Severe neurological sequelae and behaviour problems after cerebral malaria in Ugandan children

BACKGROUND: Cerebral malaria is the most severe neurological complication of falciparum malaria and a leading cause of death and neuro-disability in sub-Saharan Africa. This study aimed to describe functional deficits and behaviour problems in children who survived cerebral malaria with severe neurological sequelae and identify patterns of brain injury. FINDINGS: Records of children attending a specialist child neurology clinic in Uganda with severe neurological sequelae following cerebral malaria between January 2007 and December 2008 were examined to describe deficits in gross motor function, speech, vision and hearing, behaviour problems or epilepsy. Deficits were classified according to the time of development and whether their distribution suggested a focal or generalized injury. Any resolution during the observation period was also documented. Thirty children with probable exposure to cerebral malaria attended the clinic. Referral information was inadequate to exclude other diagnoses in 7 children and these were excluded. In the remaining 23 patients, the commonest severe deficits were spastic motor weakness (14), loss of speech (14), hearing deficit (9), behaviour problems (11), epilepsy (12), blindness (12) and severe cognitive impairment (9). Behaviour problems included hyperactivity, impulsiveness and inattentiveness as in attention deficit hyperactivity disorder (ADHD) and conduct disorders with aggressive, self injurious or destructive behaviour. Two patterns were observed; a) immediate onset deficits present on discharge and b) late onset deficits. Some deficits e.g. blindness, resolved within 6 months while others e.g. speech, showed little improvement over the 6-months follow-up. CONCLUSIONS: In addition to previously described neurological and cognitive sequelae, severe behaviour problems may follow cerebral malaria in children. The observed differences in patterns of sequelae may be due to different pathogenic mechanisms, brain regions affected or extent of injury. Cerebral malaria may be used as a new model to study the pathogenesis of ADHD

Perceptions of newly admitted undergraduate medical students on experiential training on community placements and working in rural areas of Uganda

<p>Abstract</p> <p>Background</p> <p>Uganda has an acute problem of inadequate human resources partly due to health professionals' unwillingness to work in a rural environment. One strategy to address this problem is to arrange health professional training in rural environments through community placements. Makerere University College of Health Sciences changed training of medical students from the traditional curriculum to a problem-based learning (PBL) curriculum in 2003. This curriculum is based on the SPICES model (student-centered, problem-based, integrated, community-based and services oriented). During their first academic year, students undergo orientation on key areas of community-based education, after which they are sent in interdisciplinary teams for community placements. The objective was to assess first year students' perceptions on experiential training through community placements and factors that might influence their willingness to work in rural health facilities after completion of their training.</p> <p>Methods</p> <p>The survey was conducted among 107 newly admitted first year students on the medical, nursing, pharmacy and medical radiography program students, using in-depth interview and open-ended self-administered questionnaires on their first day at the college, from October 28-30, 2008. Data was collected on socio-demographic characteristics, motivation for choosing a medical career, prior exposure to rural health facilities, willingness to have part of their training in rural areas and factors that would influence the decision to work in rural areas.</p> <p>Results</p> <p>Over 75% completed their high school from urban areas. The majority had minimal exposure to rural health facilities, yet this is where most of them will eventually have to work. Over 75% of the newly admitted students were willing to have their training from a rural area. Perceived factors that might influence retention in rural areas include the local context of work environment, support from family and friends, availability of continuing professional training for career development and support of co-workers and the community.</p> <p>Conclusion</p> <p>Many first year students at Makerere University have limited exposure to health facilities in rural areas and have concerns about eventually working there.</p

Makerere University College of Health Sciences’ role in addressing challenges in health service provision at Mulago National Referral Hospital

<p>Abstract</p> <p>Background</p> <p>Mulago National Referral Hospital (MNRH), Uganda’s primary tertiary and teaching hospital, and Makerere University College of Health Sciences (MakCHS) have a close collaborative relationship. MakCHS students complete clinical rotations at MNRH, and MakCHS faculty partner with Mulago staff in clinical care and research. In 2009, as part of a strategic planning process, MakCHS undertook a qualitative study to examine care and service provision at MNRH, identify challenges, gaps, and solutions, and explore how MakCHS could contribute to improving care and service delivery at MNRH.</p> <p>Methods</p> <p>Key informant interviews (n=23) and focus group discussions (n=7) were conducted with nurses, doctors, administrators, clinical officers and other key stakeholders. Interviews and focus groups were tape recorded and transcribed verbatim, and findings were analyzed through collaborative thematic analysis.</p> <p>Results</p> <p>Challenges to care and service delivery at MNRH included resource constraints (staff, space, equipment, and supplies), staff inadequacies (knowledge, motivation, and professionalism), overcrowding, a poorly functioning referral system, limited quality assurance, and a cumbersome procurement system. There were also insufficiencies in the teaching of professionalism and communication skills to students, and patient care challenges that included lack of access to specialized services, risk of infections, and inappropriate medications.</p> <p>Suggestions for how MakCHS could contribute to addressing these challenges included strengthening referral systems and peripheral health center capacity, and establishing quality assurance mechanisms. The College could also strengthen the teaching of professionalism, communication and leadership skills to students, and monitor student training and develop courses that contribute to continuous professional development. Additionally, the College could provide in-service education for providers on professionalism, communication skills, strategies that promote evidence-based practice and managerial leadership skills.</p> <p>Conclusions</p> <p>Although there are numerous barriers to delivery of quality health services at MNRH, many barriers could be addressed by strengthening the relationship between the Hospital and MakCHS. Strategic partnerships and creative use of existing resources, both human and financial, could improve the quality of care and service delivery at MNRH. Improving services and providing more skills training could better prepare MakCHS graduates for leadership roles in other health care facilities, ultimately improving health outcomes throughout Uganda.</p

Severe neurological sequelae and behaviour problems after cerebral malaria in Ugandan children

Abstract Background Cerebral malaria is the most severe neurological complication of falciparum malaria and a leading cause of death and neuro-disability in sub-Saharan Africa. This study aimed to describe functional deficits and behaviour problems in children who survived cerebral malaria with severe neurological sequelae and identify patterns of brain injury. Findings Records of children attending a specialist child neurology clinic in Uganda with severe neurological sequelae following cerebral malaria between January 2007 and December 2008 were examined to describe deficits in gross motor function, speech, vision and hearing, behaviour problems or epilepsy. Deficits were classified according to the time of development and whether their distribution suggested a focal or generalized injury. Any resolution during the observation period was also documented. Thirty children with probable exposure to cerebral malaria attended the clinic. Referral information was inadequate to exclude other diagnoses in 7 children and these were excluded. In the remaining 23 patients, the commonest severe deficits were spastic motor weakness (14), loss of speech (14), hearing deficit (9), behaviour problems (11), epilepsy (12), blindness (12) and severe cognitive impairment (9). Behaviour problems included hyperactivity, impulsiveness and inattentiveness as in attention deficit hyperactivity disorder (ADHD) and conduct disorders with aggressive, self injurious or destructive behaviour. Two patterns were observed; a) immediate onset deficits present on discharge and b) late onset deficits. Some deficits e.g. blindness, resolved within 6 months while others e.g. speech, showed little improvement over the 6-months follow-up. Conclusions In addition to previously described neurological and cognitive sequelae, severe behaviour problems may follow cerebral malaria in children. The observed differences in patterns of sequelae may be due to different pathogenic mechanisms, brain regions affected or extent of injury. Cerebral malaria may be used as a new model to study the pathogenesis of ADHD.</p

Poverty, life events and the risk for depression in Uganda.

BACKGROUND: Understanding the determinants of major depression in sub-Saharan Africa is important for planning effective intervention strategies. OBJECTIVE: To investigate the social and life-event determinants of major depressive disorder in the African sociocultural context of rural Uganda. METHODS: A cross-section survey was carried out in 14 districts in Uganda from 1 June 2003 to 30 October 2004. 4,660 randomly selected respondents (15 years and above) were interviewed. The primary outcome was the presence of 'probable major depressive disorder' (PMDD) as assessed by the Hopkins symptom checklist. RESULTS: The prevalence of PMDD was 29.3% (95% confidence interval, 28.0-30.6%). Factors independently associated with depression in both genders included: the ecological factor, district; age (increase with each age category after 35 years); indices of poverty and deprivation (no formal education, having no employment, broken family, and socioeconomic classes III-V). Only a few adverse life events, notably those suggestive of a disrupted family background (death of a father in females and death of a mother in males) were associated with increased risk. CONCLUSION: Socioeconomic and sociodemographic factors, operating at both ecological and the individual level are the strongest independent determinants of depression. Adverse life events were less strongly associated with depression in this sample