The impact of delays on maternal and neonatal outcomes in Ugandan public health facilities : the role of absenteeism

Maternal mortality in low and middle income countries (LMICs) continues to remain high. The Ugandan Ministry of Health’s Strategic Plan suggests that little, if any, progress has been made in Uganda in terms of improvements in Maternal Health (Millennium Development Goal 5) and, more specifically, in reducing maternal mortality (MOH, 2010:43). Furthermore, the UNDP report on the MDGs describes Uganda’s progress as ‘stagnant’ (2013: iii). The importance of understanding the impact of delays on maternal and neonatal outcomes in low resource settings has been established for some time. Indeed, the ‘3-delays’ model has exposed the need for holistic multi-disciplinary approaches focused on systems change as much as clinical input. The model exposes the contribution of social factors shaping individual agency and care seeking behaviour. It also identifies complex access issues which, when combined with the lack of timely and adequate care at referral facilities, contributes to extensive and damaging delays. It would be hard to find a piece of research on this topic that does not reference human resource factors or ‘staff shortages’ as a key component of this ‘puzzle’. Having said that, it is rare indeed to see these human resource factors explored in any detail. In the absence of detailed critique (implicit) ‘common sense’ presumptions prevail: namely that the economic conditions at national level lead to inadequacies in the supply of suitably qualified health professionals exacerbated by losses to international emigration. Eight years’ experience of action-research interventions in Uganda combining a range of methods have lead us to a rather stark conclusion: the single most important factor contributing to delays and associated adverse outcomes for mothers and babies in Uganda is the failure of doctors to be present at work during contracted hours. Failure to acknowledge and respond to this sensitive problem will ultimately undermine all other interventions including professional voluntarism which relies on local ‘co-presence’ to be effective (author ref, 2014). Important steps forward could be achieved within the current resource framework, if the political will existed. International NGOS have exacerbated this problem encouraging forms of internal ‘brain drain’ particularly among doctors. Arguably the system as it is rewards doctors for non-compliance resulting in massive resource inefficiencies

Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research ‘cycles’ designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach ‘key populations’ at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy

Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research ‘cycles’ designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach ‘key populations’ at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy

Frugal innovation in wound management within a low resource inpatient setting: a case series

This article highlights challenges of wound care in low resource settings, considering opportunities for frugal innovation and our experiences while creating virtual wound care clinics across two global communities. In addition, we will discuss four real cases presented within the virtual clinics. An adaptation of the widely accepted tissues, infection, moisture, edge, regeneration and repair of tissue, and social factors (TIMERS) wound assessment is also proposed with considerations for low-resource settings. Method: From March to December 2021 the University of Salford engaged in a virtual wound clinic initiative with colleagues in Fort Portal Regional Referral Hospital. Results: The clinics provided opportunities for professional and academic development of students on postgraduate tissue viability module in Salford, while empowering nurses and midwives in Uganda in taking their place at the centre of multidisciplinary teams in care delivery Furthermore, it created links between the university and clinicians in Uganda to develop the delivery of evidence-based wound management. Throughout this period, challenges associated with low resources were highlighted and, in some cases, innovative approaches to managing wound care were adopted to account for this. Conclusions: The development and delivery of the virtual wound care clinics between the University of Salford and Fort Portal Regional Referral Hospital provided an opportunity for reflection on practice. This led to development of a Fit4purpose wound dressing, revision of evidence-based guidelines, deeper understanding of the scarcity of essential items and frugal practice, and examination of skin tone bias in the signs and symptoms of wound infection in patients with dark skin tones

High and Persistent HIV Seroincidence in Men Who Have Sex with Men across 47 U.S. Cities

OBJECTIVE: To provide HIV seroincidence data among men who have sex with men (MSM) in the United States and to identify predictive factors for seroconversion. METHODS: From 1998-2002, 4684 high-risk MSM, age 18-60 years, participated in a randomized, placebo-controlled HIV vaccine efficacy trial at 56 U.S. clinical trial sites. Demographics, behavioral data, and HIV status were assessed at baseline and 6 month intervals. Since no overall vaccine efficacy was detected, data were combined from both trial arms to calculate HIV incidence based on person-years (py) of follow-up. Predictors of seroconversion, adjusted hazards ratio (aHR), were evaluated using a Cox proportional hazard model with time-varying covariates. RESULTS: Overall, HIV incidence was 2.7/100 py and was relatively uniform across study sites and study years. HIV incidence was highest among young men and men reporting unprotected sex, recreational drug use, and a history of a sexually transmitted infection. Independent predictors of HIV seroconversion included: age 18-30 years (aHR = 2.4; 95% CI 1.4,4.0), having >10 partners (aHR = 2.4; 95% CI 1.7,3.3), having a known HIV-positive male sex partner (aHR = 1.6; 95% CI 1.2, 2.0), unprotected anal intercourse with HIV positive/unknown male partners (aHR = 1.7; 95% CI 1.3, 2.3), and amphetamine (aHR = 1.6; 95% CI 1.1, 2.1) and popper (aHR = 1.7; 95% CI 1.3, 2.2) use. CONCLUSIONS: HIV seroincidence was high among MSM despite repeated HIV counseling and reported declines in sexual risk behaviors. Continuing development of new HIV prevention strategies and intensification of existing efforts will be necessary to reduce the rate of new HIV infections, especially among young men

Prosthetics services in Uganda : a series of studies to inform the design of a low cost, but fit-for-purpose, body-powered prosthesis

The majority of people with upper limb absence (PWULA) live in lower, or middle-income countries (LMICs). However, efforts to develop improved prostheses have largely focused on electrically powered devices, sustainable deployment of which, in LMICs, is difficult. In the ‘Fit-for-purpose, affordable body-powered prostheses’ project, teams from the UK, Uganda and Jordan are developing mechanically-operated prostheses, optimised for LMICs, and establishing local methods for fabrication, fitting and evaluation. Here we first report on preliminary studies aimed at grounding the project in the reality of current prosthetics services and the experiences of people with limb absence in Uganda. Finally, we outline our ongoing work in the context of our findings. In our first two studies we reviewed current prosthetics and associated repair services. An issue which came up repeatedly was the difficulty faced by orthopaedic technologists in accessing componentry/materials. All specialised prosthetics components and materials are imported, often at a high cost. Purchasing does not appear to be well coordinated between centres, meaning potential economies of scale are not being fully exploited. Although there is supposed to be government funding for prosthetics, in practice budgets are often inadequate and a reliance on donations is common. The resource limitations mean Orthopaedic Technologists often resort to ad-hoc solutions; unsurprisingly perhaps, failures in prostheses were reported. In particular, lamination-based socket manufacture is very difficult, given the complexity (and cost) of the processes involved. Repair services are also limited, in part also due to problems accessing materials/components. Despite (or in part, as a result of) these challenges, the orthopaedic technologists are generally an extremely resourceful and multi-skilled group and there is genuine enthusiasm to see services improve. Further, there is a growth in interest and capabilities in the area of medical device innovation. In the third of our studies, we interviewed 17 PWULA and present preliminary results from the analysis of a subset of five participants. Firstly, we found that only 2 of the participants reported experience with using an upper limb prosthesis, again supporting the picture which emerged from the other studies. The findings illustrate the emergence of four key themes: a) attitude towards disability; b) barriers to prosthesis use; c) coping without a prosthesis; and d) communication with other PWULA. Although attitudes to those with limb loss varied, participants reported impacts in terms of social isolation and a mixed experience of emotions that appeared predominantly negative; barriers to prosthesis use were broader than just cost and functionality, and included a lack of training and psychological support; given that it is difficult to access an upper limb prosthesis, PWULA have found ways to perform daily life activities without relying on one; finally, most PWULA find the suggestion of communicating with other people with the same experience appealing. In our project we are addressing some of the issues found in the preliminary studies. To make socket manufacture less dependent on access to imported materials and specialised equipment, we are investigating the development of lattice-style, adjustable sockets, made from locally available materials. We are also investigating alternatives to the traditional harness-controlled, body-powered prosthetic hands. Given that clinicians have no objective means of evaluating the value of the prosthesis to their clients, we are testing the use of low-cost digital monitoring tools. We are also exploring the potential value of using mobile-phones to reduce the isolation of PWULA. Finally, we are exploring how these innovations may be translated into the Ugandan health setting

Organisational barriers to the facilitation of overseas volunteering and training placements in the NHS

Background Undertaking a period of voluntary work or a professional placement overseas has long been a feature of medical training in the UK. There are now a number of high profile National Health Service (NHS) initiatives aimed at increasing access to such opportunities for staff at all levels. We present findings from a qualitative study involving a range of NHS staff and other stakeholders which explored barriers to participation in these activities. Methods A grounded theory methodology was drawn upon to conduct thematic based analysis. Our data included in-depth, semi-structured interviews with a range of returned volunteers, non-volunteers and other stakeholders (n=51) who were, or had been, employed by the NHS. Results There are significant barriers to placement and volunteering activity stemming from structural and organisational shortcomings within the NHS. Difficulties in filling clinical roles has a significant impact on the ability of staff to plan and undertake independent placements. There is currently no clearly defined pathway within the NHS by which the majority of grades can apply for, or organise, a period of overseas voluntary or professional placement activity. There were divergent views on the relevance and usefulness of overseas professional placements. Conclusions We argue that in the context of current UK policy initiatives aimed at facilitating overseas volunteer and professional placement activity, urgent attention needs to be given to the structural and organisational framework within which such initiatives will be required to work

Children’s Agency in Translocal Roma Families

Peer reviewe