Decentralisation as a strategy for sustainability

Decentralisation as a strategy for sustainabilit

Using Andersen's behavioral model of health care utilization to assess contraceptive use among sexually active perinatally HIV-infected adolescents in Uganda

Background: Contraceptive practices of perinatally HIV-infected adolescents (PHIAs) have implications related to pregnancy prevention, risks of HIV heterosexual transmission, reinfection, and vertical transmission. The study assessed contraceptive use among sexually active PHIAs in Uganda. Methods: Mixed methods consisting of a survey and in-depth interviews were employed among 213 sexually active PHIAs who were attending antiretroviral therapy (ART) clinics. The study was guided by Andersen's Behavioral Model of Health Service Use as a theoretical framework to identify factors that influence contraceptive use. These factors include health care factors, personal characteristics, enabling factors, and needs. The outcome was contraceptive use. Multivariable logistic regression was used to establish determinants of contraceptive use. Qualitative data were analyzed by thematic analysis. Results. Most PHIAs were female (67.6%); the mean (SD) and median (IQR) age was 17.5 (±1.4) and 18 (17-19) years. The mean age of sexual debut and at marriage were 15 (±1.7) and 17 (±1.1), respectively. Condoms were the most known method of family planning (indicated by 55.4%). Only 16.9% of the participants knew about dual protection (condom use for FP as well as HIV/STI prevention). Of the PHIAs, 43.6% had ever used modern contraception and 56.9% of the females had ever been pregnant. The odds of contraceptive ever-use were significantly higher among adolescents aged 17-19 years (OR 5.1, 95% CI: 2.1-13.3) compared to those aged 10-16 years, those in school (OR 1.8, 95% CI: 1.07-3.2) compared to those out of school, and those with perceived need to use FP (OR 2.0, 95% CI: 1.1-3.9) compared to their counterparts. The odds of contraceptive used were lower among females (OR 0.13, 95% CI: 0.06-0.28) compared to males. From the in-depth interviews, the attitude of health workers, availability of health workers, having a friend using family planning, and waiting time were viewed to affect contraceptive use. Conclusion. Contraceptive use among sexually active perinatally HIV-infected adolescents was (43.6%). However, out of those who used family planning majority were using short-term methods. The unmet need for family planning was high (47%) with high reports of pregnancy (56.9%). The factors associated with contraceptive use included education, age, sex (predisposing factors), and perceived need of family planning (need factors). Other factors that could affect contraceptive use from qualitative analysis included attitude of health workers, availability of health workers, having a friend using family planning (predisposing factors), and waiting time (health system factors). HIV care for adolescents should be promoted using SRH approach. There is a need to provide training for all providers to cater for SRH services. We should continue to provide youth-responsive adolescent sexual and reproductive health services across all ART facilities and build a supportive environment and continue to integrate SRH services into HIV care

The traditional history of the Buganda kingdom, with special reference to the historical writings of Sir Apolo Kaggwa.

In committing Buganda's oral traditions to writing, Kaggwa did not consciously set out to write a history of Buganda. Consequently, some of these traditions are mere legends, though they are being increasingly used by the historians as historical sources. Such interest, has demonstrated the need for a critical study of these traditions so as to disentangle history from mythology. And in order to make Kaggwa's work available to the world of learning, an English translation has been made with annotations. But although we have found the Kiganda traditions largely reliable some of the conclusions drawn from them are by no means definitive. One learns from these traditions, something about the settlement and the expansion of Buganda, and the growth of her political institutions. Buganda's early history is that of a struggling small kingdom surrounded by a powerful neighbour, Bunyoro. But the picture changes during the 17th century when Buganda begins to expand at Bunyoro's expense, and by the beginning of the 19th century, she had already become the dominant power. This expansion, created administrative and military problems. Hence new chieftainships were established and through them, Buganda developed an efficient system of local government dominated by the King. But originally the king was more or less equal to the Bataka. Buganda's isolation from the outside world, was broken during the reign of Suna II by the visits of the Arabs. They were followed by the European explorers and missionaries during the reign of Mutesa I. Their existence in Buganda, the introduction of firearms and other trade goods, the teachings of Christianity and Islam; combined to accelerate the political and social revolution which had begun two centuries before

evidence for acute stimulation of fibrinogen production by glucagon in humans

Fibrinogen, an acute-phase protein, and glucagon, a stress hormone, are often elevated in many conditions of physical and metabolic stress, including uncontrolled diabetes. However, the possible mechanisms for this association are poorly known. We have studied the acute effects of selective hyperglucagonemia (raised from ∼200 to ∼350 pg/ml for 3 h) on fibrinogen fractional secretion rate (FSR) in eight normal subjects during infusion of somatostatin and replacement doses of insulin, glucagon, and growth hormone. Fibrinogen FSR was evaluated by precursor-product relationships using either Phe ( n = 8) or Leu ( n = 2) tracers. Hyperglucagonemia did not change either plasma Phe or Tyr specific activity. After hyperglucagonemia, fibrinogen FSR increased by ∼65% (from 12.9 ± 3.6 to 21.5 ± 6.1% per day, P < 0.025) using plasma Phe specific activity as the precursor pool. FSR increased by ∼80% (from 16.6 ± 4.8 to 29.4 ± 8.8% per day, P < 0.025) if plasma Phe specific activity was corrected for the ketoisocaproate/Leu enrichment (or specific activity) ratio to obtain an approximate estimate of intrahepatic Phe specific activity. FSR increased by ∼60% when using plasma Tyr specific activity as precursor pool ( n = 8) ( P < 0.05), as well as when using the Leu tracer precursorproduct relationship ( n = 2). In conclusion, selective hyperglucagonemia for ∼3 h acutely stimulated fibrinogen FSR using a Phe tracer method. Thus, glucagon may be involved in the increase of fibrinogen concentration and FSR observed under stressed or pathologic conditions

Risk factors of hypertension among adults aged 35-64 years living in an urban slum Nairobi, Kenya.

BACKGROUND: Hypertension is an emerging public health problem in Sub Saharan Africa (SSA) and urbanization is considered to favor its emergence. Given a paucity of information on hypertension and associated risk factors among urban slum dwellers in SSA, we aimed to characterize the distribution of risk factors for hypertension and investigate their association with hypertension in an urban slum in Kenya. METHODS: We conducted a community based cross-sectional survey among adults 35 years and older living in Kibera slum Nairobi, Kenya. Trained interviewers collected data on socio demographic characteristics and self reported health behaviours using modified World Health Organization stepwise surveillance questionnaire for chronic disease risk factors. Anthropometric and blood pressure measurements were performed following standard procedures. Multiple logistic regression was used for analysis and odds ratios with 95 % confidence intervals were calculated to identify risk factors associated with hypertension. RESULT: A total of 1528 adults were surveyed with a mean age of 46.7 years. The age-standardized prevalence of hypertension was 29.4 % (95 % CI 27.0-31.7). Among the 418 participants classified as hypertensive, over one third (39.0 %) were unaware they had hypertension. Prevalence of current smoking and alcohol consumption was 8.5 and 13.1 % respectively. Over one quarter 26.2 % participants were classified as overweight (Body Mass Index [BMI] ≥25 to ≤29.9 kg/m(2)), and 17 % classified as obese (BMI ≥30 kg/m(2)). Overweight, obesity, current smoking, some level of education, highest wealth index, moderate physical activity, older age and being widowed were each independently associated with hypertension. When fit in a multivariable logistic regression model, being a widow [AOR = 1.7; (95 % CI, 1.1-2.6)], belonging to the highest wealth index [AOR = 1.6; (95 % CI, 1.1-2.5)], obesity [AOR = 1.8; 95 % CI, 1.1-3.1)] and moderate physical activity [AOR = 1.9; (95 % CI, 1.2-3.0)], all remained significantly associated with hypertension. CONCLUSION: Hypertension in the slum is a public health problem affecting at least one in three adults aged 35-64 years. Age, marital status, wealth index, physical inactivity and body mass index are important risk factors associated with hypertension. Prevention measures targeting the modifiable risk factors associated with hypertension are warranted to curb hypertension and its progressive effects

Effect of a Participatory Multisectoral Maternal and Newborn Intervention on Birth Preparedness and Knowledge of Maternal and Newborn Danger Signs among Women in Eastern Uganda: A Quasiexperiment Study

Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization. Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda. Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre–post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs. Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7–39% vs. 7–36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7–69% vs. 10–64%, 0–11% vs. 0–5%, and 9–14% vs. 9–13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs’ knowledge, respectively. Village health teams’ home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs’ knowledge. Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.DFI

Working with Community Health Workers to Improve Maternal and Newborn Health Outcomes: Implementation and Scale-Up Lessons from Eastern Uganda

Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation. Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy. Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences. Results: CHWs’ knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles. Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.DFI

"The actor is policy": application of elite theory to explore actors' interests and power underlying maternal health policies in Uganda, 2000-2015

Background: The persistence of high maternal mortality and consistent failure in low- and middle-income countries to achieve global targets such as Millennium Development Goal five (MDG 5) is usually explained from epidemiological, interventional and health systems perspectives. The role of policy elites and their interests remains inadequately explored in this debate. This study examined elites and how their interests drove maternal health policies and actions in ways that could explain policy failure for MDG 5 in Uganda. Methods: We conducted a retrospective qualitative study of Uganda’s maternal health policies from 2000 to 2015 (MDG period). Thirty key informant interviews and 2 focus group discussions (FGDs) were conducted with national policy-makers, who directly participated in the formulation of Uganda’s maternal health policies during the MDG period. We reviewed 9 National Maternal Health Policy documents. Data were analysed inductively using elite theory. Results: Maternal health policies were mainly driven by a small elite group comprised of Senior Ministry of Health (MoH) officials, some members of cabinet and health development partners (HDPs) who wielded more power than other actors. The resulting policies often appeared to be skewed towards elites’ personal political and economic interests, rather than maternal mortality reduction. For a few, however, interests aligned with reducing maternal mortality. Since complying with the government policy-making processes would have exposed elites’ personal interests, they mainly drafted policies as service standards and programme documents to bypass the formal policy process. Conclusion: Uganda’s maternal health policies were mainly influenced by the elites’ personal interests rather than by the goal of reducing maternal mortality. This was enabled by the formal guidance for policy-making which gives elites control over the policy process. Accelerating maternal mortality reduction will require re-engineering the policy process to prevent public officials from infusing policies with their interests, and enable percolation of ideas from the public and frontline

Heterogeneity of HIV incidence : a comparative analysis between fishing communities and in a neighbouring rural general population, Uganda, and implications for HIV control

Objectives To describe HIV heterogeneity in rural Uganda using incidence data collected between January 2012 and December 2014 among fishing cohort (FC) and in an adjacent rural general population cohort (GPC). Methods In the FC, eligible HIV high-risk adults aged 18+ years were enrolled, followed and HIV tested every 3 months. Demographic and sexual behaviour data were also collected. The GPC, approximately 47 km away from the FC, was followed through annual surveys, and sociodemographic and behavioural data collected. A subset of GPC with comparable risk profiles to the FC was selected. We presented sociodemographic and risk profiles and also computed stratified HIV incidence. Cox regression was used to assess factors associated with HIV incidence. Results Overall HIV incidence was higher in the FC than in the ‘high-risk’ GPC, 6.04 and 0.56 per 100 person years at risk, respectively, with a rate ratio (RR) of 10.83 (95% CI 6.11 to 19.76). This was higher among those aged 18–24 years, unmarried and those with more than two sex partners in the past year, RR of 15.44, 22.99 and 19.29, respectively. In the FC, factors associated with high incidence in multivariate analysis were duration in the community and unprotected sex. The factors in the GPC were ethnicity, marital status and duration in the community. Conclusions We have observed a substantial heterogeneity in HIV incidence. The high incidence in fishing communities is contributing greatly to the overall HIV burden in Uganda, and thus urgent combination prevention efforts are needed towards national goal to reduce HIV epidemic