Qualitative study of mental health attribution, perceptions and care-seeking in Kampala, Uganda

Background: Mental health problems contribute to a substantial proportion of the global burden of disease. In Uganda, the World Health Organization estimates that 2.2 million people are affected by mental health disorders. Further research is needed to highlight people’s views about mental health in order to ensure that services are appropriate, accessible and effective. Aim: This qualitative study aimed to explore perceptions, experiences and care-seeking preferences to inform stakeholders looking to provide contextually appropriate mental health programmes. Setting: A diverse neighbourhood in central Kampala, Uganda. Methods: The authors conducted 56 in-depth semi-structured interviews with people over the age of 37 years from November 2018 to May 2019. Results: Participants discussed interpersonal and systemic issues that affect mental health in their community and the existing coping mechanisms that people employ. Social factors were often associated with mental health problems, with 36% of participants attributing them to economic stressors in particular. Mental health services were often perceived to be unavailable, costly or stigmatised, which can mean that care-seeking is delayed until problems become severe. Some people said they prefer to turn to prayer (25%) or counselling within their family or community (12.5%). Conclusion: Mental health problems are often attributed to socioeconomic factors, which can also hinder access to services. An understanding of perceptions about mental health can help to align programmes for appropriateness and effectiveness. Our study suggests that beneficial additional services for people living in low-income urban settings in Uganda could include those which are free, community-based or offering financial support

Evaluation of Integrated Community Case Management in Eight Districts of Central Uganda

Objective Evidence is limited on whether Integrated Community Case Management (iCCM) improves treatment coverage of the top causes of childhood mortality (acute respiratory illnesses (ARI), diarrhoea and malaria). The coverage impact of iCCM in Central Uganda was evaluated. Methods Between July 2010 and December 2012 a pre-post quasi-experimental study in eight districts with iCCM was conducted; 3 districts without iCCM served as controls. A two-stage household cluster survey at baseline (n = 1036 and 1042) and end line (n = 3890 and 3844) was done in the intervention and comparison groups respectively. Changes in treatment coverage and timeliness were assessed using difference in differences analysis (DID). Mortality impact was modelled using the Lives Saved Tool. Findings 5,586 Village Health Team members delivered 1,907,746 treatments to children under age five. Use of oral rehydration solution (ORS) and zinc treatment of diarrhoea increased in the intervention area, while there was a decrease in the comparison area (DID = 22.9, p = 0.001). Due to national stock-outs of amoxicillin, there was a decrease in antibiotic treatment for ARI in both areas; however, the decrease was significantly greater in the comparison area (DID = 5.18; p<0.001). There was a greater increase in Artemisinin Combination Therapy treatment for fever in the intervention areas than in the comparison area but this was not significant (DID = 1.57, p = 0.105). In the intervention area, timeliness of treatments for fever and ARI increased significantly higher in the intervention area than in the comparison area (DID = 2.12, p = 0.029 and 7.95, p<0.001, respectively). An estimated 106 lives were saved in the intervention area while 611 lives were lost in the comparison area. Conclusion iCCM significantly increased treatment coverage for diarrhoea and fever, mitigated the effect of national stock outs of amoxicillin on ARI treatment, improved timeliness of treatments for fever and ARI and saved lives

Prototype Positive Control Wells for Malaria Rapid Diagnostic Tests: Prospective Evaluation of Implementation Among Health Workers in Lao People's Democratic Republic and Uganda.

Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis, but lack of quality control at point of care restricts trust in test results. Prototype positive control wells (PCW) containing recombinant malaria antigens have been developed to identify poor-quality RDT lots. This study assessed community and facility health workers' (HW) ability to use PCWs to detect degraded RDTs, the impact of PCW availability on RDT use and prescribing, and preferred strategies for implementation in Lao People's Democratic Republic (Laos) and Uganda. A total of 557 HWs participated in Laos (267) and Uganda (290). After training, most (88% to ≥ 99%) participants correctly performed the six key individual PCW steps; performance was generally maintained during the 6-month study period. Nearly all (97%) reported a correct action based on PCW use at routine work sites. In Uganda, where data for 127,775 individual patients were available, PCW introduction in health facilities was followed by a decrease in antimalarial prescribing for RDT-negative patients ≥ 5 years of age (4.7-1.9%); among community-based HWs, the decrease was 12.2% (P < 0.05) for all patients. Qualitative data revealed PCWs as a way to confirm RDT quality and restore confidence in RDT results. HWs in malaria-endemic areas are able to use prototype PCWs for quality control of malaria RDTs. PCW availability can improve HWs' confidence in RDT results, and benefit malaria diagnostic programs. Lessons learned from this study may be valuable for introduction of other point-of-care diagnostic and quality-control tools. Future work should evaluate longer term impacts of PCWs on patient management

Clinical predictors and accuracy of empiric tuberculosis treatment among sputum smear-negative HIV-infected adult TB suspects in Uganda.

The existing diagnostic algorithms for sputum smear-negative tuberculosis (TB) are complicated, time-consuming, and often difficult to implement. The decision to initiate TB treatment in resource-limited countries is often largely based on clinical predictors. We sought to determine the clinical predictors and accuracy of empiric TB treatment initiation in HIV-infected sputum smear-negative TB suspects using sputum culture as a reference standard.Out-patient HIV-TB integrated urban clinic in Kampala, Uganda.HIV-infected TB suspects were screened using sputum smear microscopy, and mycobacterial sputum liquid and solid cultures were performed. Smear results were made available to the clinician who made a clinical decision on empiric TB treatment initiation for sputum smear-negative patients. Clinic records were reviewed for patients whose sputum smears were negative to collect data on socio-demographics, TB symptomatology, chest X-ray findings, CD4 cell counts and TB treatment initiation.Of 253 smear-negative TB suspects, 56% (142/253) were females, median age 38 IQR (31-44) years, with a median CD4 cell count of 291 IQR (150-482) cells/mm(3). Of the 85 (33.6%) smear-negative patients empirically initiated on TB treatment, 35.3% (n = 30) were sputum culture positive compared to only 18 (10.7%) of the 168 untreated patients (p<0.001). Abnormal chest X-ray [aOR 10.18, 95% CI (3.14-33.00), p<0.001] and advanced HIV clinical stage [aOR 3.92, 95% CI (1.20-12.85), p = 0.024] were significantly associated with empiric TB treatment initiation. The sensitivity and specificity of empiric TB treatment initiation in the diagnosis of TB in HIV-infected patients after negative smear microscopy was 62.5% and 73.7% respectively.In resource-limited settings, clinically advanced HIV and abnormal chest X-ray significantly predict a clinical decision to empirically initiate TB treatment in smear-negative HIV-infected patients. Empiric TB treatment initiation correlates poorly with TB cultures. Affordable, accurate and rapid point-of-care diagnostics are needed in resource-limited settings to more accurately determine which HIV-infected TB suspects have smear-negative TB

Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda

Background: Human immunodeficiency virus (HIV)-infected women are at high risk of cervical cancer. Objective: This study assessed uptake and correlates of cervical screening among HIV-infected women in care in Uganda. Methods: A nationally representative cross-sectional survey of HIV-infected women in care was conducted from August to November 2016. Structured interviews were conducted with 5198 women aged 15–49 years, from 245 HIV clinics. Knowledge and uptake of cervical screening and human papillomavirus (HPV) vaccination were determined. Correlates of cervical screening were assessed with modified Poisson regression to obtain prevalence ratios (PRs) using Stata version 12.0. Results: Overall, 94.0% (n = 4858) had ever heard of cervical screening and 66% (n = 3732) knew a screening site. However, 47.4% (n = 2302) did not know the schedule for screening and 50% (n = 2409) did not know the symptoms of cervical cancer. One-third (33.7%; n = 1719) rated their risk of cervical cancer as low. Uptake of screening was 30.3% (n = 1561). Women who had never been screened cited lack of information (29.6%; n = 1059) and no time (25.5%; n = 913) as the main reasons. Increased likelihood of screening was associated with receipt of HIV care at a level II health center [adj. PR 1.89, 95% confidence interval (CI) 1.29–2.76] and private facilities (adj. PR 1.68, 95% CI 1.16–3.21), knowledge of cervical screening (adj. PR 2.19, 95% CI 1.78–2.70), where to go for screening (adj. PR 6.47, 95% CI 3.69–11.36), and low perception of risk (adj. PR 1.52, 95% CI 1.14–2.03). HPV vaccination was 2%. Conclusions: Cervical screening and HPV vaccination uptake were very low among HIV-infected women in care in Uganda. Improved knowledge of cervical screening schedules and sites, and addressing fears and risk perception may increase uptake of cervical screening in this vulnerable population

Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda

This study assessed uptake and correlates of cervical screening among HIV infected women in care in Uganda.Objective: This study assessed uptake and correlates of cervical screening among HIV-infected women in care in Uganda. Methods: A nationally representative cross-sectional survey of HIV-infected women in care was conducted from August to November 2016. Structured interviews were conducted with 5198 women aged 15–49 years, from 245 HIV clinics. Knowledge and uptake of cervical screening and human papillomavirus (HPV) vaccination were determined. Correlates of cervical screening were assessed with modified Poisson regression to obtain prevalence ratios (PRs) using Stata version 12.0. Results: Overall, 94.0% (n = 4858) had ever heard of cervical screening and 66% (n = 3732) knew a screening site. However, 47.4% (n = 2302) did not know the schedule for screening and 50% (n = 2409) did not know the symptoms of cervical cancer. One-third (33.7%; n = 1719) rated their risk of cervical cancer as low. Uptake of screening was 30.3% (n = 1561). Women who had never been screened cited lack of information (29.6%; n = 1059) and no time (25.5%; n = 913) as the main reasons. Increased likelihood of screening was associated with receipt of HIV care at a level II health center [adj. PR 1.89, 95% confidence interval (CI) 1.29–2.76] and private facilities (adj. PR 1.68, 95% CI 1.16–3.21), knowledge of cervical screening (adj. PR 2.19, 95% CI 1.78–2.70), where to go for screening (adj. PR 6.47, 95% CI 3.69–11.36), and low perception of risk (adj. PR 1.52, 95% CI 1.14–2.03). HPV vaccination was 2%. Conclusions: Cervical screening and HPV vaccination uptake were very low among HIV-infected women in care in Uganda. Improved knowledge of cervical screening schedules and sites, and addressing fears and risk perception may increase uptake of cervical screening in this vulnerable population

Patient enrollment flow diagram showing the number of patients enrolled and analyzed as well as the TB culture results distribution.

<p>Patient enrollment flow diagram showing the number of patients enrolled and analyzed as well as the TB culture results distribution.</p

Comparing characteristics of sputum smear-negative study participants empirically initiated on TB treatment and those who were not treated.

*<p>means the variable number is less than the total N = 253. These were missing data in the clinic patients records most of which were not recorded by the treating clinicians.</p><p><b>Abbreviations</b>: IQR, Interquatile range; CXR, chest X-ray; TB, tuberculosis; WHO, World Health Organization; ART, Antiretroviral therapy.</p