralobjectiveTo assess the perception of surgeons and other medical staff who attended the trainingprogram.

1.7. Specificobjectives• Toassesstheperceptiononchangeofknowledge,skillsandcompetencies• Toassesstheperceptiononchangeofprofessionalaccountabilityandsatisfaction• To explore further areas of improvement for the training program and propose

recommendationsbasedontrainees’expectations

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• Toassesspotentialrisksofincreasedworkloadfollowingthetraining

1.8. ConceptsoftrainingevaluationKirkpatrick'sfour leveltrainingevaluationmodelanalyzestheeffectivenessandimpactofthetraining,toimprovetraininginthefuture(Kirkpatrick1994).Thefourlevelsaredescribedas:

o Reaction:This levelmeasurestrainees’reactiontothetraining,theirexperience,whattheylikeanddidnotlikeinstructor,topics,material,its’presentation.

o Learning:thislevelmeasureswhattraineeshavelearned.Increaseinknowledge,skills,confidenceasaresultofthetraining.

o Behavior:Howtraineesapplytheinformationismeasuredinthislevel.o Results: this level analyses the outcomeof training. If implementation of training has

goodresults

Thismodel is referred toas thestandard toevaluate training, this studyhasalsoadapted itsfourlevel.

1.9. Conceptualframework

The conceptual framework was sketched to conceptualize, how the perception on trainingmight get influenced by various factors such as, demographic factor of participants, trainingfactors, institutional factors, patient factors and availability of equipment. The figure belowshowsdifferentaspectundereachfactor.Figure1:Conceptualframeworkofthestudy

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Percep_onofhealth

professionalsontraining

Demographicsfactor• Area(Republic,Viyolat,

Rayons)

• Professionals(surgeons,radiographer,nurses)

Trainingfactors• Saksfackonfromtraining• No.oftrainingreceived

• Applicabilityoflearnedknowledgeandskills

• Useoftrainingmaterials• Availabilityoflearningmaterials

• Experience

Pa_entfactor• Pakentlifestyle

• Pakentknowledge,informakon• Workload

Ins_tu_onal,poli_cal,socialcontext• Healthfacility

• Financialsupport• Healthpolicies

Equipmentandaccessories• Availabilityofworking

equipment• Numberofworkingequipment• Availabilityofconsumables

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1.10. Rationaleforthestudy

Theperceptionandattitudeofemployeestowardstheirjobandtrainingreceivedmayhaveagreat impact on the success of such training (Truitt 2011). This study, therefore, aimed toexplore the perception of health professionals on the training and its influence on theirknowledge,skillsimprovement,personalcompetencyandaccountabilitytowardstheirjob.Thestudyalsoexploredthetrainingsatisfaction,attitudetowardstheirjobinrelationtoincreaseddiagnosis-surgeriesandpossibleareasforimprovement.

Thisstudymightalsohelptheproject toadapttothecomments,currentneedsandpossibleareasofimprovementsproposedbythestaff.Onanationallevel,thisstudywouldcontributeto fill the gap by including the views ofmedical staff in the training and their post-trainingexperiencesinUzbekistan.

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Methods

Thischapterpresentsthestudydesign,studyareaandthestudypopulation. It illustratesthedatacollectionmethods,dataanalysisandmanagement,andtheethicalapproval.

2.1. StudydesignThis study adopted mixed methods approach with qualitative and quantitative tools. Thequantitativeapproachwaschosentoreachwiderparticipantswhohavereceivedtrainingandare spreadaround the country,whereasqualitativeapproachwasopted fordescriptiveandinterpretiveinformation.

The self- administeredquestionnaire on the perceptionof traineeswas used to quantify theperception of trainees and understand the current situation using rating scales and semistructuredquestions. The study collecteddescriptive informationvia in-depth interviewsandfocus group discussions (FGDs) to ensure exploration of the presumed theory under aframework,butatthesametimeprovidingflexibilityandadaptationtounforeseeninformationthatmightemergeintheprocessoftheactualresearch.

Theresearcherlookedatabroaderrangeofperceptions,experiencesandfurtherexpectationonthetrainingrelatedtoadvancedmedicalequipmentfromasmallnumberofpeopleundertimeand resource-limited conditions. The field visitwasdesigned tobe accompaniedby thelocalstafffromGIZ,alsofortranslationpurposes.

2.2. StudyareaThe study area was Tashkent city and 13 regions of Uzbekistan. Four core hospitals wereselected to gather qualitative data, Republican Research Centers for Emergency Medicine(RRCEM)inTashkentanditsthreepilotoblasts,Andijon,NavoiyandSamarqand.Therationalefor the selection was that these hospitals possess and utilize types of advanced medicalequipment that theproject is addressing.Also, thesehospitalshave theadvantage that theyconductsimilartypesofmedicalinterventions.Inaddition,datafromtwootherhospitalsfromTashkentwere collected: the Republican Perinatal Center and the Center of Endo-visual andMinimal-invasive Surgeryof Children.Bothhospitals are cooperationpartnersof theproject.However,thesetwohospitalsdifferfromtheRRCEMsintheprofileofmedicalinterventions.

2.3. StudypopulationThe study population was total trained personnel (489) by the project in Uzbekistan healthsystem.

Surgeons:227

Radiologists:156

Theatrenurses:106

2.4. DatacollectiontoolsDatawere collectedusingbothquantitative (Self-administeredquestionnaire)andqualitativemethods(FGDsandinterviews).

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2.4.1. Self-administeredquestionnaires

ThequestionnairewasdevelopedundertheconsultationwithHeidelbergUniversityteamandproject staff. 38 item questionnaires included basic data; satisfaction and perception ratingLikert scales, structuredaswell asopen-endedquestions. Information related to the trainingprograms, its influence in knowledge, skills improvement, personal competency andaccountabilityweregathered.

Onlinesurveyformsweredevelopedvia“Googleforms”inEnglish.TheEnglishversionoftheonline questionnaire was first tested among a population of Master course participants atHeidelbergUniversity.ThequestionnairewastranslatedtotheRussianandUzbekversionwithhelp of GIZ. All the translation to local language (Uzbek or Russian) was validated by GIZ-Uzbekistan.

Theonlinelinksweredistributedviaemail.Forthosetrainedstaffwhodidnothaveemailoranaccesstoemail,printedversionsofthesurveyformsweredistributed.Allprintedversionswereenteredonlinebytheresearcher.

2.4.2. Focusgroupdiscussionandin-depthinterviewsThedesignof the focusgroupdiscussionand interviewguideswascarriedout in suchawaythat, particular issues could be well explored. The guide with semi-structured open-endedquestions was developed, on the four thematic sections (expectation from training,contribution of training, practical application including hindrances and follow-up support-recommendationforfuture)withmorespecificsubthemesineachsection.

Thehomogeneityof focusgroupswasguaranteedaseachgroupwasselectedbythetypeoftraining (surgeons, radiologists and theater nurses) and each group was composed ofparticipantswhohavereceivedamixoftrainingatdifferenttimesbetween2011and2016,andworkingindifferentlevels.Atotalof12FGDswasundertakeninTashkentcityandotherthreeregions (Andijon, Navoiy and Samarqand) where facilities had training centers. All the FGDswereconductedinthelocallanguagewithassistancefromlocalmoderatorsofGIZ-Uzbekistan,whowereexperiencedinfacilitatingFGDs.

Interviews were conducted among 12 trainees to explore various perceptions about thetraining program. The selection of interviewees was based on purposive sampling. Inclusioncriteria included any health professionals who had received at least one training under theframeworkoftheGIZprojectandexclusioncriteriawasnothavingparticipatednFGDs.

A moderator- translator and researcher visited each study location according to scheduledappointments in order to conduct the FGDs. They were trained on the aim of the study,objectives and areas to be explored. The purpose of visit and the aim were explained (toexplorethechangeinexperiencesandperceptionsafteradvanceskillenhancementtrainingonmodernmedicalequipmentandrecommendationforfuturedirection)andthenthefloorwasopened for free discussions within the framework of predefined areas. All discussions andinterviews were audio recorded with permission. All the information was translated andtranscribedduringthestayinUzbekistan.

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2.5. DataanalysisMixedmethodsof data analysiswas employed in this study.Quantitativedatawas analyzedusing quantitativemethods and the qualitative datawas analyzed using qualitativemethods(Creswell2007),andfinallysupportingonemethodbyotherthroughtriangulation,toprovidebetterexplanation.

The online platform was closed once all the expected data were collected. The data wereextracted from “Google spreadsheet” and exported to “MS-Excel”. As the datawere in duallanguage,thedatawerecleanedandonlytheEnglishversionwaskept.Thesedatawerefurtheranalyzed using “MS-Excel 2013” and “Tableau Public 9.3”. The data were analyzed andpresentedasfrequencybyrelevantsub-groups(sex,profession,typesoftraining).

A systematic process for qualitative data analysis was generated to identify basic conceptsemergingfromtheinterviewsandFGDs.Theanalysisproceededinfivestages:familiarization,identifying thematic framework, coding, charting, and mapping and interpretation (Pope,Zieblandetal.2000).Inthefamiliarizationstage,transcriptsofeachfocusgroupwerecreatedwithvoicenumber,professionandhospital to identitytheparticipantandsite. Inthesecondstage, a thematic framework was reviewed under four priori domains: Expectation,contribution, practical application and follow-up support/ recommendation. The preliminarycodesweredefinedbasedon interview/FGDguidequestionsandprobes. Textualdata fromfield notes and transcriptionwere explored using variants of priori domain. The informationwere examined, reviewed for consistency and constant comparisonsweremadewith rest ofthedataunderanalyticalcategories.

The immense data generated from qualitative methods, transcriptions and notes weremanagedusing softwarepackage “NVIVO-pro trial”.Analysiswasdonebygenerating codes,chartingandmappingfromtranscriptionofFGDsandinterviews.Keyfindingsundereachmaintheme or category were presented, using appropriate verbatim quotes to illustrate thosefindings(Burnard,Gilletal.2008).

Apowerfultriangulationtechniquewasappliedusingthesamesoftwaretofacilitatevalidationof data through cross verification. Two types of triangulation were applied: methodtriangulation (self-administered questionnaire, interviews and FGDs) and data sourcetriangulation (individual and group perspective). The triangulation of results was developedunderthedefinedcategoriesandactual“quotes”werenotusedforpresentationofanalysis.

2.6. EthicalapprovalAll themeasures to observe ethical acceptability of the studywere formally considered andapprovedbyrespectiveauthorities.Thestudyproposal,datacollectiontools,informationformand consent formwere approvedby the Ethics Committeeunder theMedical Faculty of theRuprechtKarlsUniversityofHeidelberg(S-169/2016).AsthestudywasundertheGIZproject,the studyplanwasprovided to theproject team leaderbefore the startof field study. Sincethere is no formal institution in Uzbekistan responsible for the ethical consideration andapprovalforstudies,theprojectassuredtheresearcherthattheirsupportandinvolvementcanbeconsideredastheapproval.

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In the courseof the fieldwork, the researcher tried to ensure that all ethical considerationsrelatedtostudiesinvolvingdirectcommunicationwithpeoplewereconsideredandobserved.Themainconcernof the researcher in the fieldwasnot todoanyharmto the respondents’health,dignityandwell-being;ensureconfidentialityandanonymity,aswell asminimizeanypotentialrisksofparticipatinginthisstudy.

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Studyresults

The study results are presented according to method i.e., self-administered questionnaire,FGDs, interview and finally the triangulation. A description of the characteristics of therespondentsisfollowedbyfindingsineachmethod.

3.1. Self-administeredquestionnaire

3.1.1. CharacteristicsoftherespondentsSelf-administeredquestionnaire:Among489totaltrainedpersonnelfromaninitiallistin2014,the personnel trained had increased to almost 600 by 2016. The total response for self-administeredquestionnaireviaonlineplatformwere240.55%(132)weremaleand45%(108)respondents were female. By profession, 54.2% (130) were surgeons, 16.2% (39) wereradiographersand29.6%(71)weretheaternurses.

Figure2:Professionbysexoftheonlineplatformrespondents

The socio-demographic information on age, profession and number/title of the trainingattendedwerecollected.Theageofrespondentsrangesfrom19-65years,withoverallaverageagebeing40years.Surgeonswereyoungercomparedtoothers.

Table1:Agebyprofessionofonlineplatformrespondents

Nurse Radiographer Surgeon Allprofessions

Agegroups

<20yrs 1 0 0 1

20-29yrs 13 3 1 17

30-39yrs 19 16 63 98

40-49yrs 31 15 52 98

12,5%2,9%

29,6%

41,7%

13,3%

0%

10%

20%

30%

40%

50%

60%

Male

Female

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50-59yrs 7 4 12 23

60+yrs 0 1 2 3

Agestatistics

Mean 38.83 40.62 39.99 39.75

Mode 44 39 33 33

Gender

Male 0 32 100 132

Female 71 7 30 108

Total 71 39 130 240

The total number of training topics provided by the project are, 1 for nurses, 10 forradiographersand11 for surgeons. The training received ranges from1-10 for radiographersandsurgeonswhereas1-3 fornursesas somenursesalsoattended the trainingprovided forsurgeons. The radiographers and surgeons receivedmore trainings on average compared tonurses.

Table2:Numberoftrainingsreceivedbyprofession

Nurse Radiographer Surgeon Allprofessions

Trainingreceived

1 66 18 51 135

2-5 5 8 53 66

6-10 0 12 24 36

>10 0 1 2 3

Total 71 39 130 240

3.1.2. Knowledgeandskillsonuseandbasiccareofequipment

Ingeneral,participantsthinkthattrainingshaveenhancedtheirlevelofknowledgeonuseandbasic careof equipment. The vastmajority of surgeons (81%) and radiographers (77%) thinkthat now they have above average knowledge for basic care of equipment. Some nurses(around4%)thinktheydonothavemuchknowledgeontheuseofequipment.

Respondentsperceivedthat,theyhadagoodgainintheskilltousetheequipmentfortreatingordiagnosingpatients.Only23.33%ofrespondentsfeltthattheyhadaboveaverageskillsforthat,beforethetraining,whereasaftertraining,morethan82%ofrespondentsthinktheyhaveaboveaverageskills.

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Themajorityofprofessionalsthinktheskillsfromthetrainingcanbeappliedintheirdailywork.Most of participants (around80%) think that theynowhave above average skills of use andbasiccareofequipment.Nurses,comparedtootherprofessionals,seemtohavelessskillsevenafterthetraining.14%ofnursesdonotthinkskills learntfromtrainingareapplicableintheirdailywork.

3.1.3. TrainingreflectiontoactualworksettingMost of respondents think practical exercises during training has reflected their actualworksetting.Themajority(77%)thinkthereflectionontheiractualworkisveryhigh.Aminority(7%)ofallnursesthinksthereisnoorpoorreflection.

3.1.4. Confidenceusingequipment

Training has significantly enhanced the confidence of healthworkers on using equipment totreat patients. Earlier, 37% of respondents had no or poor confidencewhereas only 32% ofthemthoughtthattheyhadaverageorhighdegreeofconfidence.However,aftertraining,82%have excellent or good confidence on using the equipment and less than 1% still have poorconfidence.

3.1.5. NeedofsupervisionAfter the training,majorityofparticipants (59%) feel that they canwork independently. Lessthan5%thinktheyneedfull-timedirectorindirectsupervision.

3.1.6. Clinicalerrors69.23%ofsurgeonsrespondedthattheyusedtohaveoneormoreerrors,butcurrently,50%ofsurgeonsthinktheydonothaveclinicalerrors.

Almost80%ofradiographersstillthinkthattheymakesomeclinicalerrors,buttheythinkthefrequency of errors have reduced. Before training, as much as 48% of radiographers weremaking at least oneor twomistakes in amonth.After training, only 20.5%of radiographersthinkso.

3.1.7. Patientcareandworkload35.4% of respondents who thought overall patient carewas less or not effective at all nowbelievesthatoverallpatientcareismoreeffectivethanbeforethetraining.Actually78%thinkthataftertraining,qualityofcareforpatientshasimprovedsubstantially,however13%thinksthattherewasnochangeandsomeofthem(5.42%)evenfeltthatpatientcarehasdecreasedafterthetraining.66%ofprofessionalsthinkthatapplicationofnewskillsandnewequipmenthas substantially increased theirworkload and only 32% feel the otherway. Themajority ofnurses(52.11%)stillfeelstressedoutworkingwithmodernequipment.

3.1.8. HindrancesFigure7showsthat60%oftherespondentsrespondedthattherearehindrancestoapplytheirgainedknowledge.Themaincausesofhindrancesareunavailabilityofequipmentthattheyaretrained in, followed by lack of enough quantity of equipment, instruments and tools; non-

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functioning equipment due to lack ofmaintenance services and shortage or unavailability ofconsumables.