Integrated community case management of malaria and pneumonia in eastern Uganda : care-seeking, adherence, and community health worker performance

Background: Despite being easily preventable and treatable, malaria and pneumonia are major killers of children aged less than five years. Integrated community based interventions through which lay persons called community health workers (CHWs) can manage malaria, pneumonia, diarrhea and neonatal conditions are recommended by WHO and UNICEF. However, there is limited information on care-seeking and performance of CHWs in the context of integrated illness management. Main aim: To assess care-seeking and quality of care in integrated community case management of malaria and pneumonia in children aged less than five years in Uganda so as to inform the implementation of integrated community case management of childhood illness strategy (ICCM). Methods: Four studies (I-IV) were nested in a cluster randomized trial in Iganga-Mayuge demographic surveillance site in eastern Uganda. In this trial CHWs treated malaria and pneumonia (intervention arm) or malaria alone (control arm) in children aged 4-59 months. Performance of CHWs (I) was assessed using: questionnaires (with knowledge tests, case scenarios) and record reviews for 125 CHWs; observations among 57 CHWs in the intervention arm; and four focus group discussions with CHWs. Adherence to treatment was assessed using pill counts and caregiver reports among 1256 children treated by CHWs (II). Receipt of prompt and appropriate antibiotics for pneumonia symptoms and treatment outcomes were assessed among 1276 children treated by CHWs (III). Care-seeking and management of malaria and pneumonia were assessed among 1095 children and from 13 key informant interviews (IV). Results: Care-seeking from CHWs was higher in the intervention than the control arm (31% vs 22%, p=0.01) (IV). CHWs’ performance on malaria symptoms was similar in the intervention and control arms on: overall knowledge, eliciting signs and symptoms, and prescribing (I). More children treated by CHWs received prompt and appropriate malaria treatment compared to other health providers (37% vs 9%, p<0.001) (IV). CHWs had high scores in prescribing for pneumonia but had lower: overall knowledge of pneumonia (40%), and scores on eliciting pneumonia signs and symptoms (25%). Only 35% of CHWs counted respiratory rates within two breaths of rates counted by the physician, and 12% of children without fast breathing received antibiotics while 82% with fast breathing received antibiotics (I). Children treated by CHWs in the intervention arm were more likely to receive prompt and appropriate antibiotics for pneumonia symptoms compared to the control arm (RR=3.51, 95% CI = 1.75-7.03) (III). There was also a higher reduction in the proportion of children with fast breathing from day one to day four in the intervention compared to the control arm (9.2% vs 4.2%, p=0.01); and a lower proportion of febrile children on day four (1% vs 4%; RR=0.29, 95% CI = 0.11-0.78) (III). Adherence to combined antimalarials and antibiotics was similar to adherence to antimalarials alone in the intervention arm (mean 99% both groups) (II). Conclusions: CHWs’ performance on malaria was not affected by additional roles of pneumonia management, but they had challenges in assessment of pneumonia symptoms. CHWs should be supported with continued training, adequate supervision and provision of drugs, diagnostics and other supplies

Appointment keeping for medical review among patients with selected chronic diseases in an urban area of Uganda

Introduction: proper management of chronic diseases is important for prevention of disease   complications and yet some patients miss appointments for medical review thereby missing the   opportunity for proper monitoring of their disease conditions. There is limited information on missed  appointments among chronic disease patients in resource limited settings. This study aimed to   determine the prevalence of missed appointments for medical review and associated factors among  chronic disease patients in an urban area of Uganda.Methods: patients or caregivers of children with chronic diseases were identified as they bought  medicines from a community pharmacy. They were visited at home to access their medical documents  and those whose chronic disease status was ascertained were enrolled. The data was collected using: questionnaires, review of medical documents, and in-depth interviews with chronic disease patients. Results: the prevalence of missed appointments was 42% (95%CI=35-49%). The factors associated with missed appointments were: monthly income ?30US Dollars (OR=2.56, CI=1.25–5.26), affording less than half of prescribed drugs (OR=3.92, CI=1.64–9.40), not experiencing adverse events (OR=2.66, CI=1.26–5.61), not sure if treatment helps (OR=2.84, CI=1.047.77), not having a medicines   administration schedule (OR=6.77, CI=2.11–21.68), and increasing number of drugs (OR=0.72,  CI=0.53–0.98).Conclusion: patients missed appointments mainly due to: financial and health system barriers,  conflicting commitments with appointments, and perceptions of the disease condition. Patients should be supported with accessible and affordable health servicesKey words: Chronic disease, medical review appointments, missed appointment

Integrated community case management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms in children under five years in Eastern Uganda

BACKGROUND: Efforts to improve access to treatment for common illnesses in children less than five years initially targeted malaria alone under the home management of malaria strategy. However under this strategy, children with other illnesses were often wrongly treated with anti-malarials. Integrated community case management of common childhood illnesses is now recommended but its effect on promptness of appropriate pneumonia treatment is unclear. OBJECTIVES: To determine the effect of integrated malaria and pneumonia management on receiving prompt and appropriate antibiotics for pneumonia symptoms and treatment outcomes as well as determine associated factors. METHODS: A follow-up study was nested within a cluster-randomized trial that compared under-five mortality in areas where community health workers (CHWs) treated children with malaria and pneumonia (intervention areas) and where they treated children with malaria only (control areas). Children treated by CHWs were enrolled on the day of seeking treatment from CHWs (609 intervention, 667 control) and demographic, illness, and treatment seeking information was collected. Further information on illness and treatment outcomes was collected on day four. The primary outcome was prompt and appropriate antibiotics for pneumonia symptoms and the secondary outcome was treatment outcomes on day four. RESULTS: Children in the intervention areas were more likely to receive prompt and appropriate antibiotics for pneumonia symptoms compared to children in the control areas (RR = 3.51, 95%CI = 1.75-7.03). Children in the intervention areas were also less likely to have temperature ≥37.5°C on day four (RR = 0.29, 95%CI = 0.11-0.78). The decrease in fast breathing between day one and four was greater in the intervention (9.2%) compared to the control areas (4.2%, p-value = 0.01). CONCLUSIONS: Integrated community management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms and improves treatment outcomes. TRIAL REGISTRATION: ISRCTN: ISRCTN5296623

An assessment of Makerere University College of Health Sciences: optimizing health research capacity to meet Uganda’s priorities

<p>Abstract</p> <p>Background</p> <p>Health research is critical to the institutional mission of the Makerere College of Health Sciences (MakCHS). Optimizing the alignment of health research capacity at MakCHS with the health needs and priorities of Uganda, as outlined in the country’s Health Sector Strategic Plan (HSSP), is a deliberate priority, a responsibility, and a significant opportunity for research. To guide this strategic direction, an assessment of MakCHS’s research grants and publication portfolio was conducted.</p> <p>Methods</p> <p>A survey of all new and ongoing grants, as well as all publications, between January 2005 and December 2009 was conducted. Research, training, and education grants awarded to MakCHS’ constituent faculties and departments, were looked for through financial records at the college or by contact with funding organizations. Published manuscripts registered with PubMed, that included MakCHS faculty authors, were also analyzed.</p> <p>Results</p> <p>A total of 58 active grants were identified, of which 18 had been initiated prior to 2005 and there were an average of about eight new grants per year. Most grants funded basic and applied research, with major focus areas being HIV/AIDS (44%), malaria (19%), maternal and child health (14%), tuberculosis (11%), mental health (3%), and others (8%). MakCHS faculty were identified as Principal Investigators (PIs) in only 22 (38%) active grants. Grant funding details were only available for one third of the active grants at MakCHS. A total of 837 publications were identified, with an average of 167 publications per year, most of which (66%) addressed the country’s priority health areas, and 58% had MakCHS faculty or students as first authors.</p> <p>Conclusions</p> <p>The research grants and publications at MakCHS are generally well-aligned with the Ugandan Health Ministry priorities. Greater efforts to establish centralized and efficient grants management procedures are needed. In addition, greater efforts are needed to expand capacity for MakCHS faculty leadership of grants, as well as to continue to expand the contribution of MakCHS faculty to lead research publications.</p

Association between invasive cancer of the cervix and HIV-1 infection in Tanzania: the need for dual screening

<p>Abstract</p> <p>Background</p> <p>Cancer of the cervix is the second commonest malignancy in females worldwide and is the leading malignancy among women in Tanzania. Cancer of the cervix has been strongly associated with Human Papilloma Virus (HPV) which is a sexually transmitted disease. However, the role of HIV-1 in the aetiology of cancer of the cervix is less clear. Studies suggest that HPV and HIV-1 infection are synergistic and therefore their dual occurrence may fuel increased incidence of cancer of the cervix and AIDS. We therefore conducted a study to determine the association between cancer of the cervix and HIV-1.</p> <p>Methods</p> <p>The study was carried out in Ocean Road Cancer Institute, Dar-es-salaam, Tanzania between January and March 2007. A hospital-based case control design was used to study 138 cases and 138 controls. The cases were consenting women 18 years and above with histologically confirmed squamous cell carcinoma of the cervix, while the controls were consenting non-cancer adult women attendants or visitors. The participants were counselled and tested for HIV-1 and interviewed to assess risk factors for cancer of the cervix and HIV-1. Estimation of risk was done by computing odds ratios and confidence intervals. Confounding and interaction between the factors were assessed using logistic regression.</p> <p>Results</p> <p>HIV-1 prevalence was much higher among the cases (21.0%) than among the controls (11.6%). In logistic regression, HIV-1 was associated with cancer of the cervix (OR = 2.9, 95% CI = 1.4–5.9). Among the cases the mean age was lower for HIV-1 infected (44.3 years) than HIV-1 uninfected women (54 years, p = 0.0001).</p> <p>Conclusion</p> <p>HIV-1 infection is associated with invasive cancer of the cervix. Resource-constrained countries with a high burden of HIV-1 and cervical cancer should adopt a high-risk approach that targets HIV-1 positive women for screening of cervical cancer initially by utilizing HIV/AIDS resources.</p

High burden of pulmonary tuberculosis and missed opportunity to initiate treatment among children in Kampala, Uganda

Background: There is uncertainty about the actual burden of childhood TB in Uganda, but underestimation is acknowledged. We aimed at determining prevalence, factors associated with PTB among children attending PHC facilities in Kampala. Methods: This was a cross-sectional study of 255 children, with presumed TB, attending six health facilities in Kampala, Uganda, in March 2015. Socio-demographic, clinical, and laboratory data were collected using a questionnaire. TB was diagnosed using “Desk Guide” algorithms. Sputum based on ZN/FM and/or Gene-Xpert. Logistic regression was used to assess associations with outcomes. Results: Overall, prevalence of PTB 13.7 % (2.6 – 24.8). Among HIV-positive, the prevalence of PTB was 41.7%, while among malnourished children, 21.7% and contacts, 89.3%. The factors that influenced PTB included: tobacco smoker at home (OR =1.6, 95 % CI: 1.07 – 6.86), stunting (OR = 2.2, 95 % CI: 1.01 – 4.15). Only 5.3% of the smear-negative TB children and 81.3% of the smear-positive children were initiated on treatment within a month of diagnosis. Conclusion: Clinical TB among children is underdiagnosed and undertreated. There is a need for more sensitive and specific diagnostic tests, need ways to disseminate and promote uptake of standardized clinical algorithms. Also, contact TB tracing should be strengthened so that such cases can be actively detected even at community level. Keywords: Pediatric; pulmonary; tuberculosis

The effect of AIDS defining conditions on immunological recovery among patients initiating antiretroviral therapy at Joint Clinical Research Centre, Uganda

<p>Abstract</p> <p>Background</p> <p>Many HIV-infected patients only access health care once they have developed advanced symptomatic disease resulting from AIDS Defining Conditions (ADCs). We carried out a study to establish the effect of ADCs on immunological recovery among patients initiated on antiretroviral therapy (ART).</p> <p>Methods</p> <p>A retrospective cohort of 427 HIV-1 patients who were initiated on ART between January 2002 and December 2006 was studied. Data on ADCs was retrieved from Joint Clinical Research Centre (JCRC) data base and backed up by chart reviews. We employed Kaplan-Meier survival curves to estimate median time to 50 CD4 cells/μl from the baseline value to indicate a good immunological recovery process. Cox proportional hazard models were used at multivariate analysis.</p> <p>Results</p> <p>The median time to gaining 50 CD4 cells/μl from the baseline value after ART initiation was longer in the ADC (9.3 months) compared to the non-ADC group (6.9 months) (log rank test, p = 0.027). At multivariate analysis after adjusting for age, sex, baseline CD4 count, baseline HIV viral load, total lymphocyte count and adherence level, factors that shortened the median time to immunological recovery after ART initiation were belonging to the non-ADC group (HR = 1.31; 95% CI: 1.03–1.28, p = 0.028), adherence to ART of ≥ 95% (HR = 2.22; 95% CI: 1.57–3.15, p = 0.001) and a total lymphocyte count ≥ 1200 cells/mm³(HR = 1.84; 95% CI: 1.22–2.78, p = 0.003). A low baseline CD4 count of ≤ 200 cells/μl (HR = 0.52; 95% CI: 0.37–0.77, p = 0.001) was associated with a longer time to immunological recovery. There was no interaction between low CD4 counts and ADC group.</p> <p>Conclusion</p> <p>Patients with ADCs take longer to regain their CD4 counts due to the defect in the immune system. This may prolong their risk of morbidity and mortality.</p

Perinatal care in Western Uganda: Prevalence and factors associated with appropriate care among women attending three district hospitals

Background: Perinatal mortality remains high globally and remains an important indicator of the quality of a health care system. To reduce this mortality, it is important to provide the recommended care during the perinatal period. We assessed the prevalence and factors associated with appropriate perinatal care (antenatal, intrapartum, and postpartum) in Bunyoro region, Uganda. Results from this study provide valuable information on the perinatal care services and highlight areas of improvement for better perinatal outcomes. Methods: A cross sectional survey was conducted among postpartum mothers attending care at three district hospitals in Bunyoro. Following consent, a questionnaire was administered to capture the participants’ demographics and data on care received was extracted from their antenatal, labour, delivery, and postpartum records using a pre-tested structured tool. The care received by women was assessed against the standard protocol established by World Health Organization (WHO). Poisson regression with robust standard errors was used to assess factors associated with appropriate postpartum care. Results: A total of 872 mothers receiving care at the participating hospitals between March and June 2020 were enrolled in the study. The mean age of the mothers was 25 years (SD = 5.95). None of the mothers received appropriate antenatal or intrapartum care, and only 3.8% of the participants received appropriate postpartum care. Factors significantly associated with appropriate postpartum care included mothers being \u3e35 years of age (adjusted prevalence ratio [aPR] = 11.9, 95% confidence interval [CI] 2.8–51.4) and parity, with low parity (2–3) and multiparous (\u3e3) mothers less likely to receive appropriate care than prime gravidas (aPR = 0.3, 95% CI 0.1–0.9 and aPR = 0.3, 95% CI 0.1–0.8 respectively). Conclusions: Antenatal, intrapartum, and postpartum care received by mothers in this region remains below the standard recommended by WHO, and innovative strategies across the continuum of perinatal care need to be devised to prevent mortality among the mothers. The quality of care also needs to be balanced for all mothers irrespective of the age and parity

Effectiveness of a mindfulness and acceptance-based intervention for improving the mental health of adolescents with HIV in Uganda: An open-label trial

Adolescents with HIV (AWH) face the double burden of dealing with challenges presented by their developmental phase while coping with stigma related to HIV, affecting their mental health. Poor mental health complicates adherence to daily treatment regimens, requiring innovative psychosocial support strategies for use with adolescents. We assessed the effectiveness of a mindfulness and acceptance-based intervention on the mental health of AWH in Uganda. One hundred and twenty-two AWH, mean age 17 ±1.59 (range 15 to 19 years), 57% female, receiving care at a public health facility in Kampala were enrolled in an open-label randomized trial (ClinicalTrials.gov: NCT05010317) with assessments at pre-and post-intervention. The mindfulness and acceptance-based intervention involved weekly 90-minute group sessions for four consecutive weeks facilitated by two experienced trainers. Sessions involved clarifying values, skillfully relating to thoughts, allowing and becoming aware of experiences non-judgmentally, and exploring life through trial and error. The control group received the current standard of care. Three mental health domains (depression, anxiety, and internalized stigma) were compared between the intervention and control groups. A linear mixed effects regression was used to analyze the effect of the intervention across the two time points. Results showed that the intervention was associated with a statistically significant reduction in symptoms of depression (β = -10.72, 95%CI: 6.25, -15.20; p < .0001), anxiety (β = -7.55, 95%CI: 2.66, -12.43; p = .0003) and stigma (β = -1.40, 95%CI: 0.66 to -2.15; p = .0004) over time. Results suggest that mindfulness and acceptance-based interventions have the potential to improve the mental health of AWH

Good adherence to HAART and improved survival in a community HIV/AIDS treatment and care programme: the experience of The AIDS Support Organization (TASO), Kampala, Uganda

BACKGROUND: Poor adherence to highly active antiretroviral therapy (HAART) may result in treatment failure and death. Most reports of the effect of adherence to HAART on mortality come from studies where special efforts are made to provide HAART under ideal conditions. However, there are few reports of the impact of non-adherence to HAART on mortality from community HIV/AIDS treatment and care programmes in developing countries. We therefore conducted a study to assess the effect of adherence to HAART on survival in The AIDS Support Organization (TASO) community HAART programme in Kampala, Uganda. METHODS: The study was a retrospective cohort of 897 patients who initiated HAART at TASO clinic, Kampala, between May 2004 and December 2006. A total of 7,856 adherence assessments were performed on the data. Adherence was assessed using a combination of self-report and pill count methods. Patients who took 95%. The crude death rate was 12.2 deaths per 100 patient-years, with a rate of 42.5 deaths per 100 patient-years for non-adherent patients and 6.1 deaths per 100 patient-years for adherent patients. Non-adherence to ART was significantly associated with mortality. Patients with a CD4 count of less than 50 cells/mm3 had a higher mortality (HR = 4.3; 95% CI: 2.22-5.56) compared to patients with a CD4 count equal to or greater than 50 cells/mm3 (HR = 2.4; 95% CI: 1.79-2.38). CONCLUSION: Our study showed that good adherence and improved survival are feasible in community HIV/AIDS programmes such as that of TASO, Uganda. However, there is need to support community HAART programmes to overcome the challenges of funding to provide sustainable supplies particularly of antiretroviral drugs; provision of high quality clinical and laboratory support; and achieving a balance between expansion and quality of services. Measures for the early identification and treatment of HIV infected people including home-based VCT and HAART should be strengthened