Of the 228 faculty/staff invited to participate, 109 individuals gave information about 212 programs across 149 nursing institutions (response rate: 73.4%) across three countries. Most participants responded online (83.5%) versus by telephone (16.5%). Response rates were variable, ranging from 22.7% in Kenya to 71.4% in Rwanda and 96.6% in Uganda (Table 1). Reasons for non-participation included institutional protocols prohibiting participation, desire to be compensated, and lack of time.
Study participants were predominantly female (60.6%), aged 40–49 years (35.8%), had earned a master’s degree (52.3%), and were principals/deans (57.8%) at their institution (Table 2). Many had heard about podoconiosis before (52.3%), knew that podoconiosis was caused by contact with soil (68.6%), and some associated the disease with poverty (5.88%). Nearly one in five answered incorrectly that podoconiosis was caused by mosquitoes (17.6%).
Most respondents (95.5%) correctly identified farmers as the highest risk group. Knowledge of shoe wearing (59.3%) and daily skin hygiene (55.6%) to prevent the disease were less well understood. Other preventative measures mentioned by respondents included maintaining a clean environment, health education, soil surveillance, reducing contact with red soil, and using floor coverings. Incorrect prevention strategies included mosquito control, ingesting cetirizine tablets and avoiding water bodies. Of the 52.3% who had heard about podoconiosis, 58.7% were not aware that it was endemic in their country. The average time required to earn nursing credentials varied by program and country (Table 3), ranging from 1.5 years for an extension diploma in Uganda to 5 years for a degree in Kenya.
The annual number of nursing graduates ranged from 12 for nursing certificates in Uganda to 4500 for a nursing diploma in Kenya. More than three quarters (81.7%) of the nursing schools also offered programs in midwifery; some offered medicine and public health (15.6%). NTD-specific courses were offered in most of the programs (minimum—69.7%, maximum—79.8%), but provision of podoconiosis training was much lower (minimum—24.1%, maximum—55.6%). Overall, 48.6% of the nursing programs included in the study were rural; only 3.9% taught Community Health Workers (CHWs). Podoconiosis training varied considerably by program and by country (Table 4). In Kenya, NTD courses were largely integrated in curricula (> 90.0%), but podoconiosis-specific instruction was only common in certificate (88.9%) and diploma (87.2%) programs, occurring mostly during clinical rotations. The median time reported for preclinical podoconiosis instruction was 4 h; attendance was mandatory. Most respondents reported that their students were likely to interact with podoconiosis patients during clinical training (ranging from 66.9% to 100%). Approximately half (55.0%) of nursing programs were based in rural areas and 5.6% offered podoconiosis training to CHW’s. Rwanda did not offer nursing certificates. Two-thirds of degree and all diploma programs offered courses specific to NTDs; however, podoconiosis-specific training was more often reported in degree programs (66.6%). No specific amount of time was dedicated to teaching podoconiosis, but podoconiosis-specific instruction was offered both during pre-clinical coursework and/or during clinical rotations; attendance was mandatory. All respondents reported that their students were likely to interact with podoconiosis patients during their clinical attachments. All programs were rural and none offered podoconiosis training to CHWs. In Uganda, courses specific to NTDs were commonly offered for certificate (68.6%) and diploma (64.0%) programs, less in degree programs (20.8%). Podoconiosis training was reported in up to one-third of programs (certificate—15.7%, diploma—26.0%, degree—33.3%). Of the schools that offered podoconiosis-specific courses, instruction was often incorporated in pre-clinical and clinical training; and attendance for all classes was mandatory. Irrespective of program, most respondents reported that students were likely to interact with podoconiosis patients during their clinical attachments. Overall, 45.3% of programs were rural; only 3.8% offered training to CHWs.
Across the three countries, participants between (36.4–51.1%) and (45.5–50.4%) felt that the quality and quantity, respectively, was very insufficient. Furthermore, (13.6–20.1%) and (9.1–20.9%) felt that the quality and quantity, respectively, was somewhat insufficient. Programs that offered podoconiosis training during pre-clinical training often integrated it in courses, such as tropical medicine (n = 11), community health (n = 8), microbiology (n = 7), epidemiology (n = 2), communicable diseases (n = 2) and/or parasitology (n = 2). Those offering it during clinical training included it during medical surgical nursing (n = 4) and pathophysiology (n = 1) rotations. The most cited barriers to providing podoconiosis training across all programs in the three countries were: not being part of the government curriculum (53.3%), the disease being of low priority (38.3%), and low faculty knowledge (24.3%; Table 5).
Other barriers included lack of research on podoconiosis, rarity of patients and lack of resources (equipment, time, and funding). Respondents mentioned that content delivered on various nursing programs was pre-determined in the approved government curricula. Government curricula related to NTDs focused on more common ailments, such as lymphatic filariasis, trypanosomiasis, and schistosomiasis.
“It's not part of the nursing curriculum and students do not waste time on matters that will not be examined” (ID_31).
“Neglected diseases are all neglected while teaching. We tend to stick to common diseases specified in the curriculum. Since the curriculum is designed by the government any lecturer with the knowledge may bring it to learners as merely a nice to know” (ID_25).
Among the few schools that addressed podoconiosis, respondents mentioned that their teaching was not well grounded in context. Some respondents expressed difficulties in teaching a topic that they themselves were not taught. Moreover, absence of adequate research on podoconiosis, coupled with overwhelming workload, further complicated any effort to introduce podoconiosis content.
“It’s sometimes hard to teach as myself I have never seen one. You cannot teach with mere imaginations, and you don’t have the confidence to talk about it.” (ID_60).
Overall, respondents who ranked the importance of podoconiosis training as low or moderate were almost even (29.6% v 28.7%). Common reasons given for low/moderate priority were (1) podoconiosis was rare (2) disease is not fatal and (3) patients do not seek healthcare services. Respondents explained that podoconiosis patients rarely seek medical attention, and therefore, students are less likely to encounter them during clinical rotations Nonetheless, some still felt that it was very easy to integrate podoconiosis into the curriculum for tropical diseases which many nursing programs already offered as a course.
“The condition is not common and the few clients with the condition never seek medical care (ID_103).
“I would think it's not common in our country and I believe the country has not taken keen interest in this condition.” (ID_46)
The remaining 41.7% of nursing faculty across all three countries felt that providing podoconiosis training for nurses was a high priority. Common reasons for this ranking included (1) the need for differential diagnosis between lymphatic filariasis and podoconiosis, (2) the importance of delivering equitable health care, (3) the low cost of podoconiosis prevention relative to treatment, (4) the need for nurses to work in rural communities, where the disease is more prevalent, and (5) the devastating consequence of podoconiosis at late stages.
“Podoconiosis is a rare condition but should be integrated in nursing cadres that are likely to interact closely with communities, such as certificate nurses” (ID_88).
Rural populations, particularly farmers and those living in extreme poverty, were highlighted as most-at-risk for developing podoconiosis. Respondents also agreed with the benefit of having a comprehensive curriculum but noted that there are very educational activities that serve to increase podoconiosis specific knowledge and skills among nursing tutors.
“We have a challenge that we have limited CME’s [Continuous Medical Education] so there is a gap. Hospitals need to fill this gap” (ID_45).