Implementation of Patient-Centered Education for Chronic-Disease Management in Uganda: An Effectiveness Study.

BACKGROUND: The majority of non-communicable disease related deaths occur in low- and middle-income countries. Patient-centered care is an essential component of chronic disease management in high income settings. OBJECTIVE: To examine feasibility of implementation of a validated patient-centered education tool among patients with heart failure in Uganda. DESIGN: Mixed-methods, prospective cohort. SETTINGS: A private and public cardiology clinic in Mulago National Referral and Teaching Hospital, Kampala, Uganda. PARTICIPANTS: Adults with a primary diagnosis of heart failure. INTERVENTIONS: PocketDoktor Educational Booklets with patient-centered health education. MAIN MEASURES: The primary outcomes were the change in Patient Activation Measure (PAM-13), as well as the acceptability of the PocketDoktor intervention, and feasibility of implementing patient-centered education in outpatient clinical settings. Secondary outcomes included the change in satisfaction with overall clinical care and doctor-patient communication. KEY RESULTS: A total of 105 participants were enrolled at two different clinics: the Mulago Outpatient Department (public) and the Uganda Heart Institute (private). 93 participants completed follow up at 3 months and were included in analysis. The primary analysis showed improved patient activation measure scores regarding disease-specific knowledge, treatment options and prevention of exacerbations among both groups (mean change 0.94 [SD = 1.01], 1.02 [SD = 1.15], and 0.92 [SD = 0.89] among private paying patients and 1.98 [SD = 0.98], 1.93 [SD = 1.02], and 1.45 [SD = 1.02] among public paying patients, p<0.001 for all values) after exposure to the intervention; this effect was significantly larger among indigent patients. Participants reported that materials were easy to read, that they had improved knowledge of disease, and stated improved communication with physicians. CONCLUSIONS: Patient-centered medical education can improve confidence in self-management as well as satisfaction with doctor-patient communication and overall care in Uganda. Our results show that printed booklets are locally appropriate, highly acceptable and feasible to implement in an LMIC outpatient setting across socioeconomic groups

Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study.

BACKGROUND: Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda. METHODS AND RESULTS: The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13-122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections. CONCLUSION: Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease

Global, regional, and national burden of colorectal cancer and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Funding: F Carvalho and E Fernandes acknowledge support from Fundação para a Ciência e a Tecnologia, I.P. (FCT), in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of the Research Unit on Applied Molecular Biosciences UCIBIO and the project LA/P/0140/2020 of the Associate Laboratory Institute for Health and Bioeconomy i4HB; FCT/MCTES through the project UIDB/50006/2020. J Conde acknowledges the European Research Council Starting Grant (ERC-StG-2019-848325). V M Costa acknowledges the grant SFRH/BHD/110001/2015, received by Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006.proofepub_ahead_of_prin

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

Abstract Background: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. Methods: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. Results: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. Conclusion: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals

Renal handling of calcium and phosphate during mineralocorticoid “escape” in man

Renal handling of calcium and phosphate during mineralocorticoid “escape” in man. Previous work in animals and man suggests a close relationship between sodium and phosphate reabsorption in proximal tubule, and between sodium and calcium in the proximal tubule and the distal nephron; hence, decreased sodium transport in the proximal tubule may be associated with phosphaturia since phosphate is mostly unreabsorbed distally, while decreased sodium reabsorption in the distal tubules may occur with calciuria only. The sites and the renal mechanisms of mineralocorticoid “escape” were studied by Na, Ca and P balance and clearance methods in seven patients with primary aldosteronism (aldos) and in three normal subjects. In both groups, when Na intake was raised or lowered over a range of 20 to 200 mEq/day, Ca clearance (CCa) varied with CNa (r = 0.8, P < 0.001); but ΔCCa/ΔCNa was higher (P < 0.01) in the patients with aldosteronism (1.6) compared to normals (0.64). On daily intake of 20mEq Na, CCa was not different in the two groups, whereas at dietary Na of 200 mEq, CCa was higher (P < 0.001) in the patients (1.80 ml/min) than in normals (1.07 ml/min), whereas CNa was similar in the two groups. In contrast to CCa, Cp did not vary with CNa in either group at any level of Na intake. Data suggest: 1) renal adjustments to dietary Na occur mainly in the distal nephron in both groups, since changes in CNa were accompanied by changes in CCa but not Cp; 2) aldosterone “escape” occurs with hypercalciuria and results from decreased distal reabsorption at sites (insensitive to aldosterone) where Na and Ca are closely linked; 3) in normal subjects, distal tubular sodium adjustments occur at both the latter site and an aldo-sensitive site where Na and Ca are not linked

Colonization and decolonization of global health: which way forward?

Despite taking on several forms throughout history such as colonial medicine, tropical medicine, and international health, the field of global health continues to uphold colonialist structures. History demonstrates that acts of colonialism inevitably lead to negative health outcomes. Colonial powers promoted medical advancements when diseases affected their own people, and only did so for locals when in the colonies’ best interests. Numerous medical advancements in the United States also relied on the exploitation of vulnerable populations. This history is critical in evaluating the actions of the United States as a proclaimed leader in global health. A significant barrier to progress in the field of global health is that most leaders and leading institutions are located in high-income countries, thereby defining the global standard. This standard fails to meet the needs of most of the world. In times of crisis, such as the COVID-19 pandemic, colonial mentalities may be more evident. In fact, global health partnerships themselves are often ingrained in colonialism and may be counterproductive. Strategies for change have been called into question by the recent Black Lives Matter movement, particularly in evaluating the role that less privileged communities should have in their own fate. Globally, we can commit to evaluating our own biases and learning from one another

The effect of a bidirectional exchange on faculty and institutional development in a global health collaboration.

The MUYU Collaboration is a partnership between Mulago Hospital-Makerere University College of Health Sciences (M-MakCHS), in Kampala, Uganda, and the Yale University School of Medicine. The program allows Ugandan junior faculty to receive up to 1 year of subspecialty training within the Yale hospital system. The authors performed a qualitative study to assess the effects of this program on participants, as well as on M-MakCHS as an institution.Data was collected via semi-structured interviews with exchange participants. Eight participants (67% of those eligible as of 4/2012) completed interviews. Study authors performed data analysis using standard qualitative data analysis techniques.Analysis revealed themes addressing the benefits, difficulties, and opportunities for improvement of the program. Interviewees described the main benefit of the program as its effect on their fund of knowledge. Participants also described positive effects on their clinical practice and on medical education at M-MakCHS. Most respondents cited financial issues as the primary difficulty of participation. Post-participation difficulties included resource limitations and confronting longstanding institutional and cultural habits. Suggestions for programmatic improvement included expansion of the program, ensuring appropriate management of pre-departure expectations, and refinement of program mentoring structures. Participants also voiced interest in expanding post-exchange programming to ensure both the use of and the maintenance of new capacity.The MUYU Collaboration has benefitted both program participants and M-MakCHS, though these benefits remain difficult to quantify. This study supports the assertion that resource-poor to resource-rich exchanges have the potential to provide significant benefits to the resource-poor partner