Patient involvement in selection of immunosuppressive regimen following transplantation.

Transplantation has made a considerable difference to the lives of many patients. However, feedback from patients indicates that although having a transplant is a hugely positive experience, having to take medications indefinitely is one of the biggest challenges. An ideal scenario would be no medications following a transplant. A compromise would be a minimal number of medications, with minimal restrictions and as simple a regimen as possible. Although there is considerable research going into fine-tuning the management of the immune response to a transplant, to date there is no universal regimen that enables patients to remain free of immunosuppressant medications, making adherence paramount to maintain long-term allograft survival. This paper reviews the available immunosuppressant regimens and factors influencing choice from both the clinician's and the patient's perspective. Factors influencing the decision-making process, such as quality of life for patients, their satisfaction, acceptability, and adherence uptake are reviewed. We conclude with a further assessment of patient choice as a factor in regimen selection, its impact on adherence, and its implications

Does the Good Schools Toolkit Reduce Physical, Sexual and Emotional Violence, and Injuries, in Girls and Boys equally? A Cluster-Randomised Controlled Trial.

We aimed to investigate whether the Good School Toolkit reduced emotional violence, severe physical violence, sexual violence and injuries from school staff to students, as well as emotional, physical and sexual violence between peers, in Ugandan primary schools. We performed a two-arm cluster randomised controlled trial with parallel assignment. Forty-two schools in one district were allocated to intervention (n = 21) or wait-list control (n = 21) arms in 2012. We did cross-sectional baseline and endline surveys in 2012 and 2014, and the Good School Toolkit intervention was implemented for 18 months between surveys. Analyses were by intention to treat and are adjusted for clustering within schools and for baseline school-level proportions of outcomes. The Toolkit was associated with an overall reduction in any form of violence from staff and/or peers in the past week towards both male (aOR = 0.34, 95%CI 0.22-0.53) and female students (aOR = 0.55, 95%CI 0.36-0.84). Injuries as a result of violence from school staff were also lower in male (aOR = 0.36, 95%CI 0.20-0.65) and female students (aOR = 0.51, 95%CI 0.29-0.90). Although the Toolkit seems to be effective at reducing violence in both sexes, there is some suggestion that the Toolkit may have stronger effects in boys than girls. The Toolkit is a promising intervention to reduce a wide range of different forms of violence from school staff and between peers in schools, and should be urgently considered for scale-up. Further research is needed to investigate how the intervention could engage more successfully with girls

Exploring Couples' Processes of Change in the Context of SASA!, a Violence Against Women and HIV Prevention Intervention in Uganda.

There is now a growing body of research indicating that prevention interventions can reduce intimate partner violence (IPV); much less is known, however, about how couples exposed to these interventions experience the change process, particularly in low-income countries. Understanding the dynamic process that brings about the cessation of IPV is essential for understanding how interventions work (or don't) to reduce IPV. This study aimed to provide a better understanding of how couples' involvement with SASA!-a violence against women and HIV-related community mobilisation intervention developed by Raising Voices in Uganda-influenced processes of change in relationships. Qualitative data were collected from each partner in separate in-depth interviews following the intervention. Dyadic analysis was conducted using framework analysis methods. Study findings suggest that engagement with SASA! contributed to varied experiences and degrees of change at the individual and relationship levels. Reflection around healthy relationships and communication skills learned through SASA! activities or community activists led to more positive interaction among many couples, which reduced conflict and IPV. This nurtured a growing trust and respect between many partners, facilitating change in longstanding conflicts and generating greater intimacy and love as well as increased partnership among couples to manage economic challenges. This study draws attention to the value of researching and working with both women, men and couples to prevent IPV and suggests IPV prevention interventions may benefit from the inclusion of relationship skills building and support within the context of community mobilisation interventions

The impact of SASA!, a community mobilisation intervention, on women's experiences of intimate partner violence: secondary findings from a cluster randomised trial in Kampala, Uganda.

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights concern, though there is limited evidence on how to prevent it. This secondary analysis of data from the SASA! Study assesses the potential of a community mobilisation IPV prevention intervention to reduce overall prevalence of IPV, new onset of abuse (primary prevention) and continuation of prior abuse (secondary prevention). METHODS: A pair-matched cluster randomised controlled trial was conducted in 8 communities (4 intervention, 4 control) in Kampala, Uganda (2007-2012). Cross-sectional surveys of community members, 18-49 years old, were undertaken at baseline (n=1583) and 4 years postintervention implementation (n=2532). Outcomes relate to women's past year experiences of physical and sexual IPV, emotional aggression, controlling behaviours and fear of partner. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up. RESULTS: At follow-up, all types of IPV (including severe forms of each) were lower in intervention communities compared with control communities. SASA! was associated with lower onset of abuse and lower continuation of prior abuse. Statistically significant effects were observed for continued physical IPV (adjusted risk ratio 0.42, 95% CI 0.18 to 0.96); continued sexual IPV (0.68, 0.53 to 0.87); continued emotional aggression (0.68, 0.52 to 0.89); continued fear of partner (0.67, 0.51 to 0.89); and new onset of controlling behaviours (0.38, 0.23 to 0.62). CONCLUSIONS: Community mobilisation is an effective means for both primary and secondary prevention of IPV. Further support should be given to the replication and scale up of SASA! and other similar interventions. TRIAL REGISTRATION NUMBER: NCT00790959

Use of herbal medicines among pregnant women a attending antenatal clinic at Kiryandongo General Hospital, Uganda

Objective: To assess the knowledge and use of herbal medicines among pregnant women attending the antenatal clinic at Kiryandongo general hospital.Design: A descriptive cross-sectional studySetting: Kiryandongo general hospital in Masindi District, mid-western Uganda.Subjects: Four hundred (400) pregnant women attending antenatal care (ANC) were interviewed about their knowledge and use of herbal medicines during pregnancy using self-administered questionnaires, during the months of July and August 2013.Results: Of the 400 women who participated in the study, majority 246 (61.5%)was in the age range of 18 to 24 years old, married 379 (94.8%), stayed in a rural setting 293 (73.3%),had attained primary education 239(59.8%),peasant farmers 209 (52.3%), in monogamous marriage 247 (64.2%), of prime gravidae 117 (29.2%), and Banyoro by tribe 89 (22.3%). Three hundred and fifty (87.5%)of the respondents reported to have ever heard about the use of herbal medicines during pregnancy, with 169 (48.3%) reported having used herbal medicines during previous pregnancies or in the months prior to the study. One hundred and thirty two (37.7%) where found to be using herbal medicines at the time of the study, with the majority of them one hundred and eleven (84.1%) admitting that they will be using herbal medicines again in subsequent pregnancies. One hundred and fifty three (43.7%)considered herbal medicines to be safe during pregnancy and preferred them to conventional medicines because they have low side effects, are cheap and easy to access, and it is part of their tradition to use them during pregnancy.One hundred and ten (31.4%) believed that these herbs are neither dangerous to the mother nor the foetus.Conclusion: More efficient ways are required to educate the general population about the dangers of self-medication during pregnancy especially to advise pregnant mothers not to expose their unborn child to the risks of herbal medicines. Pharmacological and case control studies will be vital in assessing the efficacy and risks associated with herbal medicine use during pregnancy. Midwives, obstetricians and General Practitioners should facilitate women’s wishes without condemnation, but this must be tempered with accurate information

How to conduct good quality research on violence against children with disabilities: key ethical, measurement, and research principles.

BACKGROUND: Approximately one billion children experience violence every year. Violence against children is an urgent global public health concern and violation of children's rights. It is also a risk factor for serious negative health and social outcomes and is therefore addressed within the Sustainable Development Goals (SDGs). Children with disabilities, who make up one in 20 children worldwide, are particularly vulnerable to violence although good quality data are lacking on causes and means of prevention of violence against children with disabilities. Key challenges exist in the measurement of disability and violence, which in part explains the dearth in evidence. IMPROVING RESEARCH ON VIOLENCE AGAINST CHILDREN WITH DISABILITIES: This paper provides guidance on how to conduct good quality, ethical, and inclusive research on violence against children with disabilities, particularly in low-income settings. The lack of an international agreed 'gold standard' frustrates efforts to measure violence across settings and time. Careful consideration must be given to the design of survey tools. Qualitative and participatory research methods also offer important opportunities to explore children's subjective understanding and experiences of violence. Challenges also exist around the measurement of disability. Disability may be measured by asking directly about disability, through self-reported functioning, or through the presence of impairments or health conditions. These approaches have strengths and limitations and should build on what children are able to do and include appropriate adaptations for specific impairments where necessary. Ethical research also requires adherence to ethical guidelines and approvals, obtaining informed consent, appropriate child protection responses, and careful consideration of interviewer-related issues including their selection, training, and welfare. Key methodological gaps remain - how to include children with severe communication challenges in research; how to respond in instances of weak child protection systems; designing sampling procedures that adequately represent children with disabilities in large-scale violence surveys; and determining how best to ask about violence safely in large-scale surveys and monitoring data. This paper further advocates for the dissemination of research results in inclusive and accessible formats. CONCLUSION: With careful planning, challenges in collecting data on disability and violence can be overcome to generate evidence in this neglected area

Implementation of the Good School Toolkit in Uganda: a quantitative process evaluation of a successful violence prevention program.

BACKGROUND: The Good School Toolkit, a complex behavioural intervention designed by Raising Voices a Ugandan NGO, reduced past week physical violence from school staff to primary students by an average of 42% in a recent randomised controlled trial. This process evaluation quantitatively examines what was implemented across the twenty-one intervention schools, variations in school prevalence of violence after the intervention, factors that influence exposure to the intervention and factors associated with students' experience of physical violence from staff at study endline. METHODS: Implementation measures were captured prospectively in the twenty-one intervention schools over four school terms from 2012 to 2014 and Toolkit exposure captured in the student (n = 1921) and staff (n = 286) endline cross-sectional surveys in 2014. Implementation measures and the prevalence of violence are summarised across schools and are assessed for correlation using Spearman's Rank Correlation Coefficient. Regression models are used to explore individual factors associated with Toolkit exposure and with physical violence at endline. RESULTS: School prevalence of past week physical violence from staff against students ranged from 7% to 65% across schools at endline. Schools with higher mean levels of teacher Toolkit exposure had larger decreases in violence during the study. Students in schools categorised as implementing a 'low' number of program school-led activities reported less exposure to the Toolkit. Higher student Toolkit exposure was associated with decreased odds of experiencing physical violence from staff (OR: 0.76, 95%CI: 0.67-0.86, p-value< 0.001). Girls, students reporting poorer mental health and students in a lower grade were less exposed to the toolkit. After the intervention, and when adjusting for individual Toolkit exposure, some students remained at increased risk of experiencing violence from staff, including, girls, students reporting poorer mental health, students who experienced other violence and those reporting difficulty with self-care. CONCLUSIONS: Our results suggest that increasing students and teachers exposure to the Good School Toolkit within schools has the potential to bring about further reductions in violence. Effectiveness of the Toolkit may be increased by further targeting and supporting teachers' engagement with girls and students with mental health difficulties. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov , NCT01678846, August 24th 2012

The Good School Toolkit for reducing physical violence from school staff to primary school students: a cluster-randomised controlled trial in Uganda

Background Violence against children from school staff is widespread in various settings, but few interventions address this. We tested whether the Good School Toolkit—a complex behavioural intervention designed by Ugandan not-forprofi t organisation Raising Voices—could reduce physical violence from school staff to Ugandan primary school children. Methods We randomly selected 42 primary schools (clusters) from 151 schools in Luwero District, Uganda, with more than 40 primary 5 students and no existing governance interventions. All schools agreed to be enrolled. All students in primary 5, 6, and 7 (approximate ages 11–14 years) and all staff members who spoke either English or Luganda and could provide informed consent were eligible for participation in cross-sectional baseline and endline surveys in June–July 2012 and 2014, respectively. We randomly assigned 21 schools to receive the Good School Toolkit and 21 to a waitlisted control group in September, 2012. The intervention was implemented from September, 2012, to April, 2014. Owing to the nature of the intervention, it was not possible to mask assignment. The primary outcome, assessed in 2014, was past week physical violence from school staff , measured by students’ self-reports using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool—Child Institutional. Analyses were by intention to treat, and are adjusted for clustering within schools and for baseline school-level means of continuous outcomes. The trial is registered at clinicaltrials.gov, NCT01678846. Findings No schools left the study. At 18-month follow-up, 3820 (92·4%) of 4138 randomly sampled students participated in a cross-sectional survey. Prevalence of past week physical violence was lower in the intervention schools (595/1921, 31·0%) than in the control schools (924/1899, 48·7%; odds ratio 0·40, 95% CI 0·26–0·64, p<0·0001). No adverse events related to the intervention were detected, but 434 children were referred to child protective services because of what they disclosed in the follow-up survey. Interpretation The Good School Toolkit is an eff ective intervention to reduce violence against children from school staff in Ugandan primary schools

The impact on nurses and nurse managers of introducing PEPFAR clinical services in urban government clinics in Uganda

BACKGROUND: Improving provider performance is central to strengthening health services in developing countries. Because of critical shortages of physicians, many clinics in sub-Saharan Africa are led by nurses. In addition to clinical skills, nurse managers need practical managerial skills and adequate resources to ensure procurement of essential supplies, quality assurance implementation, and productive work environment. Giving nurses more autonomy in their work empowers them in the workplace and has shown to create positive influence on work attitudes and behaviors. The Infectious Disease Institute, an affiliate of Makerere University College of Health Science, in an effort to expand the needed HIV services in the Ugandan capital, established a community-university partnership with the Ministry of Health to implement an innovative model to build capacity in HIV service delivery. This paper evaluates the impact on the nurses from this innovative program to provide more health care in six nurse managed Kampala City Council (KCC) Clinics. METHODS: A mixed method approach was used. The descriptive study collected key informant interviews from the six nurse managers, and administered a questionnaire to 20 staff nurses between September and December 2009. Key themes were manually identified from the interviews, and the questionnaire data were analyzed using SPSS. RESULTS: Introducing new HIV services into six KCC clinics was positive for the nurses. They identified the project as successful because of perceived improved environment, increase in useful in-service training, new competence to manage patients and staff, improved physical infrastructure, provision of more direct patient care, motivation to improve the clinic because the project acted on their suggestions, and involvement in role expansion. All of these helped empower the nurses, improving quality of care and increasing job satisfaction. CONCLUSIONS: This community-university HIV innovative model was successful from the point of view of the nurses and nurse managers. This model shows promise in increasing effective, quality health service; HIV and other programs can build capacity and empower nurses and nurse managers to directly implement such services. It also demonstrates how MakCHS can be instrumental through partnerships in designing and testing effective strategies, building human health resources and improving Ugandan health outcomes