In the first two decades of the 21st century, humanity has witnessed disease outbreaks that have highlighted the danger of chronic vulnerability to infectious diseases, known and unknown. These epidemics and pandemics have resulted in high morbidity and mortality on a still-evolving scale[1]. Among these are SARS CoV, MERS, Ebola, Marburg, cholera, influenza, and current SARS CoV-2[1]. Uganda is particularly prone to infectious disease outbreaks[2, 3]. Between 2000 and 2016, Uganda reported eight outbreaks caused by filoviruses (Ebola Virus Disease(EVD) and Marburg), more than any other country in the world[4]. Other outbreaks experienced between 2017 and 2019 included yellow fever, anthrax, rift valley fever, meningitis, avian influenza, crimean-congo hemorrhagic fever (CCHF) and EVD[4]. In December 2019, a novel coronavirus (SARS-CoV-2, the causative agent for COVID-19 emerged in China and became a pandemic with the first case in Uganda reported in March 2020[5, 6].
Healthcare workers (HCWs), support staff, patients, and visitors to health facilities are at risk of acquiring such infections in healthcare settings (out-patient and in-patient departments, HIV care clinics, and operating theatres) as well as from the community[3]. With the current COVID-19 pandemic, 2299 health workers so far have contracted the disease, and 28 have died, reported as of 14th June 2021[7]. To minimize the risk of transmitting these infectious agents from one person to another, health workers to patients and vice versa, infection prevention and control (IPC) practices should be paramount[3]. IPC is a practical, evidence-based approach that focuses on preventing patients, visitors, and HCWs from being harmed by avoidable and preventable infections in a healthcare setting[3].
IPC practice in Uganda’s health facilities is still limited, demonstrated by widespread noncompliance to hand hygiene measures, poor waste management, lack of isolation protocols, and lack of functional IPC committees[2, 8, 9]. For example, at 20-50%, hand hygiene (HH) compliance is still much lower than the international standard of 80%, as demonstrated by IPC assessments at different health facility levels[2, 9-11]. Although there was near universal improvement in HH compliance between 2018 and 2019 (Table 1), the improvement scores were still significantly lower than the standard of 80%. Observed improvements were partly due to improved availability of alcohol based hand rub in some hospitals and capacity building activities that targeted the hospitals’ IPC committees[12].
Table 1 HH compliance at regional referral hospitals in Uganda
Facility
|
2018
|
2019
|
Mbale
|
9%
|
46%
|
Jinja
|
20%
|
52%
|
Naguru
|
23%
|
50%
|
Kabale
|
24%
|
40%
|
Fort Portal
|
22%
|
33%
|
Lira
|
22%
|
31%
|
Arua
|
24%
|
30%
|
Masaka
|
7%
|
12%
|
Mbarara
|
19%
|
24%
|
Gulu
|
10%
|
13%
|
Hoima
|
18%
|
20%
|
Soroti
|
19%
|
9%
|
Moroto
|
43%
|
32%
|
Mubende
|
54%
|
24%
|
Overall
|
22%
|
30%
|
In trying to bridge this gap, Uganda developed an Ebola Contingency Plan and implemented heightened highly infectious diseases preparedness activities to enhance operational readiness to handle any highly infectious cases. The Ministry of Health (MoH) mobilized resources for the response and coordinated stakeholders to: perform classroom training of teams on surveillance case management and set up nine national highly infectious diseases treatment units. Between 2018 and 2019 MoH trained 526 health workers in EVD case management; mentored 9,806 health workers in 562 health facilities across 11 districts, and 18 safe and dignified burial teams were constituted and trained[13]. It also trained 716 health workers in EVD surveillance, and 719 contact tracers in 26 districts. Nineteen laboratory technicians from Uganda National Health Laboratories Services (UNHLS), Uganda Virus Research Institute (UVRI), and National Tuberculosis Reference Lab trained in Ebola diagnostics – RDTs and gene expert. 7,575 Village Health Trainers(VHTs) trained in Community Based Disease Surveillance (CBDS) in six districts[13]. However, an EVD (representing highly infectious diseases) functional simulation exercise conducted in April 2019 to assess readiness capacities built found that there were still glaring gaps in the preparedness efforts[13]. It established weak infection prevention and control practices in districts where trainings had been conducted. Recommendations from the simulation exercise point towards further efforts in highly infectious diseases preparedness activities to strengthen and improve the country’s readiness [13].
The classroom-training model used was hectic, takes a longer time and often does not provide the actual rendition of a highly infectious setting. As a result, the health workers do not only take a longer time to learn the skills, they are also less likely to retain those skills. We therefore proposed and pioneered the use of virtual reality (VR) simulations for frontline health worker training in Uganda.
VR is the use of computer technology to create a simulated environment that immerses the user into an experience. It uses dynamic 3D-visualization to actualize a near real-world rendition of the circumstances and context[14, 15]. The technology can be used to create a near-real world environment or even simulations difficult or expensive to actualize in conventional physical reality. VR allows for the use of multiple senses (e.g., touch, hearing, seeing and sometimes smell), which are used simultaneously during the learning process[16, 17]. This could improve the engagement and mental alertness of both the students and teachers based on the significant interaction effect between the learning mode and the learners[18]. Consequently, it speeds up the rates at which individuals assimilate information and increases the extent of information retention[19, 20]. That information assimilation is driven by the technology’s ability to; more precisely simulate features and processes, give learners real-time interactive feedback and give extreme close-up and dynamic multi-perspective views of objects. Accordingly, VR is broadly applicable and has been applied to many different areas of education including technology training[21], natural sciences, history and architecture[21]. It has been described as the learning aid of the 21st century[22]. Perhaps medicine represents one of the fields where VR has proven most effective owing to that field’s dependence on elaborate illustrations of anatomic and physiological features[23, 24]. Indeed, studies done on the use of VR in medical education have shown it to yield favorably comparable outcomes in terms of knowledge and skills gain in comparison to classroom instruction[25]. Furthermore, additional studies have demonstrated that VR improves post intervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education[25]. As a result, VR is increasingly being adopted as a supplementary medium for medical training in Europe and North America [22, 26]. Forexample, the increasing financial feasibility of VR has allowed for educational institutions to incorporate the technology into their training at 96% of the universities in the UK[27] and it was forecast to reach over 95 million users in the US by 2022 [28].
However, the feasibility of VR in low-resourced, less endowed biomedical/health education systems with lower technology exposure and technology culture like Uganda has not been tested partly because of a prior of lack of requisite equipment and VR skilled individuals to develop and manage its platforms. The recent emergence of multiple epidemics in several low resourced environments including Uganda has added to the urgency to test its feasibility in such environments due to its ability to enable effective training of health workers with a minimum risk of infection. In this paper, we demonstrate the feasibility of such an approach for training health care workers in IPC within the context of an active highly infectious COVID-19 pandemic in a resource limited setting. We do so by conversion of some modules of COVID-19 IPC classroom curriculum into VR mode and piloting them with a cohort of pioneer participants using an improvised hybrid of VR and 3600 videos. The cohort is then used to assess both the feasibility and effectiveness of VR in such settings.