Maternal Attitudes about Objectively Monitored Bednet Use in Rural Uganda

Insecticide-treated bednets (ITNs) are a mainstay of malaria prevention, yet poor adherence poses a major barrier to effective prevention. Self-reports of bednet use suffer from recall and social desirability biases. We have designed a device that electronically records ITN usage longitudinally. SmartNet consists of circuits made from a conductive fabric interwoven into the sides and top of a rectangular ITN. Digital sampling of the state of these circuits allows for determining whether the SmartNet is deployed for use or folded up. We conducted a study among pregnant women and women with children <5 years in Uganda to determine attitudes about objective bednet monitoring and SmartNet. Fifty women were interviewed with an average age of 27 years and 2.3 children. Twenty-two percent were pregnant. Ninety-five percent had used a bednet and 90% reported having a bednet at home. After displaying a SmartNet, 92% thought it would be easy to use and 100% expressed interest in using SmartNet. Concerns about SmartNet included washing the net, worries about being monitored while asleep, and worries about users removing the device components. Objective monitoring of ITN use appears to be acceptable among women in rural Uganda, setting the stage for further SmartNet field testing

A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study

Background: Up to 50 % of HIV-infected persons in sub-Saharan Africa are lost from care between HIV diagnosis and antiretroviral therapy (ART) initiation. Structural barriers, including cost of transportation to clinic and poor communication systems, are major contributors. Methods: We conducted a prospective, pragmatic, before-and-after clinical trial to evaluate a combination mobile health and transportation reimbursement intervention to improve care at a publicly operated HIV clinic in Uganda. Patients undergoing CD4 count testing were enrolled, and clinicians selected a result threshold that would prompt early return for ART initiation or further care. Participants enrolled in the pre-intervention period (January – August 2012) served as a control group. Participants in the intervention period (September 2012 – November 2013) were randomized to receive daily short message service (SMS) messages for up to seven days in one of three formats: 1) messages reporting an abnormal result directly, 2) personal identification number-protected messages reporting an abnormal result, or 3) messages reading “ABCDEFG” to confidentially convey an abnormal result. Participants returning within seven days of their first message received transportation reimbursements (about $6USD). Our primary outcomes of interest were time to return to clinic and time to ART initiation. Results: There were 45 participants in the pre-intervention period and 138 participants in the intervention period (46, 49, and 43 in the direct, PIN, and coded groups, respectively) with low CD4 count results. Median time to clinic return was 33 days (IQR 11–49) in the pre-intervention period and 6 days (IQR 3–16) in the intervention period (P < 0.001); and median time to ART initiation was 47 days (IQR 11–75) versus 12 days (IQR 5–19), (P < 0.001). In multivariable models, participants in the intervention period had earlier return to clinic (AHR 2.32, 95 %CI 1.53 to 3.51) and earlier time to ART initiation (AHR 2.27, 95 %CI 1.38 to 3.72). All three randomized message formats improved time to return to clinic and time to ART initiation (P < 0.01 for all comparisons versus the pre-intervention period). Conclusions: A combination of an SMS laboratory result communication system and transportation reimbursements significantly decreased time to clinic return and time to ART initiation after abnormal CD4 test results. Trial registrations Clinicaltrials.gov NCT01579214, approved 13 April 2012. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0397-1) contains supplementary material, which is available to authorized users

Inhaled Nitric Oxide as an Adjunctive Treatment for Cerebral Malaria in Children: A Phase II Randomized Open-Label Clinical Trial

Background. Children with cerebral malaria (CM) have high rates of mortality and neurologic sequelae. Nitric oxide (NO) metabolite levels in plasma and urine are reduced in CM. Methods. This randomized trial assessed the efficacy of inhaled NO versus nitrogen (N2) as an adjunctive treatment for CM patients receiving intravenous artesunate.We hypothesized that patients treated with NO would have a greater increase of the malaria biomarker, plasma angiopoietin-1 (Ang-1) after 48 hours of treatment. Results. Ninety-two children with CM were randomized to receive either inhaled 80 part per million NO or N2 for 48 or more hours. Plasma Ang-1 levels increased in both treatment groups, but there was no difference between the groups at 48 hours (P = not significant [NS]). Plasma Ang-2 and cytokine levels (tumor necrosis factor-α, interferon- γ, interleukin [IL]-1β, IL-6, IL-10, and monocyte chemoattractant protein-1) decreased between inclusion and 48 hours in both treatment groups, but there was no difference between the groups (P = NS). Nitric oxide metabolite levels—blood methemoglobin and plasma nitrate—increased in patients treated with NO (both P \u3c .05). Seven patients in the N2 group and 4 patients in the NO group died. Five patients in the N2 group and 6 in the NO group had neurological sequelae at hospital discharge. Conclusions. Breathing NO as an adjunctive treatment for CM for a minimum of 48 hours was safe, increased blood methemoglobin and plasma nitrate levels, but did not result in a greater increase of plasma Ang-1 levels at 48 hours

Ambient PM2.5 Temporal Variation and Source Apportionment in Mbarara, Uganda

Air pollution is the leading environmental cause of death globally, and most mortality occurs in resource-limited settings such as sub-Saharan Africa. The African continent experiences some of the worst ambient air pollution in the world, yet there are relatively little African data characterizing ambient pollutant levels and source admixtures. In Uganda, ambient PM2.5 levels exceed international health standards. However, most studies focus only on urban environments and do not characterize pollutant sources. We measured daily ambient PM2.5 concentrations and sources in Mbarara, Uganda from May 2018 through February 2019 using Harvard impactors fitted with size-selective inlets. We compared our estimates to publicly available levels in Kampala, and to World Health Organization (WHO) air quality guidelines. We characterized the leading PM2.5 sources in Mbarara using x-ray fluorescence and positive matrix factorization. Daily PM2.5 concentrations were 26.7 µg m–3 and 59.4 µg m–3 in Mbarara and Kampala, respectively (p < 0.001). PM2.5 concentrations exceeded WHO guidelines on 58% of days in Mbarara and 99% of days in Kampala. In Mbarara, PM2.5 was higher in the dry as compared to the rainy season (30.8 vs. 21.3, p < 0.001), while seasonal variation was not observed in Kampala. PM2.5 concentrations did not vary on weekdays versus weekends in either city. In Mbarara, the six main ambient PM2.5 sources identified included (in order of abundance): traffic-related, biomass and secondary aerosols, industry and metallurgy, heavy oil and fuel combustion, fine soil, and salt aerosol. Our findings confirm that air quality in southwestern Uganda is unsafe and that mitigation efforts are urgently needed. Ongoing work focused on improving air quality in the region may have the greatest impact if focused on traffic and biomass-related sources

Know Your Audience: Predictors of Success for a Patient-Centered Texting App to Augment Linkage to HIV Care in Rural Uganda

Background: Despite investments in infrastructure and evidence for high acceptability, few mHealth interventions have been implemented in sub-Saharan Africa. Objective: We sought to (1) identify predictors of uptake of an mHealth application for a low-literacy population of people living with HIV (PLWH) in rural Uganda and (2) evaluate the efficacy of various short message service (SMS) text message formats to optimize the balance between confidentiality and accessibility. Methods: The trial evaluated the efficacy of a SMS text messaging app to notify PLWH of their laboratory results and request return to care for those with abnormal test results. Participants with a normal laboratory result received a single SMS text message indicating results were normal. Participants with an abnormal test result were randomized to 1 of 3 message formats designed to evaluate trade-offs between clarity and privacy: (1) an SMS text message that stated results were abnormal and requested return to clinic (“direct”), (2) the same message protected by a 4-digit PIN code (“PIN”), and (3) the message “ABCDEFG” explained at enrollment to indicate abnormal results (“coded”). Outcomes of interest were (1) self-reported receipt of the SMS text message, (2) accurate identification of the message, and (3) return to care within 7 days (for abnormal results) or on the date of the scheduled appointment (for normal results). We fit regression models for each outcome with the following explanatory variables: sociodemographic characteristics, CD4 count result, ability to read a complete sentence, ability to access a test message on enrollment, and format of SMS text message. Results: Seventy-two percent (234/385) of participants successfully receiving a message, 87.6% (219/250) correctly identified the message format, and 60.8% (234/385) returned to clinic at the requested time. Among participants with abnormal tests results (138/385, 35.8%), the strongest predictors of reported message receipt were the ability to read a complete sentence and a demonstrated ability to access a test message on enrollment. Participants with an abnormal result who could read a complete sentence were also more likely to accurately identify the message format (AOR 4.54, 95% CI 1.42-14.47, P=.01) and return to clinic appropriately (AOR 3.81, 95% CI 1.61-9.03, P=.002). Those who were sent a PIN-protected message were less likely to identify the message (AOR 0.11, 95% CI 0.03-0.44, P=.002) or return within 7 days (AOR 0.26, 95% CI 0.10-0.66, P=.005). Gender, age, and socioeconomic characteristics did not predict any outcomes and there were no differences in outcomes between those receiving direct or coded messages. Conclusions: Confirmed literacy at the time of enrollment was a robust predictor of SMS text message receipt, identification, and appropriate response for PLWH in rural Uganda. PIN-protected messages reduced odds of clinic return, but coded messages were as effective as direct messages and might augment privacy. Trial Registration: Clinicaltrials.gov NCT 01579214; https://clinicaltrials.gov/ct2/show/NCT01579214 (Archived by WebCite at http://www.webcitation.org/6Ww8R4sKq)

First-step validation of a text message-based application for newborn clinical management among pediatricians

Abstract Background Neonatal mortality is high in developing countries. Lack of adequate training and insufficient management skills for sick newborn care contribute to these deaths. We developed a phone application dubbed Protecting Infants Remotely by Short Message Service (PRISMS). The PRISMS application uses routine clinical assessments with algorithms to provide newborn clinical management suggestions. We measured the feasibility, acceptability and efficacy of PRISMS by comparing its clinical case management suggestions with those of experienced pediatricians as the gold standard. Methods Twelve different newborn case scenarios developed by pediatrics residents, based on real cases they had seen, were managed by pediatricians and PRISMS®. Each pediatrician was randomly assigned six of twelve cases. Pediatricians developed clinical case management plans for all assigned cases and then obtained PRISMS suggested clinical case managements. We calculated percent agreement and kappa (k) statistics to test the null hypothesis that pediatrician and PRISMS management plans were independent. Results We found high level of agreement between pediatricians and PRISMS for components of newborn care including: 10% dextrose (Agreement = 73.8%), normal saline (Agreement = 73.8%), anticonvulsants (Agreement = 100%), blood transfusion (Agreement =81%), phototherapy (Agreement = 90.5%), and supplemental oxygen (agreement = 69.1%). However, we found poor agreement with potential investigations such as complete blood count, blood culture and lumbar puncture. PRISMS had a user satisfaction score of 3.8 out of 5 (range 1 = strongly disagree, 5 = strongly agree) and an average PRISMS user experience score of 4.1 out of 5 (range 1 = very bad, 5 = very good). Conclusion Management plans for newborn care from PRISMS showed good agreement with management plans from experienced Pediatricians. We acknowledge that the level of agreement was low in some aspects of newborn care

Objective monitoring of Insecticide-treated bednet use to improve malaria prevention: SmartNet development and validation

Malaria is a serious health concern for three billion people worldwide, killing nearly 600,000 people a year. Insecticide-treated bednets (ITNs) are an effective and valuable tool for preventing malaria and hundreds of millions of ITNs have been distributed throughout sub-Saharan Africa. Nevertheless, our current methods for measuring ITN use are inadequate to inform malaria prevention programs. The most common method, self-reported ITN use, is limited by 1) social desirability, 2) recall and 3) sampling bias. An acceptable objective and longitudinal method of assessing adherence to ITN use would improve our ability to better understand the determinants of ITN use and design more effective malaria prevention interventions. We describe the development and initial proof-of-concept validity testing of an ITN adherence monitoring tool called SmartNet. SmartNet uses conductive thread interwoven into an ITN and a microcontroller to detect the state of the ITN. We tested SmartNet among five volunteers using the device over their beds in Boston, USA for two weeks with the goal of evaluating device reliability, accuracy and acceptability to inform future device improvements. The device recorded data for 63.1% (35172/55711) of installed two-minute time intervals, with 97.3% (19990/20539) of the recording errors relating to battery failures. Overall, the device was 71.7% (25204/35172) accurate in determining the state of the ITN (whether it was folded up or unfurled) and performed significantly better at detecting an unfurled ITN than a folded ITN, 77.3% versus 68.4% (p<0.001). Participants noted no significant acceptability concerns and all participants felt SmartNet was easy or very easy to use. SmartNet is a novel approach to objectively measure ITN adherence over time. Our results suggest a variety of device improvements to both extend reliability and improve performance of SmartNet prior to deployment in a malaria-endemic setting

ROC curve for SmartNet detection of bednet state using participant diaries as reference.

<p>ROC curve for SmartNet detection of bednet state using participant diaries as reference.</p