The survival and nutritional status of children in relation to aspects of maternal health : follow-up studies in rural Uganda

Background: Low income countries continue to experience high under-five mortality and a high prevalence of protein energy malnutrition (PEM) among surviving children. There is lack of empirical data for accurate tracking of child survival and for determining the consequences of early childhood PEM on future health and education. Main aim: To assess under –five mortality trends and associated factors to inform the design of child survival interventions, and also examine the impact of childhood PEM on future adolescent health and schooling among survivors in a rural population in Uganda. Methods: Four studies were nested in the Kyamulibwa Health and Demographic Surveillance Site in southwestern Uganda. In study 1, prospective data collected between 2002 and 2012 were extracted for 10,118 children under the age of five years and used to estimate age-specific mortality rates using the synthetic cohort life-table method. Calendar year-specific hazard rates and risk factors were explored by Cox regression. In study II, women of reproductive age were enrolled and stillbirth rates were compared using i) 12 months recall of pregnancy outcome (n= 1800) (method 1) and ii) lifetime recall (method 2) and associated risk factors were explored. In study III, 1054 children followed to adolescence were categorised as stunted/wasted, recovered, deteriorated and normal after three nutritional assessments between 1999 and 2011. Mean blood pressures and schooling years achieved measured in 2011 were compared in the 4 groups. In study IV, a pragmatic trial, involving registration of pregnancies and delivering stage-of-pregnancy-specific text message (SMS) via community health workers to pregnant women in 13 intervention villages (n=262) compared with pregnant women in control villages (n=263) with no intervention. Place of birth (home or health facility) was the main outcome. Results: Under-five mortality was 92 per 1000 live births. Overall mortality declined by 33% between 2002 and 2012 with the highest decline observed in the post-neonatal period. Early neonatal mortality did not change. Stillbirth rates differed by method of estimation; 26.2/1000 births versus 13.8/1000 births respectively by methods 1 and 2. No decline in stillbirth rates was observed. Under-five mortality increased with decreasing child age, HIV infection of the child, a birth interval 4 and a home delivery. Stillbirth risk increased with maternal age and reduced with increasing parity. In study III, wasting was negatively associated with systolic blood pressure (-7.90 95%CI [- 14.52,-1.28], p= 0.02) and diastolic blood pressure (-3.92, 95%CI [-7.42, -0.38], p= 0.03) among surviving children. Recovery from wasting was positively associated with diastolic blood pressure (1.93, 95%CI (0.11, 3.74] p=0.04). Both stunting and wasting regardless of recovery were negatively associated with school achievement. In study IV, the SMS intervention was associated with lower odds of homebirths [AOR=0.38, 95%CI (0.15-0.97)]. Home births were associated with muslim religion [AOR= 4.0, 95%CI (1.72-9.34)], primary or no maternal education [AOR= 2.51, 95%CI (1.00-6.35)] and health facility distance ≥ 2 km [AOR= 2.26, 95%CI (0.95-5.40)]. Conclusions: Survival of children in rural Uganda is improving, and could improve further with increased uptake of family planning and facility births. Promoting community health workers‘ role in improving child survival through use of mobile phones for delivering tailored messages to mothers is a potential strategy that could be scaled up in rural communities

Making Universal Health Coverage Effective in Low- and Middle-Income Countries: A Blueprint for Health Sector Reforms

Health sector reforms not only require attention to specific components but also a supportive environment. In low- and middle-income countries (LMICs), there is still much to be done on ensuring that people receive prioritized healthcare services. Despite LIMCs spending an average of 6% of their GDP on health, there have been minimal impacts compared to high-income countries. Health sector reform is a gradual process with complex systems; hence, the need for a vision and long-term strategies to realize the desired goals. In this chapter, we present our proposal to advance universal health coverage (UHC) in LMICs. Overall, our main aim is to provide strategies for achieving actual UHC and not aspirational UHC in LMICs by strengthening health systems, improving health insurance coverage and financial protection, and reducing disparities in healthcare coverage especially on prioritized health problems, and enhancing a primary care-oriented healthcare system

Non-Communicable Diseases and Urbanization in African Cities: A Narrative Review

Rapid urbanization in Africa has been linked to the growing burden of non-communicable diseases (NCDs). Urbanization processes have amplified lifestyle risk factors for NCDs (including unhealthy diets, tobacco use, harmful alcohol intake, and physical inactivity), especially among individuals of low and middle social economic status. Nevertheless, African countries are not keeping pace with the ever increasing need for population-level interventions such as health promotion through education, screening, diagnosis, and treatment, as well as structural measures such as policies and legislation to prevent and control the upstream factors driving the NCD epidemic. This chapter highlights the NCD burden in urban Africa, along with the social determinants and existing interventions against NCDs. The chapter concludes by offering insights into policy and legislative opportunities and recommends stronger efforts to apply multisectoral and intersectoral approaches in policy formulation, implementation, and monitoring at multiple levels to address the NCD epidemic in African cities

A prospective study of trends in consumption of cigarettes and alcohol among adults in a rural Ugandan population cohort, 1994-2011

OBJECTIVES: To characterise trends over time in smoking and alcohol consumption in a rural Ugandan population between 1994 and 2011. METHODS: We used self-reported data from a long-standing population cohort - the General Population Cohort. From 1989-1999, the study population comprised about 10,000 residents of 15 adjacent villages. From 1999, 10 more villages were added, doubling the population. Among adults (≥13 years, who comprise about half of the total study population) data on smoking were collected in 1994/95, 2008/9 and in 2010/11. Data on alcohol were collected in 1996/1997, 2000/2001, 2009/2010 and 2010/2011. RESULTS: The reported prevalence of smoking among men was 17% in 1994/1995, 14% in 2008/2009 and 16% in 2010/2011; equivalent figures for women were 1.5%, 1% and 2%. In the most recent time period, for both sexes combined, prevalence of smoking increased from 1.5% in those aged <29 years, to 18% in those 50+ years (P<0.001); prevalence was 14.8% in the lowest tertile of socio-economic status, decreasing to 3.7% in the highest (P<0.001). For alcohol consumption, current drinking was reported by 39% in 1996/1997, 35% in 2000/2001 and 28% in 2010/2011; men were more likely to drink than women (32.9% vs. 23.5% in 2010/2011) and consumption increased with age (P<0.001); was associated with low socio-economic status, riskier sexual behaviour and being HIV positive (P<0.001). CONCLUSION: In this rural Ugandan population, consumption of cigarettes and alcohol is higher among men than women, increases with age and is more frequent among those with low socio-economic status. We find no evidence of increases in either exposure over time. This article is protected by copyright. All rights reserved

Uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa : protocol for a systematic review and meta-analysis

Background Uncontrolled hypertension is the most important risk factor and leading cause of cardiovascular diseases. It is predicted that the number of people with hypertension will increase, and a large proportion of this increase will occur in developing countries. The highest prevalence of uncontrolled hypertension is reported in sub-Saharan Africa, and treatment for hypertension is unacceptably low. Hypertension commonly co-exists with comorbidities and this is associated with poorer health outcomes for patients. This review aims to estimate the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa. Methods and analysis All published and unpublished studies on the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa will be included. MEDLINE via OVID, Embase, and Web of Science will be searched to identify all relevant articles published from January 2000 to June 2019. Experts in the field will be contacted for unpublished literature, and Open SIGLE will be reviewed for relevant information. No language restriction will be imposed. Two reviewers will select, screen, extract data, and assess the risk of bias while a third reviewer will arbitrate the disagreements. A meta-analysis will be performed on variables that are similar across the included studies. Proportions will be stabilized before estimates are pooled using a random effects model. The presence of publication bias will be assessed using Egger’s test and visual inspection of the funnel plots. This systematic and meta-analysis review protocol will be reported in accordance with the PRISMA-P protocol guidelines. Results will be stratified by country, comorbidity, and geographic region

Feasibility of using smartphones by village health workers for pregnancy registration and effectiveness of mobile phone text messages on reduction of homebirths in rural Uganda

INTRODUCTION: Homebirths are common in low and middle income countries and are associated with poor child survival. We assessed the feasibility of using smartphones by village health workers for pregnancy registration and the effectiveness of health text messages (SMS) sent to pregnant women through village health workers in reducing homebirths in rural Uganda. METHODS: A non-randomised intervention study was undertaken in 26 villages. In the intervention arm, village health workers registered pregnant women (n = 262) in 13 villages using a smartphone app (doForm) and paper forms and gestation age-timed SMS were sent through village health workers to the pregnant women. In 13 control villages, (n = 263) pregnant women were registered on paper forms only and no SMS was sent. The main outcome was place of birth measured through a self-report. Logistic regression with generalised estimating equations was used to explore the effect of the intervention. RESULTS: Comparing 795 corresponding data fields on phone and paper revealed that numeric variable fields were 86%-95% similar while text fields were 38%-48% similar. Of the 525 pregnant women followed, 83 (15.8%) delivered at home. In the adjusted analysis, the intervention was associated with lower odds of homebirths [AOR = 0.38, 95%CI (0.15-0.97)]. Muslim religion [AOR = 4.0, 95%CI (1.72-9.34)], primary or no maternal education [AOR = 2.51, 95%CI (1.00-6.35)] and health facility distance ≥ 2 km [AOR = 2.26, 95%CI (0.95-5.40)] were independently associated with homebirths. CONCLUSION: Village health workers can register pregnant women at home using phones and relay gestation age specific SMS to them to effectively reduce homebirths

Adverse pregnancy outcomes in rural Uganda (1996-2013): trends and associated factors from serial cross sectional surveys.

OBJECTIVE: Community based evidence on pregnancy outcomes in rural Africa is lacking yet it is needed to guide maternal and child health interventions. We estimated and compared adverse pregnancy outcomes and associated factors in rural south-western Uganda using two survey methods. METHODS: Within a general population cohort, between 1996 and 2013, women aged 15-49 years were interviewed on their pregnancy outcome in the past 12 months (method 1). During 2012-13, women in the same cohort were interviewed on their lifetime experience of pregnancy outcomes (method 2). Adverse pregnancy outcome was defined as abortions or stillbirths. We used random effects logistic regression for method 1 and negative binomial regression with robust clustered standard errors for method 2 to explore factors associated with adverse outcome. RESULTS: One third of women reported an adverse pregnancy outcome; 10.8% (abortion = 8.4%, stillbirth = 2.4%) by method 1 and 8.5% (abortion = 7.2%, stillbirth = 1.3%) by method 2. Abortion rates were similar (10.8 vs 10.5) per 1000 women and stillbirth rates differed (26.2 vs 13.8) per 1000 births by methods 1 and 2 respectively. Abortion risk increased with age of mother, non-attendance of antenatal care and proximity to the road. Lifetime stillbirth risk increased with age. Abortion and stillbirth risk reduced with increasing parity. DISCUSSION: Both methods had a high level of agreement in estimating abortion rate but were markedly below national estimates. Stillbirth rate estimated by method 1 was double that estimated by method 2 but method 1 estimate was more consistent with the national estimates. CONCLUSION: Strategies to improve prospective community level data collection to reduce reporting biases are needed to guide maternal health interventions

Human cytomegalovirus epidemiology and relationship to tuberculosis and cardiovascular disease risk factors in a rural Ugandan cohort.

Human cytomegalovirus (HCMV) infection has been associated with increased mortality, specifically cardiovascular disease (CVD), in high-income countries (HICs). There is a paucity of data in low- and middle-income countries (LMICs) where HCMV seropositivity is higher. Serum samples from 2,174 Ugandan individuals were investigated for HCMV antibodies and data linked to demographic information, co-infections and a variety of CVD measurements. HCMV seropositivity was 83% by one year of age, increasing to 95% by five years. Female sex, HIV positivity and active pulmonary tuberculosis (TB) were associated with an increase in HCMV IgG levels in adjusted analyses. There was no evidence of any associations with risk factors for CVD after adjusting for age and sex. HCMV infection is ubiquitous in this rural Ugandan cohort from a young age. The association between TB disease and high HCMV IgG levels merits further research. Known CVD risk factors do not appear to be associated with higher HCMV antibody levels in this Ugandan cohort

Feasibility and acceptability of using biometric fingerprinting to track migrations and support retention in HIV prevention research in fishing population in East Africa

INTRODUCTION: Fishing populations constitute a suitable key population amongst which to conduct HIV prevention trials due to very high HIV prevalence and incidence, however, these are highly mobile populations. We determined the feasibility and acceptability of using fingerprinting and geographical positioning systems to describe mobility patterns and retention among fisherfolks on the shoreline of Lake Victoria in South-western Uganda. METHODS: Between August 2015 and January 2017, two serial cross-sectional surveys were conducted during which fingerprinting of all residents aged 18-30 years on the shoreline of Lake Victoria was done. A mapper moving ahead of the survey team, produced village maps and took coordinates of every household. These were accessed by the survey team that assigned household and individual unique identifiers (ID) and collected demographic data. Using the assigned IDs, individuals were enrolled and their fingerprints scanned. The fingerprinting was repeated 6 months later in order to determine the participant's current household. If it was different from that at baseline, a new household ID was assigned which was used to map migrations both within and between villages. RESULTS: At both rounds, over 99% accepted to be fingerprinted. No fingerprinting faults were recorded at baseline and the level was under 1% at round two. Over 80% of the participants were seen at round two and of these, 16.3%, had moved to a new location whilst the majority, 85%, stayed within the same village. Movements between villages were mainly observed for those resident in large villages. Those who did not consider a fishing village to be their permanent home were less likely to be migrants than permanent residents (adjusted odds ratio = 0.37, 95%CI:0.15-0.94). CONCLUSION: Use of fingerprinting in fishing populations is feasible and acceptable. It is possible to track this mobile population for clinical trials or health services using this technology since most movements could be traced within and between villages