Perceptions and valuation of a community-based education and service (COBES) program in Uganda

Abstract

Background: Community-based education and service (COBES) has been promoted to improve the education of health professionals, particularly in low-resource settings. However, few evaluations have been performed to guide program development.

Aim: This study assessed student and educator perceptions and valuation of a Ugandan COBES program.

Methods: We administered an internet-based survey to students, faculty, and site tutors associated with the Makerere University College of Health Sciences COBES program.

Results: 255 surveys were completed. Response rates varied (students, 188/684, 27.5%; faculty-site supervisors, 15/23, 65.2%; faculty general, 38/312, 12.2%; site tutors, 14/27, 51.9%). Students valued the COBES program (93.5% some/high value). Tutors enjoyed their work (92.9% agreeing/strongly agreeing). Faculty (n = 53) felt COBES was valuable (90.2% agreeing/strongly agreeing). High student valuation was associated with high quality accommodation (aOR 4.7, 95% CI = 1.6–13.4), free accommodation (aOR 2.9, 95% CI = 1.2–6.8), and tutors who demonstrated enthusiasm for teaching (aOR 3.4, 95% CI = 1.1–10.0). Areas identified for improvement included financial support, student preparation, and tutor training, feedback, and supervision.

Conclusion: In this study, COBES was perceived positively by students and educators and learning environment and quality of teaching both contributed to valuation of COBES. Well-implemented COBES programs may offer an opportunity to enhance health sciences education.

Introduction

Community-based education and service (COBES) is a strategy for health sciences education that was originally developed at Ilorin University in Nigeria in the 1960s (Bollag et al. 1982; Hamilton & Ogunbode 1991). Key principles of this approach are that students spend time in community placements (typically in rural settings), learning and service are interconnected, and students are attached to community-based health institutions where they are supervised by community-based site tutors (Bollag et al. 1982; Hamilton & Ogunbode 1991).

Makerere University College of Health Sciences (MUCHS) in Kampala, Uganda, underwent an extensive curricula evaluation and change in 2003 (Kiguli-Malwadde et al. 2006). One of the important changes implemented during this period was the development and integration of COBES into the health sciences clinical degree programs (medicine, dentistry, nursing, radiography, and pharmacy; Mubuuke et al. 2008; Ozgediz et al. 2008). Students in these programs now participate in COBES rotations every year, rotating among over 50 community-based sites.

While COBES has been promoted as a key initiative to improve health sciences education in Uganda and other low-resource settings, few evaluations have been performed of student, faculty and site tutors’ perceptions and valuation of their COBES experience. These types of evaluations are crucial in identifying strengths and weaknesses of current COBES programs to better guide future development of this educational strategy. Therefore, we conducted an internet-based survey of current COBES students, tutors, and associated faculty to assess their perceptions and valuation of COBES training at MUCHS.

Table

Practice points

Students and educators have positive perceptions and valuation of COBES. The learning environment and quality of teaching are important factors in affecting student valuation of COBES. COBES allows students to experience a broad spectrum of important “real-world” educational content. More and sustained financial and human resources are needed to improve the quality and impact of COBES programs.

Methods

Study setting and participants

Makerere University, the largest university in Uganda, was founded in 1922 and is considered to be one of the leading universities in Africa. MUCHS was established in December 2007, evolving from a medical school affiliated with the University College of London in the early 1900s, to a medicine faculty of Makerere University, and finally to a constituent college of the University. MUCHS consists of four schools: the School of Medicine, the School of Public Health, the School of Bio-medical Sciences, and the School of Health Sciences.

COBES has been implemented at MUCHS since 2003. During their first academic year, students participating in the COBES program initially undergo a 1 week orientation program at MUCHS that focuses on key aspects of community-based health education. Subsequently, they are sent in interdisciplinary teams to community-based sites, typically government or faith-based health facilities, where they spend about 4–6 weeks at a time. At each site, students are supervised by tutors, all of whom received prior tutor training at MUCHS. Site tutors lead students through problem-based learning sessions specific to the rotation. While at their sites, students are also expected to provide services to the community (such as helping with vaccinations). During their second to fourth academic years, students continue rotating through the COBES program on a yearly basis. Students typically return to the same site and, in addition to their previous responsibilities, are tasked to perform a community needs assessments and eventually design and implement a community project.

This survey was focused on three key target groups at MUCHS: (1) current medicine, dentistry, nursing, radiography, and pharmacy students who had already participated in at least one COBES rotation, (2) current site tutors who were responsible for supervising students and leading them in problem-based learning sessions at the community-based COBES sites, and (3) current Makerere faculty COBES site supervisors who were responsible for making regular site visits and ensuring that each site was running properly. General faculty who were not currently serving as faculty site supervisors were also surveyed, as they form the pool of potential future COBES site supervisors and are involved in related aspects of the students’ training.

Survey tool

We developed three separate, individualized multi-domain surveys for the three target groups using established principles of survey development (Kern et al. 1998). Content domains surveyed included stipends (referred to locally as “facilitation”), accommodations, feedback, supervision, readiness, educational content, tutor quality, and future plans. The surveys contained Likert scale questions (1 = disagree strongly/no value, 3 = neutral, 5 = agree strongly/high value), categorical questions, and free text questions. We pilot tested these surveys in Uganda among the study team and with volunteer students to assess face and content validity, then administered the survey using the internet-based survey software SurveyMonkey.com with Secure Sockets Layer (SSL) encryption.

Survey administration

The survey was administered from November 2, 2009 to December 4, 2009. Adapting standardized survey definitions for calculating response rate to this internet-based format (Aday & Cornelius 2006), our original sample size was 723 students, 39 site tutors, 23 faculty site supervisors, and 333 general faculty. Eligible units were defined as those persons with working email addresses which were available for 94.6% of students (684/723), 69.2% of site tutors (27/39), 100% of faculty site supervisors (23/23), and 93.7% of general faculty (312/333). Response rate was calculated as the number of surveys responded to divided by the number of eligible units. We used a variety of methods to improve response rates including reminder emails, flyers in student gathering locations, reminder short text message (SMS) text messages (using Frontline SMS, a free SMS messaging software tool, www.frontlinesms.com), reminder voice calls, letters, workshops, and personal reminders. An incentive for participation was provided in the form of entry into a lottery for USB flash drives. General faculty were not considered a priority group and only received email reminders.

Quantitative analysis

Demographics, other participant characteristics, and most categorical questions were analyzed descriptively. Wilcoxon rank sum tests were used to evaluate differences in mean response scores across different groups for several Likert responses. Univariate and multivariate logistic regression were used to calculate odds ratios for assigning high valuation (5) of COBES by students with various independent variables. As most responses were skewed towards higher values, we dichotomized most of the independent variables as “agree/strongly agree” (4, 5) versus “less than agree” (1, 2, or 3). Questions about students predicted likelihood of practicing in a rural setting were dichotomized as “greater than 50%” and “50% or less”. We a priori focused our univariate analysis on variables that we expected would be most predictive of key outcomes including demographic characteristics (gender, year in program, and degree program) as well as responses to Likert scale questions on stipends, accommodations, tutor qualities, and content of the COBES experience. Those variables that were significant at p < 0.05 in univariate analysis were entered into a multivariate model. Results for faculty were combined (n = 53) for ease of presentation. However, if there were significant differences in responses between site supervisors and general faculty, these were noted. All quantitative analyses were performed with SAS 9.2 (SAS Institute Inc., Cary, NC).

Qualitative analysis

Participants were also asked a number of free text questions which were qualitatively assessed through thematic analysis. Two study team members read all responses and collaboratively developed a codebook to reflect major themes identified from the data. Codes were then applied independently and summary statements were developed; differences in interpretation were resolved through discussion and consensus. Findings are presented by major identified themes (presented in ‘Results’ section in italics).

Ethics

This study was approved by the institutional review boards of Makerere University and the Johns Hopkins School of Medicine.

Results

A total of 255 surveys were completed. Response rates varied by target group (students, 188/684, 27.5%; faculty-site supervisors, 15/23, 65.2%; faculty general, 38/312, 12.2%; site tutors, 14/27, 51.9%). Characteristics of surveys respondents are listed in Table 1.

Table 1.  Characteristics of survey respondents

Characteristic	Subcharacteristic	Result
Students (n = 188)
Male gender, n (%)		141 (75%)
Age, years, and mean (range)		22.6 (19–39)
Degree program, n (%)*
	Medicine	143 (76%)
	Nursing	11 (6%)
	Dentistry	7 (4%)
	Radiography	6 (3%)
	Pharmacy	20 (11%)
Year in program
	2	71 (38%)
	3	51 (27%)
	4	38 (20%)
	5	28 (15%)
Faculty (n = 53)
Male gender, n (%)		31 (59%)
Age, years, and mean (range) n = 48		42.3 (26–61)
Site supervisor status
	Current supervisor	15 (28%)
	Non-site supervisor	38 (72%)
Tutors (n = 14)
Male gender, n (%)		13 (93%)
Age, years, and mean (range)		36.4 (28–52)
Years as tutor, mean (range)		4.1 (2–8)
Official title, n
	Medical Officer	8
	District Health Officer	2
	Other (one each District Health Educator, Site Manager, Medical Superintendent, Nurse)	4

Students

Table 2 shows student responses to Likert scale questions, student assessment of tutors, and importance placed on tutor characteristics. Students reported high valuation of the COBES experience and rated their tutors highly on most characteristics. However, they noted challenges with stipends, preparation for their posting, and accommodations.

Table 2.  Student responses to Likert scale questions^a

Statement	N	Mean (SD) [range]
“I was prepared for the COBES experience.”	186	3.34 (1.1) [1–5]
“The COBES stipend was enough for my financial needs associated with the COBES rotation.”	186	1.63 (0.83) [1–4]
Please rate the quality of your accommodations at your COBES site.	152	3.07 (0.96) [1–5]
Please rate the overall value of the COBES experience to your overall training.	186	4.44 (0.93) [1–5]
Tutor assessment and student valuation
“My tutor is readily available when I need to discuss a case.”	188	3.71 (1.1) [1–5]
–“Important to my education?”^b	187	4.70 (0.58) [1–5]
“My tutor gives constructive feedback.”	187	4.24 (0.81) [1–5]
–“Important to my education?”	188	4.77 (0.60) [1–5]
“My tutor would often fail to show up for scheduled meetings.”	188	2.21 (1.2) [1–5]
–“Important to my education?”	188	4.70 (0.54) [1–5]
“My tutor respects my judgment.”	184	3.98 (0.75) [2–5]
–“Important to my education?”	186	4.47 (0.64) [3–5]
“My tutor demonstrates enthusiasm for teaching.”	187	3.99 (0.89) [1–5]
–“Important for my education”	187	4.64 (0.64) [1–5]
“My tutor is effective in making me aware of clinic and social resources for my patients.”	188	4.04 (0.92) [1–5]
–“Important to my education?”	188	4.78 (0.42) [4–5]
“My tutor provides a good role model of professional behavior.”	187	4.13 (0.88) [1–5]
–“Important to my education?”	188	4.71 (0.54) [1–5]

Notes: ^aLikert scale response options were as follows: 1 = disagree strongly/no value; 2 = disagree; 3 = neutral; 4 = agree; 5 = agree strongly/high value.

^bRefers to statement immediately above, e.g., It is important to “my education that my tutor is readily available …”

Table 3 shows univariate and multivariate analyses of factors associated with high student valuation of COBES. Only factors found to be statistically significant at p < 0.05 are included in this table. No association with high student valuation was found for gender, year in program, type of degree program, or any other student responses’ to Likert scale questions (all p-values >0.05). Multivariate analyses found that three factors were significantly associated with high student valuation: accommodations of high quality, free accommodations, and a tutor who demonstrated enthusiasm for teaching.

Table 3.  Univariate and multivariate analyses of factors associated with high student valuation of COBES

Characteristic	Odds ratio (95% CI)	Adjusted odds ratio (95% CI)	p-value^a
Accommodations of high quality	4.1 (1.7–9.6)	4.7 (1.6–13.4)	0.0043
Free accommodations	2.5 (1.3–5.0)	2.9 (1.2–6.8)	0.015
Seeing patients with a wide range of ages	4.1 (1.5–11.3)	1.3 (0.29–6.0)	0.72
Seeing a wide range of social conditions	2.3 (1.0–5.2)	1.4 (0.45–4.6)	0.54
Seeing a wide range of child and neonatal health problems	2.1 (1.1–3.8)	1.7 (0.71–4.4)	0.22
Seeing a wide range of infectious diseases	2.0 (1.7–3.8)	1.1 (0.42–3.0)	0.81
A tutor who gives constructive feedback	3.4 (1.3–8.3)	0.66 (0.14–3.2)	0.61
A tutor who respects my judgment	2.9 (1.4–5.7)	2.1 (0.71–6.0)	0.18
A tutor who demonstrates enthusiasm for teaching	3.5 (1.7–7.2)	3.4 (1.1–10.0)	0.037
A tutor who provides a good role model	2.3 (1.2–4.7)	1.6 (0.60–4.5)	0.33

Note: ^ap-value is for adjusted odds ratio.

In categorical responses, almost all students (93%, 174/188) indicated they did not receive their stipend before their COBES rotation began. Almost half (48%, 74/154) received free accommodations. About half (56%, 104/186) did not speak the native language of the community. Most students (86%, 160/186) recommended their COBES site to future students with most (86%, 159/186) also recommending their tutors. Half of the students (50%, 93/187) felt they saw the right amount of patients, with a significant minority (35%, 65/187) responding that they saw too many patients and some (16%, 29/187) reporting too few patient encounters. Most students (80%, 148/185) felt they interacted the right amount with community members. Also, Figure 1 shows student responses to the likelihood they would work in a rural setting after graduating; the most common response was a 50% chance of working in a rural setting (42.8%, 80/187).

Figure 1. Student rankings of likelihood they will pursue work in a rural setting after they graduate (n = 187).

In free text responses, almost all students (155/188) said that the best thing about COBES was the opportunity for a real-world experience where they were able to apply their medical education in a community-based setting. As one student stated, the best thing about COBES was “being able to see the relevancy of my medical school training to the communities in our country”. A significant number of students (52/188) cited the excitement of travel and adventure as a positive aspect of COBES as they were exposed to a “new environment, culture, way of living”. Students also noted (29/188) the positive benefits of friendships and teamwork developed through COBES.

The worst things about COBES which were frequently cited (130/188) included poor facilitation (stipends), i.e., lack of adequate financial support for students and tutors, and delays in receiving this facilitation. As one student described it, the worst thing about COBES was “poor facilitation, which greatly limits our ability to do as much as we could have been able to do, which in turn demoralizes us”. Poor accommodation was also frequently noted (67/188), as well as language barriers (31/188), and poor learning conditions (62/188), such as not having internet or adequately trained tutors at the COBES sites. When asked how student preparation for COBES placement could be improved, students reported that increased and more timely facilitation (127/188) and an improved learning environment (83/188) through provision of laptops, more orientation materials, better trained tutors, and more careful site selection would have been helpful.

Tutors

Table 4 shows faculty and tutor responses to Likert scale questions. These responses demonstrated that most tutors enjoyed being a tutor and felt adequately prepared for their jobs, but many still wanted additional trainings. Categorical responses found that only half of tutors (50%, 7/14) indicated they received feedback from Makerere on their performance; just over half (57%, 8/14) received feedback from Makerere on the quality of their site. Most tutors (71%, 10/14) did not receive their stipend before the start of their last COBES rotation. However, despite these challenges, most (79%, 11/14) indicated they planned to be COBES tutors again in the future.

Table 4.  Faculty and tutor responses to Likert scale questions

Statement	N	Mean (SD) [range]
Tutors
“I felt well trained to be a good tutor.”	14	3.57 (0.85) [2–5]
“I would like to have more trainings in being a good tutor.”	14	4.64 (0.63) [3–5]
“I can easily contact Makerere faculty for help with problems related to COBES.”	14	3.86 (1.1) [1–5]
“Feedback from Makerere was useful in improving the COBES experience.“	14	3.57 (1.3) [1–5]
“I felt poorly prepared to do a good job as a tutor.”	14	2.21 (0.98) [1–4]
“I felt supported in my job as a tutor by Makerere faculty and staff.”	14	3.50 (1.2) [1–5]
“I had enough time to teach the students.”	14	3.57 (0.85) [2–5]
“I believe COBES will encourage students to work in rural communities after they graduate.”	14	4.14 (0.95) [2–5]
“I enjoyed being a tutor.”	14	4.43 (0.85) [2–5]
Faculty
“Students are prepared for going into the field during their COBES course.”	52	3.67 (0.71) [1–5]^a
“Students should receive more teaching at Makerere before going on their COBES course.”	52	3.56 (1.1) [1–5]^b
“The COBES course has been valuable for students.”	51	4.33 (0.77) [2–5]^a
“I believe COBES will encourage students to work in rural communities after they graduate.”	52	3.73 (1.1) [1–5]^a
“The tutors receive enough training to do a good job.”	53	2.87 (0.98) [1–4]
“The tutors should have yearly re-trainings.”	53	4.38 (0.81) [2–5]^a
“Tutors have a hard time contacting Makerere faculty for help with problems related to COBES.”	53	3.36 (0.90) [1–5]

Notes: ^aCurrent site supervisors answered more positively than non-site supervisors, all p-values < 0.05.

^bCurrent site supervisors answered more negatively than non-site supervisors, p-value < 0.05.

Free text responses found that tutors felt the best things about COBES were most often (11/14) centered around perceived personal benefits such as “learned a lot of new things from students”. Worst things about COBES included poor facilitation (insufficient or delayed stipends) for both students and tutors (10/14). When asked what could have been done to help tutors better prepare for COBES, most (10/14) asked for more training and some specifically mentioned more supervision and feedback (4/14) and better facilitation (5/14).

Faculty

Table 4 shows combined faculty responses to Likert scale questions. Faculty who were current site supervisors generally answered questions more positively than faculty non-site supervisors. In free text responses, faculty (43/53) said that the best thing about COBES was that it provided a community-based experience for students, e.g., “contextual learning is the ultimate leverage of COBES”. The worst things about COBES included poor facilitation (23/53) of tutors and students. Also mentioned was poor supervision (8/53), inadequate learning resources (7/53), and poor accommodations (6/53). Suggestions for improving COBES centered on increasing financial support (18/53), increasing learning resources (11/53) such as internet access and textbooks, and more trainings (14/53) of tutors and students.

Finally, Table 5 shows student, faculty, and tutor responses to statements about the content of the COBES experience. Responses were generally positive across all groups. However, students were more likely to indicate that they did not see a wide range of medical conditions, that they did see a poor balance between men and women, and did not see a wide range of infectious diseases (all p-values < 0.05). Faculty who were current site supervisors tended to answer more positively than faculty who were not current site supervisors.

Table 5.  Student, faculty, and tutor responses to COBES experience statements

	Students (n = 188)	Faculty (n = 52)	Tutors (n = 14)
Statement	Mean (SD) [range]	Mean (SD) [range]	Mean (SD) [range]
“During the COBES rotation, the students …”
“Saw a wide range of medical conditions.”	3.42 (1.1) [1–5]^a	3.90 (0.93) [1–5]^a,b	4.21 (0.98) [2–5]^a
“Saw patients with a wide range of ages.”	4.20 (0.84) [1–5]	4.15 (0.72) [2–5]^b	4.57 (0.65) [3–5]
“Saw a poor balance between men and women.”	3.97 (1.0) [1–5]^a	2.75 (1.0) [1–5]^a	3.50 (1.2) [1–5]^a
“Identified a number of community health needs.”	4.56 (0.61) [2–5]	4.33 (0.68) [3–5]^b	4.57 (0.51) [4–5]
“Learned a great deal about the district health administrative system.”	4.32 (0.80) [1–5]	4.10 (0.80) [3–5]^b	4.57 (0.51) [4–5]
“Saw a wide range of social conditions.”	4.15 (0.83) [1–5]	4.21 (0.70) [3–5]^b	4.57 (0.51) [4–5]
“The students saw a wide range of maternal health problems.”	3.93 (1.0) [1–5]	4.08 (0.71) [3–5]	4.21 (0.70) [3–5]
“Saw a wide range of child and neonatal health problems.”	3.59 (1.1) [1–5]	4.02 (0.75) [2–5]	3.86 (0.95) [2–5]
“Saw a wide range of infectious diseases.”	3.77 (1.1) [1–5]^a	4.25 (0.68) [3–5]^a	4.08 (0.86) [2–5]^a
“Saw a wide range of environmental health problems.”	4.11 (0.89) [1–5]	4.31 (0.76) [3–5]^b	4.21 (0.70) [3–5]
“Worked in-depth on a community health problem.”	3.85 (0.96) [1–5]	3.92 (0.81) [2–5]	4.29 (0.47) [4–5]

Notes: ^aSignificantly different mean score across the three groups, all p-values < 0.05.

^bCurrent faculty site supervisors answered more positively than non-site supervisors, all p-values < 0.05.

Discussion

An internet-based survey of students, faculty, and tutors participating in a Ugandan COBES program found that all groups generally perceived the program positively and valued the COBES experience. Survey participants felt a variety of real-world content was present in the COBES experience – content which is consistent with COBES principles of providing a diverse, community-based learning environment (Kiguli-Malwadde et al. 2006). However, this study also identified several key areas for improvement, including the need for better stipends/facilitation, improved accommodations, more training and better preparation for tutors and students, and improved learning conditions and resources.

Our findings indicate that both social and educational issues need to be addressed in order to improve the COBES experience. For example, accommodation, both its quality and cost, was positively associated with student valuation of COBES and was frequently mentioned by tutors and faculty as needing improvement. These results highlight the importance of providing a holistically supportive learning environment for students, involving physical resources such as accommodations as well as building upon strongly valued team and community interactions (Williams et al. 1999).

Students’ perceptions of their tutors’ characteristics indicated that certain characteristics were important to them and influenced how they valued the overall COBES experience. These characteristics, particularly enthusiasm for teaching, may serve as a model of ideal tutor behavior during future COBES training activities. These findings are consistent with previous reports that student satisfaction with tutors impacts their valuation of clinical training (Sisson et al. 2007).

Students repeatedly cited the benefits of learning in a real-world environment, the positive aspects of working in a team, and the opportunity to explore new areas of Uganda they had not visited before. However, they also noted several negative aspects of their experience. Inadequate stipends were frequently cited, an area challenging to address in low-resource settings. Many students felt they were unprepared for the COBES experience indicating the need for improvements in pre-COBES orientation and logistical support. Language barriers were also noted; pairing students with local bilingual community members may offer one solution to this problem.

Interestingly, many students indicated a greater than 50% likelihood they would work in a rural setting after graduating. Tutors and faculty also generally believed that the COBES program would encourage students to work in a rural setting in the future. Little is known about practice patterns after graduating from a COBES program (Ranmuthugala et al. 2007), and it will be important to follow cohorts such as this one to see if students do eventually end up working in rural, low-resource settings rather than contributing further to “brain drain” (List 2009; Zachariah et al. 2009).

Faculty responses were mostly positive toward various aspects of COBES. It is notable that responses from current site supervisors (whose efforts are compensated) were often more positive than from non site supervisors, pointing to the importance of surveying a variety of persons involved with such programs in order to gain a more complete understanding of perceptions. Faculty also indicated the need for tutors to have more trainings and the under-resourced nature of the program. Tutor responses indicated they enjoyed their experience though were also challenged by issues such as poor stipends. Tutors strongly indicated their desire and need for more training, supervision, and feedback, indicating an opportunity for targeted, evidence-based tutor trainings (Baroffio et al. 2007).

Study limitations include our response rates which, while consistent with internet-based survey response rates in the developed world, were still lower than we had hoped (Cook et al. 2000; Sheehan 2001; Nulty 2008; Shih & Xitao 2008). Our sub-optimal response rate may have resulted in a biased sample and limits generalizability within our participant groups. We also had difficulty finding working email addresses for many potentially eligible participants which may have been an additional source of bias. In particular, the number of working email addresses from tutors was small, an indication of the difficulty this program has with consistently communicating with tutors in areas which sometime lack electricity and often lack internet capacity. Further research on methods to reach hard to access subjects and improve response rates would be informative. However, to our knowledge, this study is one of the first reports of an internet-based survey performed in sub-Saharan Africa, and it confirms that it is feasible to conduct these types of surveys. Finally, our study was limited to assessing perceptions and valuation and was unable to measure more objective outcomes such as what environments students ultimately end up working in or competencies gained from the COBES experience. Future studies addressing these outcomes would be informative.

Conclusion

In summary, a multi-domain internet-based survey of students, tutors, and faculty involved with the COBES program at MUCHS in Uganda found a generally positive perception of the program and significant valuation by all groups. However, key areas needing improvement were also identified, most of which will require dedicated resources, human and financial, to address. Studies such as this one are useful in assessing current satisfaction, perceptions, and valuation of health education program participants and contribute important guidance for future iterations of these training strategies. This study's findings provide evidence that well supported and administered COBES programs offer an excellent opportunity to enhance the health sciences educational experience in this and similar low-resource settings.

Acknowledgments

This study was funded by a grant from the Bill and Melinda Gates Foundation. We thank the survey participants for their contributions. We also thank Ann Kasozi Nambi for her invaluable administrative and logistical support of this project.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.