Understanding pathways to better nutrition at district level: lessons from Uganda

For countries looking to implement multisectoral nutrition plans, it is critical to understand what works and how programs should be delivered and scaled-up in each context. Programs can learn from each other on how to adapt to new information, evidence and events related to scaling-up and district stakeholders can play important roles in implementation of this multisectoral plan. As part of "Pathways-to-Better Nutrition" (PBN) case study conducted by USAID/SPRING Project, this research set out to explore district leaders’ perceptions of the nutrition situation, programs and opportunities for integration. Qualitative data were collected through key-informant interviews and focus group discussions. Thirty-five district and local leaders belonging to district and sub-county multisectoral nutrition committees in Kisoro and Lira were interviewed. Grounded Theory Approach was used to identify themes for coding and key domains included: learning, adoption and evidence of scale-up; adoption of innovations/interventions to local context, financing of nutrition-sensitive activities and long-term planning. Additionally, quantitative data collected by Feed the Future Innovation Lab for Nutrition were analyzed in each of the districts to provide nutrition snapshots. Malnutrition in the study districts was worse than the national average for stunting, anemia and women’s underweight. The majority (91%) of respondents were not familiar with these nutrition statistics. Both study areas have formed nutrition multisectoral working groups (District Nutrition Coordinating Committees) and have developed management structures to implement interventions. Government stakeholders from every nutrition-sensitive sector referred to the lack of clear government programs that support nutrition directly in local policy environment. Key agricultural-related programs are focusing on wealth creation, value-addition or increasing agricultural productivity without nutrition lens (not “nutrition sensitive”). Nutrition is not on the ‘list’ of key priorities of district health departments unlike HIV/AIDS, malaria or sexual reproductive health. About 69% respondents believe they lack operational capacities and soft-power skills to design, implement and manage nutrition interventions such as leveraging of resources and being able to convey evidence. The understanding of “Scaling-up Nutrition” also differed by respondent, and this has resulted in different goals and measurements. Challenges related to nutrition financing were also noted, including fiscal decentralization, use of Output-Based Financing mechanisms, limited flexibility to re-allocate funds for nutrition, and lack of standard reporting procedures or implementation strategy. Efforts to address malnutrition need to be multisectoral, coupled with increased coordination of different sectors and ministries for sustained impact on nutrition outcomes.Keywords: Pathways, nutrition, scaling-up, multisectoral, coordination, nutrition action plan, district, Ugand

Malnutrition amidst plenty: An assessment of factors responsible for persistent high levels of childhood stunting in food secure western Uganda

In spite of favourable natural and human resource capacity, malnutrition remains an important health and welfare problem in Uganda especially among children below 5 years. Western Uganda has persistently registered highest levels of childhood malnutrition despite being referred to as gthe food basketh of the country. This study sought to establish the causes of persistent child undernutrition to guide design of effective nutritional  policies and interventions. This was a cross-sectional study that used both quantitative and qualitative methods. Multistage random sampling and stratified sampling were used to select study areas and households with children 6.59 months, respectively. Stunting levels were determined using anthropometric measurements of height-for-age using the US National Center for Health Statistics (NCHS) Reference Standards, which were  approved for use in developing countries by the World Health Organization (WHO). The main causes of malnutrition were determined by logistic regression analysis. Almost half (46%) of children below 5 years were stunted, which is comparable to national prevalence of 47.8% for Western Uganda and this is unacceptably high. The major causes of stunting at (p .0.05) were improper health and sanitation, poor child feeding practices, poor access to appropriate knowledge for health and nutrition, poor socio-economic variables of access to food, type of employment, distance to main roads and markets, housing facility, income flow regime, gender disparities and access to fuel for cooking. Overall, there is low intake of animal protein and generally constrained access to adequate amount of food required for normal growth and development. At multivariate level, the main risk factors included; lack of information on child health feeding, socio-economic capacity of household, poor hygiene practices, and preparation of special foods for children. Results suggest that more emphasis needs to be put on community nutrition and health education with a focus on diet, hygiene, sanitation, social-economic and livelihood programs, improvement of health care services and diversification of interventions especially into poverty alleviation programs with a nutrition focus.Key words: Stunting, young children, nutrition, Ugand

Secondary hyperparathyroidism among Nigerians with chronic kidney disease

Backround: Secondary hyperparathyroidism (SHPT) is a manifestation of chronic kidney disease mineral bone disorder (CKD-MBD). SHPT is common in patients with chronic kidney disease (CKD) and is associated with significant morbidity and mortality.Methods: A cross- sectional descriptive study involving 230 patients with CKD. Results: The mean age of the study population was 44.17±15.24 years. The median intact parathyroid hormone and alkaline phosphatase levels were 96pg/ml (range 4-953pg/ml) and 88 iu/l (range 10-800 iu/l) respectively. The mean (with standard deviation) calcium, serum phosphate, calcium phosphate product and haemoglobin levels were 2.22±0.29mmol/l, 1.8±0.62mmol/l, 3.94±1.42mmol2/l2 and 9.90±1.87g/dl respectively. Majority of patients had advanced CKD with 70.3% of patients in stage G5. The prevalence rates of SHPT, hypocalcaemia, hyperphosphataemia, elevated alkaline phosphatase and elevated calcium phosphate product were 55.2%, 34.8%, 66.1%, 42.2% and 25.2% respectively. Univariate analysis revealed that SHPT was associated with hypocalcaemia, hyperphosphataemia, elevated alkaline phosphatase, proteinuria, anaemia, hypertension, left ventricular hypertrophy and stage of kidney disease; being worse with advancing kidney disease. Independently associated with SHPT were hypocalcaemia (OR=4.84), hyperphosphataemia (OR=3.06), and elevated alkaline phosphatase (OR=2.04).Conclusion: The prevalence of SHPT in CKD is high, occurs early and is independently associated with hypocalcaemia, hyperphosphataemia and elevated alkaline phosphatase. The prevalence of SHPT also increases with worsening renal function.Keywords: Secondary hyperparathyroidism, chronic kidney disease, intact parathyroid hormone, hypocalcaemia, hyperphosphataemia, elevated alkaline phosphatase

Vδ2+ T cell response to malaria correlates with protection from infection but is attenuated with repeated exposure.

Vδ2+ γδ T cells are semi-innate T cells that expand markedly following P. falciparum (Pf) infection in naïve adults, but are lost and become dysfunctional among children repeatedly exposed to malaria. The role of these cells in mediating clinical immunity (i.e. protection against symptoms) to malaria remains unclear. We measured Vδ2+ T cell absolute counts at acute and convalescent malaria timepoints (n = 43), and Vδ2+ counts, cellular phenotype, and cytokine production following in vitro stimulation at asymptomatic visits (n = 377), among children aged 6 months to 10 years living in Uganda. Increasing age was associated with diminished in vivo expansion following malaria, and lower Vδ2 absolute counts overall, among children living in a high transmission setting. Microscopic parasitemia and expression of the immunoregulatory markers Tim-3 and CD57 were associated with diminished Vδ2+ T cell pro-inflammatory cytokine production. Higher Vδ2 pro-inflammatory cytokine production was associated with protection from subsequent Pf infection, but also with an increased odds of symptoms once infected. Vδ2+ T cells may play a role in preventing malaria infection in children living in endemic settings; progressive loss and dysfunction of these cells may represent a disease tolerance mechanism that contributes to the development of clinical immunity to malaria

The impact of advocacy and community mobilization on the utilization of health services at the Comprehensive Health Centre, Gindiri.

Primary Health Care facilities provide promotive, preventive, curative and rehabilitative services to a community. They may be well built and equipped with adequate resources but grossly underutilized due to several factors. Health records at the Comprehensive Health Centre Gindiri for 2005 were compared with those of 2007 after a wellcoordinated advocacy and mobilization programme in that community. The results show that the total out patient attendance in 2007 increased by 220.6% when compared to that of 2005. 293 patients were admitted into the wards in 2005 compared to 813 in 2007(277%). There was no surgery carried out in the whole of 2005, whereas in 2007 there were 98 surgeries. Advocacy and community mobilization could be important factors in the utilization of primary health service

Transcriptional profiling of cattle infected with Trypanosoma congolense highlights gene expression signatures underlying trypanotolerance and trypanosusceptibility

<p>Abstract</p> <p>Background</p> <p>African animal trypanosomiasis (AAT) caused by tsetse fly-transmitted protozoa of the genus <it>Trypanosoma </it>is a major constraint on livestock and agricultural production in Africa and is among the top ten global cattle diseases impacting on the poor. Here we show that a functional genomics approach can be used to identify temporal changes in host peripheral blood mononuclear cell (PBMC) gene expression due to disease progression. We also show that major gene expression differences exist between cattle from trypanotolerant and trypanosusceptible breeds. Using bovine long oligonucleotide microarrays and real time quantitative reverse transcription PCR (qRT-PCR) validation we analysed PBMC gene expression in naïve trypanotolerant and trypanosusceptible cattle experimentally challenged with <it>Trypanosoma congolense </it>across a 34-day infection time course.</p> <p>Results</p> <p>Trypanotolerant N'Dama cattle displayed a rapid and distinct transcriptional response to infection, with a ten-fold higher number of genes differentially expressed at day 14 post-infection compared to trypanosusceptible Boran cattle. These analyses identified coordinated temporal gene expression changes for both breeds in response to trypanosome infection. In addition, a panel of genes were identified that showed pronounced differences in gene expression between the two breeds, which may underlie the phenomena of trypanotolerance and trypanosusceptibility. Gene ontology (GO) analysis demonstrate that the products of these genes may contribute to increased mitochondrial mRNA translational efficiency, a more pronounced B cell response, an elevated activation status and a heightened response to stress in trypanotolerant cattle.</p> <p>Conclusion</p> <p>This study has revealed an extensive and diverse range of cellular processes that are altered temporally in response to trypanosome infection in African cattle. Results indicate that the trypanotolerant N'Dama cattle respond more rapidly and with a greater magnitude to infection compared to the trypanosusceptible Boran cattle. Specifically, a subset of the genes analyzed by real time qRT-PCR, which display significant breed differences, could collectively contribute to the trypanotolerance trait in N'Dama.</p

Phenotypic diversity within Ugandan yam (Dioscorea species) germplasm collection

Open Access JournalA proper understanding of the diversity of the available germplasm is an initial step for the genetic improvement of a crop through breeding. However, there is limited information on the diversity of Uganda’s yam germplasm. The study sought to characterize the diversity of yam germplasm utilized for decades in Uganda together with germplasm recently introduced from West Africa using phenotypic traits. A germplasm collection of 291 genotypes was characterized using 28 phenotypic traits. Data were subjected to multivariate analysis using principal component analysis and cluster analysis. The traits assessed were informative and discriminating, with 62% of the total variation explained among the first six principal components. Results showed that the important phenotypic traits contributing to most of the variability among the genotypes were leaves, flowering, and tuber traits. Ugandan genotypes were identified with amorphous tuber shapes compared to West African genotypes. The study has shown that there is ample phenotypic variability within the major yam genotypes in Uganda yam germplasm that can be used for genetic improvement. More in-depth molecular and biochemical studies to further understand the diversity are recommended. The preprint was made available by research square in the following link: “https://www.researchsquare.com/article/rs-1518551/v1.

Treatment Outcomes in a Decentralized Antiretroviral Therapy Program: A Comparison of Two Levels of Care in North Central Nigeria

Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug naïve patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (P < 0.001) and 24 weeks (P < 0.001) with similar responses at 48 weeks (P = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (P < 0.001) and 48 weeks (P = 0.03), but similar responses at 24 weeks (P = 0.21). Mortality was 2.3% versus 5.0% (P < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (P = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care

Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system.

OBJECTIVE: To determine the ability to accurately diagnose acute rheumatic fever (ARF) given the resources available at three levels of the Ugandan healthcare system. METHODS: Using data obtained from a large epidemiological database on ARF conducted in three districts of Uganda, we selected variables that might positively or negatively predict rheumatic fever based on diagnostic capacity at three levels/tiers of the Ugandan healthcare system. Variables were put into three statistical models that were built sequentially. Multiple logistic regression was used to estimate ORs and 95% CI of predictors of ARF. Performance of the models was determined using Akaike information criterion, adjusted R2, concordance C statistic, Brier score and adequacy index. RESULTS: A model with clinical predictor variables available at a lower-level health centre (tier 1) predicted ARF with an optimism corrected area under the curve (AUC) (c-statistic) of 0.69. Adding tests available at the district level (tier 2, ECG, complete blood count and malaria testing) increased the AUC to 0.76. A model that additionally included diagnostic tests available at the national referral hospital (tier 3, echocardiography, anti-streptolysin O titres, erythrocyte sedimentation rate/C-reactive protein) had the best performance with an AUC of 0.91. CONCLUSIONS: Reducing the burden of rheumatic heart disease in low and middle-income countries requires overcoming challenges of ARF diagnosis. Ensuring that possible cases can be evaluated using electrocardiography and relatively simple blood tests will improve diagnostic accuracy somewhat, but access to echocardiography and tests to confirm recent streptococcal infection will have the greatest impact