Tackling sexually transmitted infection burden in Ugandan communities living in the United Kingdom: a qualitative analysis of the socio-cultural interpretation of disease and condom use

Background: Despite being in a different country and social environment, Ugandans living in the UK still reportedly have the lowest rates of condom usage and one of the highest incidences of STIs in UK. In Uganda, STIs and HIV prevalence has been reported to be on the increase. Understanding peoples\u2019 beliefs and the attitudes that influence their behavior is a key factor to effectively designing control programs. Methods: A qualitative study that interviewed 37 purposively selected Ugandans living in the UK was conducted. Lay theories and interpretations were derived using thematic analysis. Results: Condoms generally carried a lot of stigma and were perceived for use primarily in extramarital affairs and pregnancy control. HIV/AIDS was most feared due to its perceived socio-psychological or physical effects unlike other STIs described as \u201cnon-threatening\u201d due to wide availability of \u201cquality\u201d treatment in UK. Notions of trust, the purpose of relationships, symptom recognition and partner selection greatly influenced decisions to undertake consistent condom use. Conclusions: The socio-cultural understanding of STIs, sex, trust and relationships are symbolic in influencing consistent condom use among Ugandans. This indicates a need to acknowledge community beliefs and values about sexual health and design messages about STIs and condoms that would help eliminate these serious condom-related misconceptions

Sublingual misoprostol versus intramuscular oxytocin for prevention of postpartum hemorrhage in Uganda: a double-blind randomized non-inferiority trial

Background: Postpartum hemorrhage (PPH) is a leading cause of maternal death in sub-Saharan Africa. Although the World Health Organization recommends use of oxytocin for prevention of PPH, misoprostol use is increasingly common owing to advantages in shelf life and potential for sublingual administration. There is a lack of data about the comparative efficacy of oxytocin and sublingual misoprostol, particularly at the recommended dose of 600 mu g, for prevention of PPH during active management of labor. Methods and Findings: We performed a double-blind, double-dummy randomized controlled non-inferiority trial between 23 September 2012 and 9 September 2013 at Mbarara Regional Referral Hospital in Uganda. We randomized 1,140 women to receive 600 mu g of misoprostol sublingually or 10 IU of oxytocin intramuscularly, along with matching placebos for the treatment they did not receive. Our primary outcome of interest was PPH, defined as measured blood loss >= 500 ml within 24 h of delivery. Secondary outcomes included measured blood loss >= 1,000 ml; mean measured blood loss at 1, 2, and 24 h after delivery; death; requirement for blood transfusion; hemoglobin changes; and use of additional uterotonics. At 24 h postpartum, primary PPH occurred in 163 (28.6%) participants in the misoprostol group and 99 (17.4%) participants in the oxytocin group (relative risk [RR] 1.64, 95% CI 1.32 to 2.05, p<0.001; absolute risk difference 11.2%, 95% CI 6.44 to 16.1). Severe PPH occurred in 20 (3.6%) and 15 (2.7%) participants in the misoprostol and oxytocin groups, respectively (RR 1.33, 95% CI 0.69 to 2.58, p = 0.391; absolute risk difference 0.9%, 95% CI -1.12 to 2.88). Mean measured blood loss was 341.5 ml (standard deviation [SD] 206.2) and 304.2 ml (SD 190.8, p = 0.002) at 2 h and 484.7 ml (SD 213.3) and 432.8 ml (SD 203.5, p<0.001) at 24 h in the misoprostol and oxytocin groups, respectively. There were no significant differences between the two groups in any other secondary outcomes. Women in the misoprostol group more commonly experienced shivering (RR 1.91, 95% CI 1.65 to 2.21, p<0.001) and fevers (RR 5.20, 95% CI 3.15 to 7.21, p = 0.005). This study was conducted at a regional referral hospital with capacity for emergency surgery and blood transfusion. High-risk women were excluded from participation. Conclusions: Misoprostol 600 mu g is inferior to oxytocin 10 IU for prevention of primary PPH in active management of labor. These data support use of oxytocin in settings where it is available. While not powered to do so, the study found no significant differences in rate of severe PPH, need for blood transfusion, postpartum hemoglobin, change in hemoglobin, or use of additional uterotonics between study groups. Further research should focus on clarifying whether and in which sub-populations use of oxytocin would be preferred over sublingual misoprostol

The role of mobile health technologies in promoting COVID-19 prevention

Background: Researchers have found innovative ways of using mobile health (mHealth) technologies to prevent the spread of coronavirus disease 2019 (COVID-19). However, fewer studies have been done to determine their adoption and effectiveness. Objective: This review summarises the published evidence on the effect of mHealth technologies on the adoption of COVID-19 preventive measures, prevention knowledge acquisition and risk perception as well as technology adoption features for COVID-19 prevention. Methods: PubMed, IEEE and Google Scholar databases were searched for peer-reviewed literature from 1 January 2020 to 31 March 2022 for studies that evaluated the effect of mHealth technologies on COVID-19 preventive measures adoption, prevention knowledge acquisition and risk perception. Thirteen studies met the inclusion criteria and were included in this review. All the included studies were checked for quality using the mHealth evidence reporting and assessment (mERA) checklist. Results: The review found out that the utilisation of mHealth interventions such as alert text messages, tracing apps and social media platforms was associated with adherence behaviour such as wearing masks, washing hands and using sanitisers, maintaining social distance and avoiding crowded places. The use of contact tracing was linked to low-risk perception as users considered themselves well informed about their status and less likely to pose transmission risks compared to non-users. Privacy and security issues, message personalisation and frequency, technical issues and trust concerns were identified as technology adoption features that influence the use of mHealth technologies for promoting COVID-19 prevention. Conclusion: Utilisation of mHealth may be a feasible and effective way to prevent the spread of COVID-19. However, the small study samples and short study periods prevent generalisation of the findings and calls for larger, longitudinal studies that encompass diverse study settings.Peer Reviewe

Functionality and acceptability of a wireless fetal heart rate monitoring device in term pregnant women in rural Southwestern Uganda

Background: Over 3 million stillbirths occur annually in sub Saharan Africa; most occur intrapartum and are largely preventable. The standard of care for fetal heart rate (FHR) assessment in most sub-Saharan African settings is a Pinard Stethoscope, limiting observation to one person, at one point in time. We aimed to test the functionality and acceptability of a wireless FHR monitor that could allow for expanded monitoring capacity in rural Southwestern Uganda. Methods: In a mixed method prospective study, we enrolled 1) non-laboring healthy term pregnant women to wear the device for 30 min and 2) non-study clinicians to observe its use. The battery-powered prototype uses Doppler technology to measure fetal cardiotocographs (CTG), which are displayed via an android device and wirelessly transmit to cloud storage where they are accessible via a password protected website. Prototype functionality was assessed by the ability to obtain and transmit a 30-min CTG. Three obstetricians independently rated CTGs for readability and agreement between raters was calculated. All participants completed interviews on acceptability. Results: Fifty pregnant women and 7 clinicians were enrolled. 46 (92.0%) CTGs were successfully recorded and stored. Mean scores for readability were 4.71, 4.71 and 4.83 (out of 5) with high agreement (intra class correlation 0.84; 95% CI 0.74 to 0.91). All pregnant women reported liking or really liking the device, as well as high levels of comfort, flexibility and usefulness of the prototype; all would recommend it to others. Clinicians described the prototype as portable, flexible, easy-to-use and a time saver. Adequate education for clinicians and women also seemed to improve correct usage and minimise concerns on safety of the device. Conclusions: This prototype wireless FHR monitor functioned well in a low-resource setting and was found to be acceptable and useful to both pregnant women and clinicians. The device also seemed to have potential to improve the experience of the users compared with standard of care and expand monitoring capacity in settings where bulky, wired or traditional equipment are unreliable. Further research needs to investigate the potential impact and cost of such innovations to improve perinatal outcomes

Incidence and Factors Associated with Postpartum Anemia at Mbarara Regional Referral Hospital

Background: The World Health organization defines postpartum anemia as hemoglobin &lt;11g/dl at 1 week postpartum and &lt;12g/dl at 8 weeks postpartum. Postpartum anemia can also be defined as less than 11.8 g/dl for women aged 12–15 years and less than 12g/dl for women at least age 15 years. In Uganda, 23% of women age 15-49 are anemic, with 18 percent having mild anemia, 5 percent having moderate anemia, and less than 1 percent having severe anemia. Objective: To determine the incidence and factors associated with the new cases of post natal anemia in Mbarara Regional Referral Hospital. Methods:  A prospective cohort study of 271 postpartum mothers without anemia enrolled on discharge after delivery. Participants were followed up to determine development of anemia at 10 weeks postpartum and associated factors on the subsequent postnatal visits. Incidence of postpartum anemia in MRRH was 29.9%, 95% CI (24 - 35). Helminthes infestations AOR95%CI; 12.88(5.25- 31.64, P&lt;0.000), malaria infections AOR95%CI 4.74(1.50-14.94, P=0.008), poor hematinic adherence AOR95%CI, 6.81(3.17-14.62, P&lt;0.000), high parity AOR95%CI, 2.48(1.11- 5.54, P=0.026), and husband unemployment AOR 3.92(1.14 – 13.39, P=0.030) were found to be statistically associated with post-partum anemia. Conclusion: The incidence of postpartum anemia in Mbarara Regional Referral Hospital is very high. Hematinics non adherence, husband unemployment, increased parity; malaria infection and helminthes infestation were found to be associated with post-partum anemia at MRRH

Changes over time in creatinine clearance and comparison of emergent adverse events for HIV-positive adults receiving standard doses (300 mg/day) of lamivudine-containing antiretroviral therapy with baseline creatinine clearance of 30-49 vs ≥50 mL/min.

A retrospective analysis of the randomized controlled DART (Development of AntiRetroviral Therapy in Africa; ISRCTN13968779) trial in HIV-1-positive adults initiating antiretroviral therapy with co-formulated zidovudine/lamivudine plus either tenofovir, abacavir, or nevirapine was conducted to evaluate the safety of initiating standard lamivudine dosing in patients with impaired creatinine clearance (CLcr). Safety data collected through 96 weeks were analyzed after stratification by baseline CLcr (estimated using Cockcroft-Gault) of 30-49 mL/min (n = 168) versus ≥50 mL/min (n = 3,132) and treatment regimen. The Grade 3-4 adverse events (AEs) and serious AEs (for hematological, hepatic and gastrointestinal events), maximal toxicities for liver enzymes, serum creatinine and bilirubin and maximum treatment-emergent hematology toxicities were comparable for groups with baseline CLcr 30-49 versus CLcr≥50 mL/min. No new risks or trends were identified from this dataset. Substantial and similar increases in the mean creatinine clearance (>25 mL/min) were observed from baseline though Week 96 among participants who entered the trial with CLcr 30-49 mL/min, while no increase or smaller median changes in creatinine clearance ( 150 cells/ mm3) in mean CD4+ cells counts from baseline to Week 96 were also observed for participants who entered the trial with CLcr 30-49 mL/min and those with baseline CLcr ≥50 mL/min. Though these results are descriptive, they suggest that HIV-positive patients with CLcr of 30-49 mL/min would have similar AE risks in comparison to patients with CLcr ≥50 mL/min when initiating antiretroviral therapy delivering doses of 300 mg of lamivudine daily through 96 weeks of treatment. Overall improvements in CLcr were observed for patients with baseline CLcr 30-49 mL/min

Bridging the data gap in global health: an electronic surgical outcomes database at Mbarara Regional Referral Hospital, Uganda

Background: Annually, an estimated 17 million lives are lost from conditions requiring surgical care and at least 77·2 million disability-adjusted life-years could be averted through provision of basic surgical services. Despite the staggering burden of surgical disease, there are scarce data available to track current capacity, volume, epidemiology, outcomes, and quality of surgical care delivery in low-income and middle-income countries. We aimed to organise the hospital record system into a high-quality and high-fidelity searchable database that can be used to measure and guide expansion and provision of quality care at Mbarara Regional Referral Hospital (MRRH) in western Uganda. Methods: Initiated in 2013, the Surgical Services QUality Assessment Database (SQUAD) arose from a shared commitment to improving surgical quality and capacity through a collaboration between MRRH and Massachusetts General Hospital. SQUAD systematically enrols and collects data on all surgical patients admitted to MRRH. Data are extracted from patient charts and admission, discharge, and operation logbooks by trained clerks—a process overseen by a data manager/statistician. Data variables are grouped into patient demographics, disease characteristics, cadre of clinicians, interventions, outcomes, and time. Data access and use is supervised by a committee of representatives. Findings: To date, SQUAD contains more than 49 000 patient records in a searchable electronic database. Quality assurance reports have been produced for internal use at MRRH, and in-hospital initiatives have been made in response to findings. SQUAD was prospectively validated in 2016, and retrospective validation studies are currently underway. Interpretation: Ongoing challenges include transitioning data capture methods from chart and log book review to a point-of-care electronic medical register and record system, while maintaining data entry. A future objective is the dissemination of clinical outcome reports through peer reviewed publications by authors from the collaborating institutions. Funding: GE Foundation, Milton Foundation, Kletjian Foundation, and MGH Department of Anesthesia, Critical Care and Pain Medicine

Women’s Choice to Deliver at Home: Understanding the Psychosocial and Cultural Factors Influencing Birthing Choices for Unskilled Home Delivery among Women in Southwestern Uganda

Background. Utilization of perinatal services in Uganda remains low, with correspondingly high rates of unskilled home deliveries, which can be life-threatening. We explored psychosocial and cultural factors influencing birthing choices for unskilled home delivery among postpartum women in rural southwestern Uganda. Methods. We conducted in-depth qualitative face-to-face interviews with 30 purposively selected women between December 2018 and March 2019 to include adult women who delivered from their homes and health facility within the past three months. Women were recruited from 10 villages within 20 km from a referral hospital. Using the constructs of the Health Utilization Model (HUM), interview topics were developed. Interviews were conducted and digitally recorded in a private setting by a native speaker to elicit choices and experiences during pregnancy and childbirth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive categories using inductive content analytic approach. Results. Eighteen women (60%) preferred to deliver from home. Women’s referent birth location was largely intentional. Overall, the data suggest women choose home delivery (1) because of their financial dependency and expectation for a “natural” and normal childbirth, affecting their ability and need to seek skilled facility delivery; (2) as a means of controlling their own birth processes; (3) out of dissatisfaction with facility-based care; (4) out of strong belief in fate regarding birth outcomes; (5) because they have access to alternative sources of birthing help within their communities, perceived as “affordable,” “supportive,” and “convenient”; and (6) as a result of existing gender and traditional norms that limit their ability and freedom to make family or health decisions as women. Conclusion. Women’s psychosocial and cultural understandings of pregnancy and child birth, their established traditions, birth expectations, and perceptions of control, need, and quality of maternity care at a particular birthing location influenced their past and future decisions to pursue home delivery. Interventions to address barriers to healthcare utilization through a multipronged approach could help to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial.

BackgroundUnwanted pregnancies remain a burden for women living with HIV (WLWH). Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health. We evaluated the effect of a family planning voucher, inclusive of immediate postpartum counseling, on uptake, early initiation, and continuation of modern contraceptive methods among recently postpartum WLWH delivering at a publicly funded regional referral hospital in rural, southwestern Uganda.Methods and findingsWe performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis includes adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrollment and 6 months postpartum. Our primary outcome of interest for this analysis is initiation of a modern family planning method within 8 weeks postpartum. Secondary outcomes included family planning initiation at 12, 14, 16, and 20 weeks postpartum, family planning discontinuation and/or change, pregnancy incidence, and mean time without contraception. The trial was registered with clinicaltrials.gov (NCT02964169). At enrollment, half of the women in both the voucher (N = 87, 55%) and control (N = 86, 54%) groups wanted to have a child in 2 years postpartum. Over 80% of referent pregnancies in the voucher (N = 136, 86%) and control (N = 128, 81%) groups were planned. All women were accessing ART. The mean CD4 count was 396 cells/mm3 (SD = 61) for those enrolled in the control group versus 393 cells/mm3 (SD = 64) in the family planning voucher group. By 8 weeks postpartum, family planning was initiated in 144 (91%) participants in the voucher group and 83 (52%) participants in the control group (odds ratio [OR] 9.42; CI 4.67-13.97, P ConclusionThese findings indicate that a well-structured, time-bound family planning voucher program appeared to increase early postpartum contraceptive uptake and continuation in a setting in which users are faced with financial, knowledge, and structural barriers to contraceptive services. Further work should clarify the role of vouchers in empowering WLWH to avoid unintended pregnancies over time.Trial registrationClinicalTrials.gov NCT02964169