Posted inCardiagtech

Developing a Health Care Needs Analysis Tool for Snakebite Envenoming Management

No Comments

Abstract

Each year, a significant number of patients in Eswatini require hospital treatment due to venomous snakebites. Effective diagnosis and management of snakebite envenoming necessitate that healthcare professionals possess a diverse set of general and snakebite-specific medical competencies. However, studies across various countries have revealed gaps in healthcare workers’ skills in managing snakebite cases. This study employed the Delphi method to adapt the Hennessy-Hicks training needs analysis questionnaire, tailoring it to the specific context of snakebite envenoming. Subsequently, this adapted questionnaire was utilized to evaluate the self-perceived training needs of 90 healthcare workers from ten hospitals in Eswatini. The participant group consisted of nursing staff (63%) and medical doctors (34%). Overall, 74% of these healthcare workers had previously received some form of snakebite training. While a training need was identified across all skill areas surveyed, the degree of need varied depending on the specific skill and the healthcare worker group. The domains of ‘research and audit’ and ‘clinical tasks’ showed the highest average training needs, with clinical tasks encompassing nine of the ten skills identified as having the greatest need for improvement. Nurses expressed a greater training need than doctors, particularly in clinical procedures. Prior snakebite training, both before and after initial professional qualification, was associated with the lowest average training need, especially in clinical skills. A significant majority (93%) of healthcare workers surveyed indicated they would welcome more frequent training opportunities focused on the clinical management of snakebite patients. This newly developed Health Care Needs Analysis Tool for snakebite management offers a valuable resource for tailoring training programs to the evolving needs of a dynamic healthcare workforce and is designed for applicability in snakebite-prone regions globally.

Author summary

Snakebite envenoming is a critical, life-threatening condition prevalent in low- and middle-income countries within the Global South. Research among healthcare professionals in snakebite-endemic regions indicates that the diagnosis and appropriate treatment of snakebite envenoming can be challenging. Strengthening the competency and skill set of the healthcare workforce is crucial to reducing deaths and disabilities caused by snakebite envenoming. In this study, a panel of international snakebite experts collaborated to create a questionnaire based on essential skills for the clinical care of snakebite envenoming patients. This health care needs analysis tool is designed to be universally applicable for assessing the snakebite-specific training requirements of healthcare workers across different regions. The questionnaire was then implemented in Eswatini, a country where snakebite envenoming is a recognized public health concern, with a sample group of healthcare workers. The analysis of training needs revealed variations based on the specific skill, the professional role of participants, and the extent and context of prior snakebite training. Notably, healthcare workers with previous specialized snakebite training demonstrated a significantly reduced training need for clinical skills. This study provides a practical health care needs analysis tool that can be instrumental in customizing snakebite-specific clinical training initiatives to meet the specific needs of healthcare workers at local and regional levels.

Citation: Steinhorst J, Baker C, Padidar S, Litschka-Koen T, Ngwenya E, Mmema L, et al. (2025) Developing and applying a training needs analysis tool for healthcare workers managing snakebite envenoming: A cross-sectional study in Eswatini. PLoS Negl Trop Dis 19(1): e0012778. https://doi.org/10.1371/journal.pntd.0012778.ref000

Editor: Wuelton Monteiro, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado: Fundacao de Medicina Tropical Doutor Heitor Vieira Dourado, BRAZIL

Received: August 19, 2024; Accepted: December 10, 2024; Published: January 8, 2025

Copyright: © 2025 Steinhorst et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data used in this manuscript contain confidential information about healthcare workers and the facilities involved in this study and therefore cannot be shared publicly. Requests can be made by submitting a proposal to University of Eswatini at [email protected] or the Eswatini Ministry of Health at [email protected]. Access will be granted for those who meet the criteria for access to the confidential data.

Funding: This research was funded in part by the Wellcome Trust (grant 217264/Z/19/Z), awarded to TL-K, DGL, JP and RAH. JS received funding from The Royal Society of Tropical Medicine and Hygiene (RSTMH Small Career Grants Programme) and project funding for his MD PhD from the University Medical Centre Groningen. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Venomous snakebites represent a significant public health challenge across much of South America, South Asia, and Sub-Saharan Africa, posing complex medical emergencies at both the public health and clinical levels. Globally, the annual incidence of snakebite envenoming ranges from 421,000 to 1,841,000 cases, leading to an estimated 20,000 to 94,000 deaths [1]. This alarming statistic positions snakebite envenoming as the deadliest among the neglected tropical diseases [2]. Patients suffering from snakebite envenoming (SBE) present intricate diagnostic and treatment scenarios, demanding a wide array of skills from healthcare personnel. Local symptoms can include swelling and tissue destruction, manifesting as blistering, bruising, and skin necrosis [3–5]. Systemic symptoms may involve neurotoxicity (such as ophthalmoplegia, flaccid or respiratory paralysis), hemorrhage, and signs of internal organ dysfunction [3–5]. Identifying the specific snake species involved in a bite is often challenging. Therefore, a syndromic management approach is generally recommended, which is based on understanding the medically significant snakes within a region and their characteristic envenoming syndromes [4,5]. Healthcare facilities treating snakebite patients must be adequately equipped and prepared to: (i) initiate essential resuscitative measures, including circulatory and ventilatory support; (ii) manage local tissue complications; (iii) administer antivenom; and (iv) handle treatment-related complications [4–6]. Antivenom remains the only proven effective treatment to neutralize venom toxins circulating in the body [6]. However, antivenom availability is often limited, their geographical effectiveness can be narrow, they can trigger adverse reactions [7–9], and they are frequently unaffordable for the populations who need them most [10,11].

Numerous studies across different nations have highlighted significant knowledge gaps among healthcare workers (HCWs) concerning the assessment and treatment of snakebite patients [12]. For instance, in Laos, 40% of physicians and nurses were unaware of life-threatening envenoming syndromes, such as coagulopathy and muscular paralysis, resulting from bites by snakes endemic to the region [13]. Insufficient understanding of snake types and envenoming syndromes also hinders the clinical evaluation of snakebite patients, including decisions on when to administer antivenom, determining the correct dosage [14,15], and how to identify and manage adverse reactions [14,16]. Consistent with these findings, snakebite envenoming is often either absent from medical and nursing training programs [13,17] or is inadequately covered in the curriculum [18,19], and opportunities for postgraduate training remain scarce [14]. Training healthcare workers in the management of SBE has demonstrated effectiveness in increasing knowledge [13,17], improving patient care, and reducing mortality rates associated with snakebites [20]. Enhancing and expanding HCW training in snakebite envenoming is crucial for achieving the World Health Organization’s (WHO) goal of halving snakebite-related morbidity and mortality by 2030 [21].

Eswatini, a landlocked nation in southern Africa with approximately 1.2 million inhabitants [22], faces significant socioeconomic challenges. In 2016, the World Bank estimated that 36% of the population lived below the international poverty line of USD 2.15 per day [23]. A significant portion of the workforce is engaged in agriculture and industry [24], with over half of the population practicing subsistence agriculture [25]. Snakebites are a frequent occurrence in Eswatini, with an average of 466 cases documented annually in the national snakebite registry [7]. Highly venomous snakes of medical significance in Eswatini include the Black mamba (Dendroaspis polylepis), Snouted cobra (Naja annulifera), Mozambique spitting cobra (Naja mossambica), Rinkhals (Hemachatus haemachatus), Puff adder (Bitis arietans), Boomslang (Dispholidus typus), and Vine snake (Thelotornis capensis) [26]. However, this list is not exhaustive, as several other venomous snake species are also present. Eswatini lacks medical schools, and snakebite training is partially integrated into emergency nursing courses. Recognizing the need, the Eswatini Antivenom Foundation (EAF), in collaboration with the Ministry of Health (MoH), has been conducting regular in-service training for HCWs and public education initiatives in recent years [27]. Moreover, the treatment guidelines utilized in EAF training for many years were officially adopted by the MoH in 2021 [26]. This study aimed to develop a snakebite-specific health care needs analysis tool (SB-TNA tool) and to assess healthcare workers’ self-perceived training needs in snakebite management within this context.

Methods

Ethics statement

This study received ethical approval from the Research Ethics Committee of the Liverpool School of Tropical Medicine, United Kingdom (Reference LSTM REF 21–006) and the Eswatini Health and Human Research Review Board, Eswatini (EHHRRB034/2021). Written informed consent was obtained from all participants, including Delphi panel members and HCWs, before their enrollment in the study.

Study design

A Delphi methodology was employed in 2021 to design the SB-TNA tool. Subsequently, a cross-sectional survey was conducted in May-June 2022, utilizing the SB-TNA tool on a sample of HCWs in Eswatini.

Preparation of the SB-TNA tool

The SB-TNA tool was designed with the following objectives: (i) to offer a comprehensive overview of essential skills for HCWs to effectively manage SBE; (ii) to be easily understandable for HCWs across different levels of expertise; and (iii) to align with the structure of the Hennessy-Hicks Training Needs Analysis Questionnaire (HH-TNA tool) to maintain the psychometric validity of the original, validated instrument. The tool is designed to evaluate participants’ perceptions of their training needs by assessing competencies relevant to their specific job roles. By focusing on competencies rather than just knowledge, the aim was to assess the self-perceived capability to apply knowledge in practice and achieve successful skill-based outcomes. Furthermore, while the specific knowledge needed to effectively treat snakebites can vary regionally due to differences in snake species, competencies represent universal qualities applicable across contexts and healthcare systems. This ensures the SB-TNA tool’s adaptability and transferability.

To develop the SB-TNA tool, the original HH-TNA tool template, developed by Hennessy & Hicks at the University of Birmingham and licensed to the WHO [28], was adapted. The HH-TNA tool is structured into three sections: (1) demographics; (2) a skills rating section with 30 skills across five competency domains (research/audit, communication/teamwork, clinical tasks, administration, management/supervisory tasks) relevant to the participant’s role; and (3) an open-ended section for participants to suggest training, resource, and facility/organizational improvements. In the core skills rating section, skills are assessed in two categories, A and B. Category A measures the skill’s importance to the job role, and Category B assesses the participant’s performance in that skill. A 7-point Likert scale is used for ratings, where 7 indicates high importance (Category A) or very good performance (Category B), and 1 signifies low importance (Category A) or poor performance (Category B). The questionnaire can be expanded with Categories C and D, also using the 7-point Likert scale. Category C measures the perceived potential for skill improvement through organizational change, and Category D assesses the perceived benefit of skill-specific training. Initially, Categories C and D were included in the SB-TNA tool, as their data can inform the design of training programs.

Initially, the demographic section of the HH-TNA tool was modified to align with the context of clinical snakebite management in Eswatini. Then, the skills rating section was adapted to incorporate snakebite-specific training, education, and experience aspects. Skills relevant to the clinical management of snakebite patients were identified from the WHO clinical snakebite management guidelines [4,5]. A preliminary list of skills was reviewed by five researchers with expertise in public health and/or clinical SBE management from the Liverpool School of Tropical Medicine. The initial draft of the SB-TNA tool contained 60 skills, with 30 from the original HH-TNA and 30 added by the research team. This skill list was then used as input for the first Delphi panel round. The Delphi procedure aimed to refine the 60-skill list to a more concise set of the most relevant skills, creating an SB-TNA tool focused on core competencies in clinical snakebite management. Modifications were limited to replacing no more than 8 and adding no more than 10 skills from the original HH-TNA tool to preserve the instrument’s psychometric properties [28]. The third section, the open-ended question about needs for training, resources, and facility/organizational improvements, remained unchanged. The final SB-TNA tool was pilot-tested with a small group of Eswatini HCWs before broader implementation.

The Delphi procedure and panellists

Given the absence of an evidence-based selection of skills for snakebite patient care, expert consensus was essential for developing the SB-TNA tool. Therefore, the Delphi methodology, as outlined by Woodcock et al. [29], was employed. Panellists were selected based on their recognized expertise in clinical snakebite envenoming management in low- and middle-income countries. Potential panellists were contacted via email, which included a participant information sheet detailing the study and a consent form for participation. A snowball sampling technique was used, encouraging initial invitees to extend the invitation to other experts in their network. The draft SB-TNA tool, featuring 60 skills, was distributed to the Delphi panellists, who were asked to vote on each skill using ‘Keep’, ‘Remove’, ‘Modify’, or ‘Unsure’ options. Consensus was defined as ≥ 75% agreement among panellists across all Delphi rounds. Panellists also had an open field to provide skill-specific suggestions. The CREDES checklist for Delphi studies [30] was used as a guideline (S1 Appendix).

Sample population of HCWs

The study included HCWs from 10 health facilities in Eswatini that routinely manage snakebite patients. These facilities had a total healthcare workforce of 1133 (1025 nurses, 108 doctors) (Fig 1). The ten facilities, comprising clinics, health centers, and hospitals with varying service levels (e.g., surgery, ICU, outpatient), represented a sample of the 20 health facilities in Eswatini capable of treating snakebite patients. Facilities were selected to represent HCWs across the four administrative and agro-ecological regions (Highveld, Middleveld, Lowveld, Lubombo plateau) of Eswatini (Fig 1). The sample included government-operated facilities (Dvokolowako Health Centre, Matsanjeni Health Centre, Good Shepherd Hospital, Mankayane Government Hospital, Piggs Peak Government Hospital, Raleigh Fitkin Memorial Hospital), a non-governmental hospital (The Luke Commission), and clinics operated by the Royal Eswatini Sugar Corporation (RES). This selection aimed to represent healthcare delivery models ranging from clinics providing outpatient care to hospitals with surgical specialties and intensive care (including ventilation). This cross-section of facilities was representative of those routinely involved in snakebite patient management.

Download:

Fig 1. Map of Eswatini showing the location of the ten health facilities included in the healthcare worker survey.

Based on geoBoundaries country dataset (CC BY 4.0 License) by Runfola et al. [31] and created using ArcGIS software version 10.8.1, ESRI Inc., Redlands, CA, U.S.A (modified to include names of regions and hospital locations). ‘RES’ denotes clinics operated by the Royal Eswatini Sugar Corporation.

https://doi.org/10.1371/journal.pntd.0012778.g001

Administration of the SB-TNA tool

All HCWs involved in direct patient care and potentially tasked with managing snakebite patients were eligible for inclusion. HCWs not directly involved in bedside patient care were excluded. Participants were selected in consultation with senior medical officers at each facility. In some cases, senior officers delegated HCW selection to department heads, doctors, or matrons to minimize disruption to work schedules. Peer-to-peer recruitment was also common. The SB-TNA tool was administered through interviews using the RedCap (Research Electronic Data Capture) mobile app [32] by JS and EN, who visited the health facilities in May and June 2022, shortly after the end of the snakebite season (October-March). Interviews were conducted in English, privately, either in quiet outdoor areas at the hospital or in closed rooms like conference or consultation rooms.

Analysis

Demographic data was analyzed using descriptive statistics. All statistical analyses were performed using IBM SPSS statistics version 29. Training needs were identified by calculating the difference between importance and performance ratings for each skill. Ratings between HCW groups were compared using independent samples t-tests, Wilcoxon signed-rank tests, or Mann-Whitney U tests, as appropriate. Participant responses from the open-ended section of the questionnaire were reviewed to identify and report the most frequently mentioned resource gaps. Relevant participant quotes were selected to illustrate the context of resource gaps, skill deficiencies, and suggested solutions.

Results

Development of the SB-TNA tool

In the first Delphi round, fifteen panellists reviewed and commented on the draft SB-TNA tool. Panellist professions included medical doctor (n=10), nurse (n=3), public health specialist (n=1), clinical research assistant (n=1), and researcher (n=7); individuals could select multiple professions. The median duration of panellist involvement with snakebite was 15 years (range: 1–45 years). Panellists had experience in snakebite management in various countries across Senegal, Ivory Coast, Ghana, Togo, Benin, Burkina Faso, Mali, Niger, Cameroon, Guinea, Uganda, Kenya, Eswatini, South Africa, India, Sri Lanka, Papua New Guinea, Brazil, and Bolivia. The first round resulted in consensus to keep 47 skills, 30 of which were from the original HH-TNA list. Panellists proposed adding sixteen skills to the SB-TNA tool. A key recommendation was to avoid a ‘vertical approach’ that overly specialized general skills as ‘snakebite-specific.’ The aim was to prevent overemphasizing the complexity of skills that are broadly applicable to various diseases and situations. Panellists emphasized designing an SB-TNA tool relevant across diverse facilities and treatment settings where snakebites are endemic. Following the first round, eight panellists participated in an online forum via Zoom [33] to discuss the SB-TNA tool content and finalize skill selection. While anonymity was encouraged through pseudonyms, chat function use, and webcam disabling, many panellists remained identifiable. Participants discussed skill wording, phrasing, and voted anonymously via private message to the lead researcher on skill inclusion/exclusion and potential skill mergers, aiming for a total of 40 skills to meet modification limits. Respondent attrition and the need for the SB-TNA tool to adhere to HH-TNA tool specifications necessitated a final vote on 13 remaining skills, conducted via email, where all modifications were approved. Ultimately, eight of the original 30 HH-TNA skills were modified, and ten new skills were added. Due to an oversight, the field version of the SB-TNA tool omitted a skill regarding antibiotic treatment indications for snakebite patients, noticed post-administration. The complete SB-TNA tool approved by the Delphi panel, including the antibiotic indication question, is available in S2 Appendix.

Piloting of the SB-TNA tool

The SB-TNA tool was pilot tested with three registered nurses. Interviews were considered lengthy, approximately 45 minutes, with Categories C and D found repetitive and potentially compromising data quality. Consequently, Categories C and D were removed, reducing interview time by 15–20 minutes. This removal does not impact the SB-TNA tool’s validity but reduces data for choosing between training or organizational change for future training delivery methods.

Results of the training needs analysis in Eswatini HCWs

Ninety HCWs across ten facilities were interviewed, with a median of six HCWs (IQR 5–14) per facility, representing approximately 8% of the total healthcare workforce at these facilities during the study year. Demographic characteristics are detailed in Table 1. Over half (53%) of HCWs regularly worked in multiple departments. Nearly a third (32%) reported snakebite management training as part of their primary qualification, with a median duration of 3 hours (IQR 2-8h). A majority (66%) had received continuous medical education on snakebite management through lectures, symposia, seminars, or courses. In total, 74% of HCWs had received snakebite training at some point. A higher proportion of medical doctors (77%) had received post-qualification training compared to nurses and nursing aides (61%). Most HCWs (52%) reported training by the EAF, with eleven receiving on-site training at their facilities and two trained abroad. When recalling training content, 93% of the 59 trained HCWs mentioned discussions on snakes, venoms, and envenoming syndromes. Topics such as diagnosis, treatment, and management of antivenom reactions were reportedly covered in nearly all training sessions. HCWs cited various guidance sources for managing snakebite patients (Table 1). The Eswatini National Snakebite Management Guidelines [26] were specifically mentioned by 65 participants, with awareness higher among previously trained HCWs (78%) than untrained (61%).

Download:

Table 1. Demographic characteristics of HCWs (n = 90), experience in managing snakebite envenoming patients and mean training need.

https://doi.org/10.1371/journal.pntd.0012778.t001

Mean performance and importance scores for all forty skills, as self-perceived by HCWs, are shown in Figs 2 and 3. HCWs rated all skills as important to very important, with no mean importance rating below six. Recognizing and treating circulatory shock had the highest mean importance (6.96; SD 0.21). All top ten skills in importance were clinical tasks. Conversely, in self-rated performance, clinical tasks occupied seven of the ten lowest ranks. The lowest performance score was for knowing fasciotomy indications and risks (mean 3.68; SD 1.98).

Download:

Fig 2. Graph showing the mean importance and performance rating of all HCWs (n = 90) for skills ranked 1–20 according to mean training need.

Skills are ranked according to the difference between importance and performance ratings, which is depicted as the horizontal distance between the dashed and solid lines. Skills were abbreviated; the exact phrasing of skills can be found in the SB-TNA tool provided in the S2 Appendix. An overview of skills grouped according to domain is provided in the S3 Appendix.

https://doi.org/10.1371/journal.pntd.0012778.g002

Download:

Fig 3. Graph showing the mean importance and performance rating of all HCWs (n = 90) for skills ranked 21–40 according to mean training need.

Skills are ranked according to the difference between importance and performance ratings, which is depicted as the horizontal distance between the dashed and solid lines. Skills were abbreviated; the exact phrasing of skills can be found in the SB-TNA tool provided in the S2 Appendix. An overview of skills grouped according to domain is provided in the S3 Appendix.

https://doi.org/10.1371/journal.pntd.0012778.g003

HCWs perception of their training needs

Mean importance scores exceeded performance scores for all forty skills (p<0.001), indicating a perceived training need across all areas. The average training need across all skills was 1.88 (SD 0.84) out of a maximum of 6. Domain-specific training needs varied (Fig 4). Research and audit had the highest mean training need (2.42; SD 1.02), followed by clinical tasks (2.14; SD 0.86). Lower training needs were reported for administrative skills (1.83; SD 1.22), management and supervisory tasks (1.56; SD 0.83), and communication and teamwork (1.34; SD 0.85). HCWs perceived greater training needs for snakebite-specific skills, while general patient care tasks had lower needs. Nurses reported a higher training need (mean 2.05; SD 0.87) than doctors (mean 1.38; SD 0.66; p<0.001) (Fig 4), particularly in clinical skills. This difference was primarily driven by clinical skills outside the usual scope of nursing practice in Eswatini snakebite care. Analyzing training needs by training type showed the highest average need among HCWs trained only during primary qualification (mean 2.41; SD 0.62) (Fig 5). In descending order, needs were next highest for those with no training (mean 2.22; SD 0.93), training only post-qualification (mean 1.79; SD 0.80), and training both during and after qualification (mean 1.35; SD 0.85). HCWs without post-qualification training had significantly higher needs across all domains (p<0.05) (Fig 6). Generally, training needs decreased with age and snakebite treatment experience (Table 1). Post hoc analysis revealed that HCWs treating fewer than 10 snakebite patients in two years (n=53) had a training need (mean 1.98; SD 0.87) not significantly different (P=0.098) from those managing ≥ 10 patients (n=37; mean 1.67; SD 0.91).

Download:

Fig 4. Mean training need for medical doctors (n = 31) and nurses (n = 57) shown per competency domain.

The number of skills per domain are 24 (Clinical tasks), 3 (Research and audit), 2 (Administration), 6 (Management and supervisory tasks) and 5 (Communication and teamwork). Error bars represent standard errors.

https://doi.org/10.1371/journal.pntd.0012778.g004

Download:

Fig 5. Training need of 90 HCWs who either did or did not receive different forms of training on snakebite management during different stages of their education/ careers.

Group sizes are as follows: Training during primary qualification (n = 8), No training (n = 23), Training after primary qualification only (n = 38), and Training during and after primary qualification (n = 21). Error bars represent standard errors.

https://doi.org/10.1371/journal.pntd.0012778.g005

Download:

Fig 6. Mean training need for HCWs who received training on snakebite management after completing their primary qualification (n = 59) versus HCWs who had not (n = 31).

The number of skills per domain are 24 (Clinical tasks), 3 (Research and audit), 2 (Administration), 6 (Management and supervisory tasks) and 5 (Communication and teamwork). Error bars represent standard errors.

https://doi.org/10.1371/journal.pntd.0012778.g006

Improvements to snakebite care suggested by HCWs

In the SB-TNA tool’s third section, HCWs suggested improvements for snakebite patient medical treatment, highlighting three main resource gaps: training (93%), antivenom availability (68%), and more ventilators (21%).

Suggestions for training included formats and implementation strategies. The value of annual national snakebite symposia and EAF training was emphasized. On-site training was highlighted for its accessibility to more HCWs. Many participants desired more frequent training opportunities.

‘Bedside teaching, for e.g. now there is a snakebite patient in the ward, so going by the patient with the team and discussing.’ [JS 14, Registered nurse; Mean training need on ‘clinical tasks’ domain 2.67]

‘And then training should be several days, so that you can immerse yourself in the subject. And seeing the snakes yourself would also help to remember and learn about snakebite.’ [EN 14, Registered nurse; Mean training need on ‘clinical tasks’ domain 3.17]

‘Currently there is only annual EAF training in Simunye. Downside is that people who are at work cannot attend. Workshops by EAF should be held more frequently. More on-site training at facility. More guidelines and posters on treatment of snakebite would be helpful.’ [JS 51, Medical doctor; Mean training need on ‘clinical tasks’ domain 1.54]

HCWs suggested additional training topics such as antivenom pharmacology and appropriate use, managing adverse reactions, wound care, psychological impacts of snakebites, and community/patient education on snakes and snakebite. EAF trainings and national guidelines already cover many of these topics (S4 Appendix).

‘How to recognize when antivenom needs to be given. Sometimes antivenom is given when not needed, then no more vials left. Management of anaphylaxis.’ [JS 31, Medical doctor; Mean training need on ‘clinical tasks’ domain 1.96]

Beyond antivenom and ventilators, HCWs mentioned the need for more ICU beds and snakebite-specific health products, like specialized wound dressings for cytotoxic bites. At the time of the survey, only one polyvalent antivenom was registered in Eswatini, facing supply challenges across southern Africa.

‘Two years back a 5-year-old boy died because antivenom was unavailable.’ [JS 43, Medical doctor; Mean training need on ‘clinical tasks’ domain 0.96]

‘Ventilatory support is lacking, only ventilators are in intensive care unit. No ventilator on the emergency room.’ [JS 25, Registered nurse; Mean training need on ‘clinical tasks’ domain 2.75]

‘Special dressings for cytotoxic bites, for necrotic wounds. Those dressings had holes, do not remember the name.’ [JS 50, Nurse working in the pharmacy; Mean training need on ‘clinical tasks’ domain 4.33]

Discussion

The global effort to accurately assess snakebite burden, develop new diagnostic and therapeutic tools, and reduce SBE morbidity and mortality relies heavily on frontline HCWs’ skills and competencies [21]. This study developed a snakebite-specific health care needs analysis tool, based on a validated instrument, to assess HCWs’ perceived training needs in Eswatini. The Delphi panel was professionally diverse, with significant clinical experience, reflected in their consensus to prioritize emergency snakebite care skills over specialized research skills. Maintaining generic skills in the SB-TNA tool is crucial, as they benefit from broader healthcare training initiatives [34] and need proper consideration.

The HCW sample’s age aligns with Eswatini’s healthcare workforce demographics [35]. Doctors were oversampled relative to nurses to ensure sufficient group size for comparative training needs analysis, given their smaller numbers and supervisory roles. Thus, the doctor-nurse ratio in the sample is not representative of Eswatini’s actual ratio [35].

Eswatini HCWs are experienced in snakebite care, with nearly half managing ≥10 patients in the prior two years. However, they perceived skill gaps, reporting training needs across all SB-TNA tool skills. Research-related skills showed the highest domain-specific need, though represented by only three skills. Our survey did not assess research skills in primary training, but EAF training, attended by many HCWs [36], does not typically cover research skills. Eswatini’s general health research capacity is below the average for low- and middle-income countries [37]. Enhancing HCW research skills is essential for strengthening health research capacity and addressing SBE evidence gaps [38]. Initiatives like the D43 Programme are strengthening public health research in Eswatini, primarily focused on HIV/TB [39]. The African Snakebite Alliance, with Eswatini as a core member, addresses snakebite-specific research capacity [40].

Eswatini HCWs’ self-perceived clinical training priorities are comparable to other countries, though specific topics vary. Other studies using knowledge-based questionnaires identified HCW knowledge gaps in snake identification, envenoming syndromes [13,15,19,41], and antivenom administration [14,17,19,42]. Clinical tasks had a high training need but also showed the greatest reduction in need among HCWs trained post-qualification. This confirms that past training, largely by EAF, effectively addressed critical needs. Training’s positive impact on snakebite knowledge is well-documented [13,17,42–45]. Regular in-service training can also boost HCW morale, motivation, job satisfaction, and organizational commitment [46,47]. HCWs, in this and other studies [48–50], consistently desire regular snakebite management training. Given HCW brain-drain in many snakebite-endemic areas [51], training’s positive effect on retention is important.

Future training initiatives should consider ‘who needs training’ and ‘what content is needed.’ Targeting HCWs without specialized snakebite training could maximize impact in Eswatini. Including HCWs not directly involved in snakebite care ensures preparedness for staff rotations. Profession-based targeting is also relevant. Nurses showed higher training needs, particularly in skills outside their typical Eswatini practice, warranting further investigation into their perceived importance and performance of these skills relative to their roles and national guidelines. Nurse training programs in Eswatini offer an opportunity to address these needs at the primary training level. Unexpectedly, untrained HCWs showed similar training needs to those trained during primary qualification. Without comparing self-perceived needs to actual skills, it’s unclear if untrained HCWs over-assessed their competencies or had skills from non-formal training. Ameade et al. [43] found that untrained HCWs in Ghana overestimated their snakebite knowledge. HCWs introduced to snakebite management during primary training may better understand the required competencies and self-assess more accurately [52].

Knowledge gaps are often attributed to inadequate snakebite education in medical and nursing curricula [13,17–19]. However, in our sample, one-third reported snakebite training in primary education, and 74% had received some form of snakebite management training. This training prevalence is higher than reported elsewhere [17,43,44,53]. Eswatini’s small size, limited health facilities, and EAF advocacy [36,54] likely contributed to extensive training reach. Targeted snakebite training in Eswatini has proven effective. Capacity building in other countries requires resources and collaboration with local and international SBE experts. The Delphi panel also stressed the importance of generic clinical skills. By identifying common diagnostic and treatment principles between snakebite envenoming and other conditions, training can reach more HCWs and deliver universally applicable clinical skills [55].

Strengths and limitations

Limitations in SB-TNA tool development include respondent attrition between Delphi rounds and potential response bias due to lack of anonymity in panel discussions, possibly leading to ‘group think’ [56, p. 102]. Omitting Categories C and D from the SB-TNA tool prevented assessment of preferences between organizational change and targeted training for skill improvement. However, open-ended responses partially addressed this. The missing antibiotic indication question likely has minimal impact on SB-TNA tool validity and reliability, as it falls within the well-represented clinical tasks domain. Interviews, rather than private skill ratings, might have introduced bias. Consistently high importance ratings could be due to social desirability bias, though similar trends appear in other HH-TNA tool studies [57–59]. Statistical comparisons between HCW groups are exploratory, not based on a priori sample size calculations. Facility selection aimed for representativeness of Eswatini’s SBE treatment facilities, recruiting from 10 of 20 facilities with necessary infrastructure and resources. Crucially, the SB-TNA tool measured self-perceived training needs, not actual HCW competency. Future research could evaluate how HCW training translates to improved clinical outcomes.

Conclusion

HCWs in Eswatini frequently manage snakebite patients. Our adapted SB-TNA tool identified variations in self-perceived training needs for different snakebite management skills and HCW subgroups. Research-related and clinical skills showed the greatest training needs, and nurses reported higher needs than doctors. The SB-TNA tool is designed for transferability to other snakebite-endemic regions globally, where its utility should be further explored. The effectiveness of snakebite training programs in improving clinical outcomes remains an important area for future research.

Supporting information

S1 Appendix. Checklist for Conducting and Reporting Delphi Studies in palliative care (CREDES).

https://doi.org/10.1371/journal.pntd.0012778.s001

(PDF)

S2 Appendix. SB-TNA Tool Delphi Panel-approved version.

https://doi.org/10.1371/journal.pntd.0012778.s002

(PDF)

S3 Appendix. Index of SB-TNA Tool skills and domains.

https://doi.org/10.1371/journal.pntd.0012778.s003

(XLSX)

S4 Appendix. Content of healthcare worker training courses on the management of snakebite envenoming offered by the Eswatini Antivenom Foundation.

https://doi.org/10.1371/journal.pntd.0012778.s004

(PDF)

Acknowledgments

We thank the Delphi panel members who volunteered to help with the design of the SB-TNA tool. We also thank the healthcare workers for agreeing to participate in this study and we would like to extend our gratitude to the Eswatini Ministry of Health for supporting this study.

References

  1. Gutiérrez JM, Warrell DA, Williams DJ, Fan HW, Johnson D, de Silva HJ, et al. Snakebite envenoming from a global perspective. Toxicon. 2017 Nov 15;140:7–15. doi:10.1016/j.toxicon.2017.07.024

  2. World Health Organization. Snakebite envenoming [Internet]. World Health Organization. 2021 [cited 2024 Dec 13]. Available from: https://www.who.int/news-room/fact-sheets/detail/snakebite-envenoming

  3. Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med. 2002 Jul 25;347(5):347–56. doi:10.1056/NEJMra013477

  4. Warrell DA. Guidelines for the management of snake-bites. World Health Organization; 2010. Available from: https://apps.who.int/iris/handle/10665/44136

  5. World Health Organization. Guidelines for the Prevention and Clinical Management of Snakebite in Africa. Volume 1: Regional Guidelines [Internet]. WHO Regional Office for Africa; 2023. Available from: https://iris.who.int/handle/10665/370485

  6. Harrison RA, Gutiérrez JM, Sykes MJ, Williams DJ, Warrell DA. Progress in the development of antivenoms for snakebite envenoming. Toxicon. 2018 Nov 15;155:165–74. doi:10.1016/j.toxicon.2018.09.013

  7. Lalloo DG, Theakston RDG. Snake antivenoms. Lancet. 2003 Mar 15;361(9358):763–9. doi:10.1016/S0140-6736(03)12656-1

  8. Brown SGA, Carroll P, Sutter R, Cocks RA, Lee N, هايزلباور إي, et al. Development of a grading system for local envenoming in Russell’s viper (Daboia russelii) bites and its application in a prospective antivenom trial. Toxicon. 2011 Dec 1;58(6–7):551–63. doi:10.1016/j.toxicon.2011.09.009

  9. Leonardi-Bee J, Lee P, Theakston RDG, Warrell DA, Griffiths JM. Early administration of antivenom for severe envenoming after bites by the saw-scaled or carpet viper Echis species. Trans R Soc Trop Med Hyg. 2004 Dec;98(12):715–29. doi:10.1016/j.trstmh.2004.04.006

  10. Sharma SK, Chappuis F, Jha N, Pio Rodriguez L, Lalloo DG. Impact of geographical variation in snake species distribution on clinical manifestations of snake bites and antivenom use: prospective study in the Terai region of Nepal. PLoS Negl Trop Dis. 2016 Nov 17;10(11):e0005139. doi:10.1371/journal.pntd.0005139

  11. Williams DJ, Faiz MA, Abela-Overton K, Adu-Attah A, Al-Mamun A, Bajaj S, et al. Strategy for a globally affordable supply of effective snake antivenoms. Lancet. 2011 Jan 29;377(9765):486–9. doi:10.1016/S0140-6736(10)61539-1

  12. Tan CH, Fung SY, Murugesu K, Tan KY, Ismail AK, Khomvilai S, et al. Clinician knowledge gaps in snakebite management: a systematic review and meta-analysis. PLoS Negl Trop Dis. 2021 Aug 19;15(8):e0009640. doi:10.1371/journal.pntd.0009640

  13. Vongphachanh P, Syphanmavong S, ফোনথিলাথ পি, Alirol E, ইনথাভং এম, ফোনথিলাথ বি, et al. Knowledge, attitudes and practices of health care providers in rural Laos towards snakebite management. PLoS Negl Trop Dis. 2017 Jul 27;11(7):e0005783. doi:10.1371/journal.pntd.0005783

  14. Tyndall J, 브레슬িন এম, Williams SS, ও’রিলি এম, Moloney E. Snakebite management in resource-poor settings: identifying and addressing knowledge gaps. Ir J Med Sci. 2021 May;190(2):697–705. doi:10.1007/s11845-020-02452-w

  15. Sharma N, Simpson ID, Hodgson WC, Carter PE, Brown SGA, Underwood M, et al. Clinical audit of the management of snake bite in rural Nepal. Trans R Soc Trop Med Hyg. 2004 Dec;98(12):730–6. doi:10.1016/j.trstmh.2004.03.008

  16. Bawaskar HS, Bawaskar PH. منظره سريري و پيشگيري از واكنشهاي جانبي به پادزهر مار. JAPI. 2006 Sep;54:645–7.

  17. Visser LE, Khoirom S, Van Beek FG, Van Genderen PJJ. Knowledge and attitudes of health workers in Myanmar regarding snakebite and snakebite management. PLoS Negl Trop Dis. 2015 Jun 11;9(6):e0003848. doi:10.1371/journal.pntd.0003848

  18. Rahman R, Valecha N, Sengupta S, Hossain E, Khan F, Faiz MA, et al. Snake bite in Bangladesh: hospital incidence and geographical variation. Trop Med Int Health. 2001 Aug;6(8):643–7. doi:10.1046/j.1365-3156.2001.00766.x

  19. Kulkarni ML, Anees S. Adequacy of knowledge of doctors in the management of snake bite. Indian Pediatr. 1994 Feb;31(2):197–200.

  20. Mohapatra B, Warrell DA, Reddy N, Dhingra N, Hogland M, Das SS, et al. Snakebite mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis. 2011 Apr 26;5(4):e1018. doi:10.1371/journal.pntd.001018

  21. World Health Organization. Snakebite envenoming: a strategy for prevention and control [Internet]. World Health Organization. 2019 [cited 2024 Dec 13]. Available from: https://www.who.int/publications/i/item/snakebite-envenoming-strategy-prevention-control

  22. The World Bank. Eswatini [Internet]. Data. [cited 2024 Dec 13]. Available from: https://data.worldbank.org/country/SZ

  23. The World Bank. Poverty headcount ratio at $2.15 a day (2017 PPP) (% of population) – Eswatini [Internet]. Data. [cited 2024 Dec 13]. Available from: https://data.worldbank.org/indicator/SI.POV.DDAY?locations=SZ

  24. Central Intelligence Agency. Eswatini [Internet]. [cited 2024 Dec 13]. Available from: https://www.cia.gov/the-world-factbook/countries/eswatini/

  25. Food and Agriculture Organization of the United Nations. Eswatini – FAO [Internet]. [cited 2024 Dec 13]. Available from: https://www.fao.org/eswatini/fao-in-eswatini/eswatini-at-a-glance/en/

  26. Eswatini Ministry of Health. Eswatini Snakebite Guidelines 2021. Mbabane; 2021.

  27. Eswatini Antivenom Foundation. Eswatini Antivenom Foundation – Saving lives from snakebite envenoming [Internet]. [cited 2024 Dec 13]. Available from: https://www.eswatiniantivenomfoundation.com/

  28. Hennessy D, Hicks C. The Hennessy Hicks Training Needs Analysis Questionnaire. University of Birmingham; 2000.

  29. Woodcock J, Humphrey C, Barlow J. Beyond consensus? Using the Delphi technique to realize participatory action in health services research. Health Expect. 2012 Jun;15(2):184–97. doi:10.1111/j.1369-7625.2011.00146.x

  30. Jünger S, Payne SA, Brine J, Radbruch L, Brearley SG. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliat Med. 2017 Dec;31(10):888–906. doi:10.1177/0269216317719068

  31. Runfola D, Anderson A, Baier H, Czaplewski L, Dong E, Small M, et al. geoBoundaries: A global database of political administrative boundaries. PLoS One. 2020 Apr 23;15(4):e0230983. doi:10.1371/journal.pone.0230983

  32. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, et al. REDCap Mobile App for Electronic Data Capture at the Point of Research. J Biomed Inform. 2023 Aug;144:104423. doi:10.1016/j.jbi.2023.104423

  33. Zoom Video Communications Inc. Zoom [Internet]. [cited 2024 Dec 13]. Available from: https://zoom.us/

  34. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010 Dec 4;376(9756):1923–58. doi:10.1016/S0140-6736(10)61854-5

  35. World Health Organization. Eswatini: WHO health workforce statistics [Internet]. Geneva: World Health Organization; 2023. Available from: https://apps.who.int/gho/data/node.main.HWFSTAFF?lang=en

  36. Eswatini Antivenom Foundation. Snakebite Training – Eswatini Antivenom Foundation [Internet]. [cited 2024 Dec 13]. Available from: https://www.eswatiniantivenomfoundation.com/snakebite-training/

  37. Kirigia JM, Ota MM, Soumbey-Alley EW. Health research capacity strengthening in the WHO African Region: progress, challenges and prospects. Health Res Policy Syst. 2023 Dec 7;21(1):130. doi:10.1186/s12961-023-01071-1

  38. Abubakar I, Tillmann T, Banerjee A. Global health research: time for a change. Bull World Health Organ. 2015 Jul 1;93(7):518–23. doi:10.2471/BLT.14.150342

  39. University of Alabama at Birmingham. UAB-ESWATINI D43 Public Health Research Training Program [Internet]. [cited 2024 Dec 13]. Available from: https://www.uab.edu/globalhealth/images/Eswatini_D43_Program_Summary_508C.pdf

  40. African Snakebite Alliance. African Snakebite Alliance – Working to reduce snakebite morbidity and mortality in Africa [Internet]. [cited 2024 Dec 13]. Available from: https://africansnakebitealliance.com/

  41. Rahman SA, Valecha N, Hossain E, Faiz MA, Warrell DA. Snake bite–a community survey in rural Bangladesh. Community Eye Health. 2001;14(39):40–2.

  42. Ghimire P, Dhakal P, Sharma S, Bhattarai MD, Khanal P, Kc B, et al. Effectiveness of snakebite management training for health workers in community health centers of Nepal: a quasi-experimental study. Wilderness Environ Med. 2023 Jun;34(2):232–40. doi:10.1016/j.wem.2023.01.004

  43. Ameade EP, Dzefi-Tettey K, Abugri J, Williams S, Kudzi W, Lawson-Evi P, et al. Knowledge and practices of health workers on snakebite management in the middle belt of Ghana. PLoS One. 2020 Feb 27;15(2):e0229453. doi:10.1371/journal.pone.0229453

  44. Fahrmann J, Hlongwana V, Maduna TP, Muller R, Blumberg L, Frean J. Snakebite knowledge, attitudes and practices of healthcare providers in a rural South African community. PLoS Negl Trop Dis. 2018 Mar 22;12(3):e0006344. doi:10.1371/journal.pntd.0006344

  45. Lindquist LA, Ramirez-Garnica G, Clark RF, Walter FG. A prospective evaluation of physician knowledge of rattlesnake envenomation and treatment guidelines before and after a continuing medical education activity. Wilderness Environ Med. 2016 Dec;27(4):510–4. doi:10.1016/j.wem.2016.07.013

  46. Forde R,ুনু এম, লেপেল এম, O’Keeffe C, গেইল সি, পার্কিন এফ, et al. “It’s just about feeling valued”: a qualitative study of doctors’ and nurses’ experiences of continuing professional development. BMJ Open. 2017 Oct 17;7(10):e017221. doi:10.1136/bmjopen-2017-017221

  47. De Clercq M, Galletta M, Kerckhove MD, Buregeya J, Mukantwari J, Gasana P, et al. The impact of training on motivation and job satisfaction of community health workers: evidence from a randomized controlled trial in Rwanda. Hum Resour Health. 2021 May 18;19(1):38. doi:10.1186/s12960-021-00576-2

  48. Frame JD, වීරසිංහ এস, ডি সিলভা এ, de Silva HJ. Knowledge of doctors, nurses, and first aid providers on snakebite management in rural Sri Lanka. Wilderness Environ Med. 2012 Dec;23(4):345–52. doi:10.1016/j.wem.2012.08.006

  49. Simić V, Tomić V, Stefanović V, Vuković D, Đurđević M, Ilić V, et al. Knowledge and attitudes of healthcare professionals regarding snakebite envenomation in Serbia. PLoS One. 2023 Oct 26;18(10):e0293079. doi:10.1371/journal.pone.0293079

  50. Araújo MR de, Nogueira R de A, Oliveira SS de, Bernarde PS. Snakebite accidents: knowledge and practice of health professionals from hospitals in Rio Branco, Acre, Brazil. Rev Soc Bras Med Trop. 2013 Dec;46(6):715–22. doi:10.1590/0037-8682-0229-2013

  51. Campbell J, Buchan J, Cometto G, Dhillon I, Dolea C,োভেল এইচ, et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Health Organ. 2013 Nov 1;91(11):853–63. doi:10.2471/BLT.12.117052

  52. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999 Dec;77(6):1121–34. doi:10.1037/0022-3514.77.6.1121

  53. Mukthar AM, Gireesh Kumar KP, Masthi AR, Shashidhara YN. A study on assessment of knowledge, attitude and practices regarding snake bite management among doctors and nurses in tertiary care hospitals of Mysore city. J Family Med Prim Care. 2020 Oct 30;9(4):1870–4. doi:10.4103/jfmpc.jfmpc_102_20

  54. Eswatini Antivenom Foundation. Snakebite Awareness – Eswatini Antivenom Foundation [Internet]. [cited 2024 Dec 13]. Available from: https://www.eswatiniantivenomfoundation.com/snakebite-awareness/

  55. Thindwa D, Chimwani MB, Walls C, Kelley E, Mandala W, Chimzizi R, et al. Using common clinical algorithms to improve hospital care in Malawi. Malaw Med J. 2020 Dec 21;32(4):216–24. doi:10.4314/mmj.v32i4.8

  56. Keeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using and reporting Delphi studies in palliative and supportive care. Palliat Med. 2006 Mar;20(2):101–6. doi:10.1191/0269216306pm110oa

  57. Naidoo N, Van Wyk JM, Singh S. Development of a training needs analysis tool for district clinical specialist teams in KwaZulu-Natal Province, South Africa: a Delphi study. BMC Health Serv Res. 2015 Jul 17;15:264. doi:10.1186/s12913-015-0935-4

  58. Khoza LB, Peu MD, Van Wyk JM, Malakoane BM. Development of a training needs analysis tool for primary health care supervisors in the Tshwane District of Gauteng Province, South Africa: a Delphi study. BMC Health Serv Res. 2017 Oct 19;17(1):701. doi:10.1186/s12913-017-2655-8

  59. Nkosi ZZ, Heyns T, Mudzi W. Development of a tool to determine the training needs of rehabilitation professionals in primary health care in the Western Cape, South Africa: a Delphi study. BMC Health Serv Res. 2018 Feb 21;18(1):134. doi:10.1186/s12913-018-2944-7

Comments

No comments yet. Why don’t you start the discussion?

Leave a Reply

Your email address will not be published. Required fields are marked *