Drawing and interpreting data: Children's impressions of onchocerciasis and community-directed treatment with ivermectin (CDTI) in four onchocerciasis endemic countries in Africa

Although the depiction of a child leading a blind man is the most enduring image of onchocerciasis in Africa, research activities have hardly involved children. This paper aims at giving voice to children through drawings and their interpretation. The study was conducted in 2009 in Cameroon, Democratic Republic of Congo (DRC), Nigeria and Uganda. Children aged 6–16 years were asked to draw their perceptions of onchocerciasis and community-directed treatment with ivermectin (CDTI) in their communities. A total of 50 drawings were generated. The drawings depicted four main aspects of onchocerciasis: (1) the disease symptoms, (2) the negative consequences of onchocerciasis among children and in the community generally, (3) the ivermectin distribution process, and (4) the benefits or effects of taking ivermectin. Out of the 50 drawings, 30 were on symptoms, 7 on effects of the disease on children, 8 on distribution process, and 5 represented multiple perceptions on symptoms, drug distribution processes, benefits, and effects of treatment. The lack of clarity when treatment with ivermectin can be stopped in endemic areas requires working with children to ensure continued compliance with treatment into the future. Children's drawings should be incorporated into health education interventions

The feasibility of introducing rapid diagnostic tests for malaria in drug shops in Uganda

BACKGROUND: National malaria control programmes and international agencies are keen to scale-up the use of effective rapid diagnostic tests (RDTs) for malaria. The high proportion of the Ugandan population seeking care at drug shops makes these outlets attractive as providers of malaria RDTs. However, there is no precedent for blood testing at drug shops and little is known about how such tests might be perceived and used. Understanding use of drug shops by communities in Uganda is essential to inform the design of interventions to introduce RDTs. METHODS: We conducted a qualitative study, with 10 community focus group discussions, and 18 in-depth interviews with drug shop attendants, health workers and district health officials. The formative study was carried out in Mukono district, central Uganda an area of high malaria endemicity from May-July 2009. RESULTS: Drug shops were perceived by the community as important in treating malaria and there was awareness among most drug sellers and the community that not all febrile illnesses were malaria. The idea of introducing RDTs for malaria diagnosis in drug shops was attractive to most respondents. It was anticipated that RDTs would improve access to effective treatment of malaria, offset high costs associated with poor treatment, and avoid irrational drug use. However, communities did express fear that drug shops would overprice RDTs, raising the overall treatment cost for malaria. Other fears included poor adherence to the RDT result, reuse of RDTs leading to infections and fear that RDTs would be used to test for human immune deficiency virus (HIV). All drug shops visited had no record on patient data and referral of cases to health units was noted to be poor. CONCLUSION: These results not only provide useful lessons for implementing the intervention study but have wide implications for scaling up malaria treatment in drug shops

Informal economic activities of public health workers in Uganda: implications for quality and accessibility of care

This paper reports the results of a study in Uganda of the 'informal' economic activities of health workers, defined as those which earn incomes but fall outside official duties and earnings. The study was carried out in 10 sub-hospital health facilities of varying size and intended role and used a variety of quantitative and qualitative methods. The paper focuses on those activities which are carried out inside public health facilities and which directly affect quality and accessibility of care. The main strategies in this category were the leakage of drug supply, the informal charging of patients and the mismanagement of revenues raised from the formal charging of patients. Few of the drugs supplied to health units were prescribed and issued in those sites. Most health workers who have the opportunity to do so, levy informal charges. Where formal charges are collected, high levels of leakage occur both at the point of collection and at higher levels of the system. The implications of this situation for the quality and accessibility of services in public health facilities were assessed. Utilisation levels are less than those expected of the smallest rural units and this workload is managed by a handful of the expected staff complement who are available for a fraction of the working week. Even given these few patients, drugs available after leakage were sufficient to cover less than half of those attending in most facilities. Evidence on staff motivation was mixed and better motivation was associated with better performance only in a minority of units. Informal charging was associated with better performance regarding hours worked by health workers and utilisation rates. Drug leakage was associated with worse performance with respect to both of these and unsurprisingly, with drug availability. Short term strategies to effect marginal performance improvements may focus on the substitution of strategies based inside health units (such as informal charging) for those based outside (facilitated by drug leakage). In the long term, only substantially higher funding of the sector can be expected to facilitate major change, but alone will be insufficient. Investment strategies supported by appropriate policy development has to be informed by understanding and monitoring of the 'informal' dimension of health sector activity.

Introducing malaria rapid diagnostic tests at registered drug shops in Uganda: limitations of diagnostic testing in the reality of diagnosis.

In Uganda, around two thirds of medicines are procured from the private sector, mostly from drug shops. The introduction of malaria rapid diagnostic tests (RDTs) at drug shops therefore has the potential to make a significant contribution to targeting antimalarial drugs to those with malaria parasites. We undertook formative research in a district in Uganda in preparation for a randomised trial of RDTs in drug shops. In May to July 2009, we interviewed 9 drug shop workers, 5 health workers and 4 district health officials and carried out 10 focus group discussions with a total of 75 community members to investigate the role of drug shops and the potential for implementation of RDTs at these health care outlets. Drug shops were seen to provide an important service to community members, the nature of which is determined by responsiveness to client demands. However, drug shops hold a liminal status: in the eyes of different actors, these outlets are at once a shop and clinic; legitimate and illegitimate; and trusted and distrusted. Malaria treatment was found to be synonymous with diagnosis. Diagnostic testing was deemed useful in theory, and community members were curious about the results, with the expectation that a test would decrease uncertainty and help secure an end to illness. However, whether testing would be sought as a routine step in treatment decisions in practice is uncertain, since the appeal of the tests waned in light of their costs and potential for results to conflict with presumed diagnosis. Interventions that increase awareness of multiple causes and management of malaria-like illness will be needed to support the new rationalisation for malaria treatment represented by parasitological diagnosis