GULU UNIVERSITY

FACULTY OF MEDICINE

DEPARTMENT OF PUBLIC HEALTH

COMMUNITY CLERKSHIP REPORT

ACADEMIC YEAR 2012/2013 SEMESTER TWO

APRIL/MAY 2013

MADI OPEI HEALTH CENTRE IV

LAMWO DISTRICT

NORTHERN UGANDA

Student Name

Reg No Signature

Mr. TURYASIIMA MUNANURA K

Email: tumiek@yahoo.com

09/U/041/GUM ….………………………

Site Supervisor

Signature

Ms. ACAYO EDNA

……………………………………………….

ACKNOWLEDGEMENTS

We would like to extend my sincere thanks to Gulu University for the wonderful program

of community clerkship, Madi Opei Health Centre IV for hosting and giving us the

opportunity to learn more clinical skills.

Special thanks go to Ms. Edna Acayo (The In-charge), Mr. Okumu George (Assistant In-

charge), the Health Inspector Mr. Bongomin Richard and the entire staff of Madi Opei

HC IV.

Finally thank the Madi Opei community and community leaders at large for allowing us

work with them for the 5 weeks at Madi Opei HC IV.

God bless all of you.

ACRONYMS/ ABBREVIATIONS

ANC Antenatal Clinic

ARI Acute Respiratory Infection

ART Anti-Retroviral Therapy

BCG Bacillus Calmette Guerin

COBERS Community Based Education Research

and Service

DPT Diptheria Pertussis Tetanus

EID Early Infant Diagnosis

ETC And So On

F/P Family Planning

H/C Health Center

H/I Health Inspector

HSD Health Sub District

IPD In Patient Department

LC Local Council

MCH Maternal Child Health

NGO Non-Governmental Organisation

OPD Out Patient Department

ORS Oral Rehydration Salts

SCO Senior Clinical Officer

TBA Traditional Birth Attendants

OPERATIONAL DEFINITIONS

COBERS Community Based Education Research and Service

CTRR HIV Positive result

Depo Provera An injectable contraceptive

Environmental

surrounding

Circumference or influences

Immunization Rendering immunity

Malaria A tropical disease contracted from mosquito bites leading to

the presence of protozoal parasites in red blood cells

Nutrition The process by which food is ingested and assimilated in the

body.

Population Number of people living in an area at a particular time

Sanitation Use of measures designed to promote health and prevent

disease

VDRL An antigen test for syphilis

SUMMARY

Gulu University situated in Northern Uganda is spearheading community transformation

with its motto “for community transformation” and the mission of faculty of medicine

“to produce highly competent human resources for health, conduct high quality

health research and provide effective community services in order to contribute to a

healthy and productive population appropriate for community transformation”.

Also through the introduction of community based education research and service

(COBERS) sites, the Faculty of Medicine sends fourth year medical students to Health

Centre III/IV facilities within Northern Uganda to do community clerkship and have

experience with the rural Ugandan setting.

Two medical students were sent to each health facility and to Madi Opei Health Centre

IV in particular for community clerkship for a period of 5 weeks (April and May 2013).

The purpose of community clerkship is to equip the medical students with the clinical

skills and to nurture our desire and responsibility to “give back” to the people less

fortunate than themselves as they strive to improve population health and transform the

communities. The program also allows students to learn and practice community research

through the introduction of community based education research and service (COBERS).

We were able to attain clinical skills by clerking patients, administering treatment,

monitoring the patients, general management of common conditions, making outreaches

to communities as well as giving health talks. We also had time at the health facility to

carry out the research on “Determinants of First antenatal care visit by pregnant

mothers at COBERS sites in Northern Uganda”

BACKGROUND

Community clerkship is part of the academic requirement for a medical student to acquire

Bachelors of Medicine and Surgery at Gulu University. Its goal is to provide students

with the opportunity for practical training and learning in the real world situation while

providing the most needed health care services to communities in Northern Uganda.

Madi Opei HC IV is found in Central village, Kal Parish, Madi Opei Sub-county, Lamwo

County, East of Lamwo district in the Northern part of Uganda

It is about 28 miles from Kitgum town along Kitgum Lamwo district-Sudan Road.

The total Land area is about 16sq.km mostly covered by undulating plateaus and hills.

The vegetation type is savannah grassland.

The soil is of alluvial type and in some areas especially in the west, its tropical black soil

that is mixture of sand, silt and clay. It experiences tropical climate with moderate rainfall

ranging between 500mm-1000mm per annum and the rainfall is convectional in nature.

According to the 2002 population census, Madi Opei sub-county had an estimated

population of 14,722 people.

However the population projection for the year 2010 was 16,695 people.

The major social services and infrastructure existing in the sub-county include; 6

government aided primary schools, 1 missionary funded secondary school, 1 health

center IV and 1 health Centre II (non-functional) in Okol parish among others.

Economic Activities in the sub-county

The population is involved in various social economic activities including peasant

farming with a percentage of close to 96%. Women are mainly included in small scale

farming, domestic work and small scale agriculture related business. Agriculture receives

support from NAADs and NUSAF.

Other economic activities include; brick laying, seasonal hunting, firewood selling,

rearing domestic animals, small scale business, carpentry and joinery, fishing in river

Aringa, lumbering(on small scale), charcoal burning and sale, selling of liqor.

Water sources in Madi Opei Sub-county

TYPE NUMBER FUNCTIONAL NON-FUNCTIONAL

Borehole 58 50 8

Shallow Well 0 0 0

Dams 5 2 3

Springs 0 0 0

Hand-dug Well 0 0 0

Valley Dams 0 0 0

Some villages however don‟t have access to clean water for example Pama village, Okol

parish has no single borehole and they are at the moment depending on river Aringa.

MADI OPEI HEALTH CENTRE IV

It is the only public health Centre IV in the sub-county.

Staffing at the health unit:

Human Resource

Professional staff

Approved

staffing Norm

Position currently

filled

Gap(s)

Medical Officer 0

01 Senior Clinical officer 1

Senior Nursing officer

01 Public Health Nurse 1

01 Nursing officer(Nursing) 1

01 Nursing officer(Midwifery) 1

01 Nursing officer(psychiatry) 1

Enrolled psychiatric Nurse

01 Enrolled nurse 1

01 Enrolled Midwife 1

01 Nursing Assistant 1

01 Clinical officer 1

Ophthalmic clinical officer

01 Health inspector 1

Public Health Dental officer

01 Laboratory Technician 1

Assistant Entomological officer

Assistant Health Educator

Anesthetic officer

Anesthetic Assistant

02 Theatre Assistant 2

01 Laboratory Assistant 1

Cold chain Assistant

Health Assistant

Dispenser

Sub-total 14

Support staff

Account Assistant

Stores Assistant

01 Health information Assistant 1

Office typist

Driver

01 Askari 1

Porter

01 Cleaner 2

02 Vaccinators 2

Office Attendant

Sub-total 6

Total 20

Infrastructure

The health unit comprises of the following infrastructure:-

Premises

A block which houses OPD, ANC clinic, pharmacy and clinicians‟ offices

A block which houses the triage Centre.

A block which houses in-patient department comprising of three wards, minor

theatre and Labour suit and Records room and vaccine and drug store and the

Young child Unit on the verandah.

A block which houses the Laboratory.

A block housing the ART clinic and TB clinic

A block housing the theater

A block housing the isolation ward.

2 incinerators

1 placenta pit

Others

1 borehole

Ambulance services for obstetrics cases (complications during labour) and other

emergencies.

Staff Quarters

5 blocks, each has two units and each unit has two rooms for the nursing and

other support staffs

one self-contained 2-bed roomed house for the resident doctor and

Semi-permanent Grass-thatched houses (about 19 in number)

Activities carried out at Madi Opei HC IV

On arrival at the facility, we were warmly welcomed and escorted to our place of

residence formerly occupied by Medicins Sans Frontiers (MSF), which seemed

comfortable. We got acquainted with one senior midwife, an enrolled nurse and a nursing

assistant with whom we saw the patients over the first few days.

During this time, we also got acquainted with our residence and the trading Centre. We

underwent orientation in the second week about the general health unit system/activities.

We made our duty Rota which we started using from the 2nd

week up to the last week,

after consultation with the in-charge and the various departmental heads.

We rotated in the major departments of Out-patient, In-patient, laboratory, immunization,

Maternity and the HIV/AIDS Clinic following a rota we had designed.

We generally participated in all the facility programmes but key to note here include:

OPD, IPD clerkship/ treatment, family health days, PMTCT follow up for pregnant and

lactating mothers and immunization outreach activities.

Our outreaches targeted the Villages of Guda in Pobura Parish, Lubiri-wigweng in Pobura

parish, Malech in Kal Parish, Central in Kal parish and Kalala in Kal parish. Out-reaches

done on Sabbath days were done in collaboration with UNICEF and are named Family

Health Days (targeting people from churches and mosques).

Generally the health Centre carries out the following;

o General in-patient and out-patient care

o Voluntary counseling and testing for HIV

o HIV/AIDS care and treatment for children, adolescents, and Adults including

ART, septrine prophylaxis, Post Exposure Prophylaxis, etc.

o Prevention of mother to child transmission of HIV.

o Maternal child health services (ANC deliveries, PNC family planning services)

o Immunization

o Laboratory services

o Therapeutic and supplementary feeding services

o Minor surgical procedures including safe male circumcision

o Health education

o Participated in generating, recording and updating data in appropriate HMIS

registers in the health facility

Some of the out-reach activities done include.

o Immunization

o School health programs

o Home visits including follow-up of TB patients

o VCT, HIV/AIDS and support including ART

o Supplementary feeding

o Support supervision of lower level health facilities and supervision of VHTs.

o Measuring of MUAC to access for malnutrition

Common conditions (According to the hospital records and observation)

The top ten disease conditions in the HSD are:-

1- RTI (Upper)

2- Acute diarrhea

3- Skin conditions

4- Pneumonia

5- Intestinal worms

6- Malaria

7- Dysentery

8- Oral conditions

9- Epilepsy

10- Trauma and other miscellaneous conditions

Rare conditions

1. Tetanus.

2. Nodding syndrome.

3. Snake bites etc.

ACHIEVEMENTS (OUTPUT)

Out-patient department

MONTH MALE FEMALE BELOW 5

YEARS

TOTAL

April 281 544 297 1122

May 211 328 235 774

Conducted health talks on the management of common conditions like use of

ORS in treatment of acute diarrhea, use of mosquito nets.

Educated pregnant mothers on the benefits of early enrolment for antenatal care

and problems of late attendances

Clerking of patients, carrying out minor surgical procedures like STS, I&D,

injections, wound dressing

In- patient Department:

April 2013

ITEM NUMBER

ADMISSIONS 99

REFERRALS 10

DEATHS 0

May 2013

ITEM NUMBER

ADMISSIONS 80

REFERRALS 07

DEATHS 0

HIV/AIDS CLINIC report (2012)

Number of clients newly enrolled on ART 30

Number of clients who come for septrine refill 640

Number of clients who come for ART refill 261

Number of infants attending EID 57

Number of infants newly enrolled for EID 12

Number of infants transferred from EID to chronic care 3

The HIV/AIDS clinic works separately from the health facility but under the same

management.

Patients tested and proven to be HIV positive are counseled and eligibility for HAART

treatment done by the staff. Some of the measures used are CD4+ counting with machine

provided by the government.

We were each on the A-clinic for about 5 days and did HIV/AIDS counseling and testing

plus administration of drugs.

MATERNITY

ANC and Maternity Reports as for march 2013

a) HIV counseling and testing:

HIV counseling and testing of new

clients

160

Number of pregnant women

counseled, tested and received HIV

test

Total: 150

CTRR: 07

Number of women who knew their

HIV serostatus before 1st ANC visit.

WHO: 05

b) HAART administration during pregnancy:

Number of mothers given AZT +

sdNVP for PMTCT in ANC

05

Number of mothers given AZT/3TC +

sdNVP in PMTCT in ANC

00

Number of mothers receiving full

HAART

02

c) Labour and Intensive care:

Total number of deliveries Total: 22

CTRR: 5

Number of women( new clients ) tested during

labour and delivery

00

Number of clients who received AZT/3TC and

swallowed NEV during labour.

04

Number of clients who swallowed NVP only

during labour

03

Number of clients who initiated EBF within 1hr

of delivery

07

Number of given NVP suspension at birth 05

d) Post natal care for mothers:

Number of women tested and received results

during PNC( new clients)

00

Number of women tested HIV positive during ANC 00

Total number of women who received any method

of Family planning post-partum

26

Number of HIV positive women who received

Family Planning post-partum.

04

Family planning for the month of March;

METHOD NUMBER

COCs 07

Depo provera 50

Copper T 04

Condoms 11

Implanol 08

Total 80

We conducted normal deliveries in the supervision of nursing officers/mid wife, managed

common cases like abortions, Malaria in pregnancy, neonatal septicemia, Anemia in

pregnancy, carried out immunization of neonates.

Family planning techniques like implants, IUD‟s, Depo provera injection, contraceptive

pills and male condoms.

We delivered health talks on PMTCT, feeding, malaria prevention. We also vaccinated

the mothers against tetanus, examined the mothers. Also distributed folic acid, malaria

prophylaxis

NB: The above data results are estimates from observation and patient records, and

should not be used as references.

IMMUNISATION

BCG 28

OPV 60

DPT+HepB+Hib 50

Measles 23

Tetanus 27

Vitamin A 37

Deworming 23

NUTRITION

In-patients Therapeutic Care

New admission from 19th

April to 15th

May 2013……………………………….….3

Outpatient therapeutic care

Clients under care of OTC from 29th

April to 15th

May 2013 .......………………….10

THEATRE

Major procedures: None

Minor procedures:

o Debridement and wound care …..……………………… 03

o Incision and Drainage ………………………………..… 04

o Medical male circumcision …………………………..… 00

o Total ……………………………………………………. 07

NB: The above data results are estimates from observation and patient records, and

should not be used as references.

ROTATION AT THE HEALTH UNIT

We rotated in the different departments for easy work and maximum achievements and

switched after two weeks as follows:

Weeks 1 and 2 OPD, IPD and ANC Clinic Maternity

Weeks 3 and 4 AIDS Clinic, IN-PATIENT and Theatre

Other activities for example emergencies, ward-rounds, out-reaches, maternity care and

environmental activities were randomly done.

Note: We could however freely rotate in any department at any time.

Organization of clinical work at the facility

Duration

(weeks)

Activities Objectives Achievements Hindrances Supervisors

1 Briefing and

orientation at the unit.

Starting clerkship at

the unit.

Integration into

the system

Managing and

monitoring of

patients

Well oriented,

and integrated

into the unit

None Ms. Acayo

Edinah

(In-Charge)

2 Collect data on social

demographic issues.

Give health education

to mothers about care

for children on ward

and at OPD on how to

prevent common

diseases

Clerkship and start

community out

reaches

Data was

attained Health

talks at OPD,

ANC, and on

ward were

given.

Well done No outreach

due to fuel

Site supervisors

3 Make community

visits

Active participation

in ANC

Determine

utilization of

F/P and MCH

services at the

unit

We had an

outreach to

Lawiye Dul

P/S

Family Health

days with

UNICEF

Walking

6Km to and

fro to give

services

Mr. Bongomin

Ms. Sharlon

and Ms. Miriam

4 Immunisation,

HIV/AIDS

Counselling and

Testing

To acquire

necessary

skills.

Well done None Ms. Pasca

Note:

Any free time was used to collect research done on “Determinants of ANC utilisation

by pregnant mothers at COBERS sites Northern Uganda”

„Family Health Days‟ every Sunday were done at churches targeting people who have

come to attend Sunday services. This is a program going on all health centres under

support from UNICEF.

Services offered include: Immunisation, vaccination, health talks, family planning and

deworming and assessment for malnutrition. Three of these out-reaches were done under

supervision.

OUTREACH PROGRAM

School Health

We carried out an outreach to Lawiye-Dul Primary School and Kwon-Choc P/S where we

offer free HIV/AIDS counseling and deworming

We conducted a health talk on relevance of Tetanus Toxoid (TT) vaccination to a group of

about 30 girls from this school after seeking permission from the school authorities.

Common diseases found among the students (from health Centre records) were Malaria,

Upper Respiratory Tract Infections, skin fungal infections (ring worms) diarrheal diseases

etc.

According to our findings, students at Lawiye-Dul school have access to safe drinking

water from a borehole but poor sanitation around the school compound.

Health promoting activities in the Community

We delivered health talks in Malec, Guda and Lubiri villages in Kal parish on

environmental health, After doing a survey together with the VHT‟s and community

leaders in the villages with special interest in the number of households with pit latrines,

number of households with mosquito nets, bushes around homes, hand washing practices

.In the event, we briefed them on the findings of the survey.

Thereafter we went on to sensitize them on the importance of using mosquito nets,

drinking safe and clean water, and use of pit latrines. The session was interactive as we

got their views, of which some were right and others we had to correct.

In summary the following activities were conducted;

Sensitization on diarrheal diseases

Demonstration on appropriate hand washing, making tippy taps and latrine covers

using cheap and locally available materials.

Finding out and sensitization on prevention of common diseases

Latrine coverage

Results of the survey in Guda and Lubiri villages

Village Popula

tion

No of

Households

Latrine

use

Latrines

under

constructions

Bathing

shelter

Drying

rack

Refuse

pit

Hand

washing

Safe

water

source

Lubiri 250 57 23 9 20 25 08 12 02

Guda 165 36 27 5 07 10 04 09 01

Community Diagnosis

From the results of the survey in the table above, Lubiri had poor latrine coverage (57

households having 23 latrines). Refuse pits were also few implying that there is poor

disposal of wastes. All the above were attributed to overcrowding hence shortage of

space. The level of hand washing was low for both Lubiri and Guda possibly because of

lack of a safe water source as indicated in the table above.

The common conditions found were diarrheal diseases in children, respiratory tract

infections, fungal skin infections and reproductive tract infections in women like Vaginal

Candidiasis.

RECOMMENDATIONS

o It was suggested that the sub county should allocate some land for construction of

pit latrines and digging pits for proper waste disposal in Lubiri.

o There was need to repair broken down boreholes and construction of protected

wells and bore holes.

o There was also need to sensitize the community on routine hand washing

practices.

o In order to curb the common conditions, the community was advised to take every

disease condition experienced to the health centre in time and adhere to the

treatment.

CHALLENGES MET DURING THIS COMMUNITY CLERKSHIP

University

Lack of funding and inadequate supervision by the Lecturers.

Poor accommodation at the Centre.

Health Centre

Untimely request for drugs and delay in delivery of drugs.

Understaffing leading to work overload.

Inability to conduct outreaches in distant communities due to shortage of means

and fuel.

Language barrier that necessitated an assistant to translate most times

WAY FORWARD

The health Centre management should consider timely request for drugs and more

staffing from the Government.

CONCLUSION

Community clerkship/ placement provide a great opportunity for medical students to

discover what happens beyond the class and town life. We had a wonderful time and

interaction with the patients at Madi Opei HC IV which helped us see other determinants

of ill-health other than the biology (that is poverty or the socio-economic life of a

patient).

Reviewed and corrected by: Mr. Bongomin Richard (Health Inspector Madi Opei HC

IV)

“FOR COMUNITY TRANSFORMATION”

Cc. Own copy

Cc. Department of Public health Gulu University

Cc. Madi Opei Health Centre

Cc. Sub-County Chief Madi Opei