Dan Kibuule

Awareness of, responsiveness to and practice of patients’ rights at Uganda’s national referral hospital

Abstract Background The realisation of patients’ rights in resource-constrained and patient-burdened public health care settings in Uganda remains an obstacle towards quality health care delivery, health care-seeking behaviour and health outcomes. Although the Uganda Patients’ Charter of 2009 empowers patients to demand quality care, inequitable access and abuse remain common. Aim The study aimed to assess level of awareness of, responsiveness to and practice of patients’ rights amongst patients and health workers (HWs) at Ugandas national referral hospital, Mulago Hospital in Kampala. Methods A three-phase cross-sectional questionnaire-based descriptive survey was conducted amongst 211 patients, 98 HWs and 16 key informants using qualitative and quantitative data collection methods. The study was conducted in May–June 2012, 2.5 years after the launch of the Uganda Patients’ Charter. Results At least 36.5% of patients faced a challenge regarding their rights whilst seeking health care. Most of the patients (79%) who met a challenge never attempted to demand their rights. Most patients (81.5%) and HWs (69.4%) had never heard of the Uganda Patients’ Charter. Awareness of patients’ rights was significantly higher amongst HWs (70%) than patients (40%) (p < 0.01). Patients’ awareness was associated with education level (χ2 = 42.4, p < 0.001), employment status (χ2 = 33.6, p < 0.001) and hospital visits (χ2 = 3.9, p = 0.048). For HWs it was associated with education level (χ2 = 155.6, p < 0.001) and length of service (χ2 = 154.5, p <0.001). Patients feel powerless to negotiate for their rights and fear being discriminated against based on their ability to bribe HWs with money to access care, and political, socio-economic and tribal status. Conclusion and recommendations Awareness of, responsiveness to and practice of patients’ rights remains limited at Mulago Hospital. There is a need for urgent implementation of an integrated multilevel, multichannel, patient-centred approach that incorporates social services and addresses intrinsic patient, HW and health system factors to strengthen patients’ rights issues at the hospital.

Antibiotic use in acute respiratory infections in under-fives in Uganda: findings and implications.

ABSTRACT Background: Self-medication with antibiotics among households is common in Uganda. However, there are limited studies evaluating self-purchasing of antibiotics for acute respiratory infections (ARI) in the under-fives. Consequently, the objective of this study was to evaluate patterns of household self-medication with antibiotics in ARI among under-fives in Kampala. Methods: Descriptive cross-sectional observational design. Care takers at households were selected from five divisions of Kampala using the WHO 30-cluster method and interviewed using a standardized questionnaire in June - July 2011. Results: Out of the 200 households, most ARI cases 107 (53.5%; p = 0.322) were inappropriately managed. The prevalence of antibiotic use in ARI was 43% (p < 0.001). Amoxicillin (31.4%) and cotrimoxazole (30%) were the most self-medicated antibiotics. Antibiotics use was associated with pneumonia symptoms and access to antibiotics. Conclusions: Household use of antibiotics in ARIs among under-fives is suboptimal. There is an urgent need for guidelines on awareness to reduce self-medication of ARIs in Uganda.

Outcome of the first Medicines Utilization Research in Africa group meeting to promote sustainable and rational medicine use in Africa

The first Medicines Utilization Research in Africa group workshop and symposium brought researchers together from across Africa to improve their knowledge on drug utilization methodologies as well as exchange ideas. As a result, progress was made on drug utilization research and formulating future strategies to enhance the rational use of medicines in Africa. Anti-infectives were the principal theme for the 1-day symposium following the workshops. This included presentations on the inappropriate use of antibiotics as well as ways to address this. Concerns with adverse drug reactions and adherence to anti-retroviral medicines were also discussed, with poor adherence remaining a challenge. There were also concerns with the underutilization of generics. These discussions resulted in a number of agreed activities before the next conference in 2016.

Compliance to guidelines for the prescribing of antibiotics in acute infections at Namibia’s national referral hospital: a pilot study and the implications

ABSTRACT Background: Sub-optimal antibiotic prescribing remains a public health concern in Namibia. The objective was to determine the level and predictors of compliance to guidelines in the prescribing of antibiotics in acute infections at a national referral hospital in Namibia to improve future prescribing. Methods: An analytical cross-sectional survey design. The clinical records of patients receiving care were reviewed. Prescribing practices were assessed using a self- administered questionnaire with reference to Namibia Standard Treatment Guidelines (NSTG). Results: The majority of prescriptions (62%) complied with the NSTGs; however, lower than national targets (95%). Most prescriptions were empiric and prescribers typically made reference to the NSTG (58%). Diagnosed infections were principally respiratory infections (58%) and penicillins were the most used antibiotics. Good concurrence between signs and symptoms with the diagnosis indicated on the prescription - OR=5.2 (95% CI: 1.4, 19.2), a diagnosis of upper respiratory tract (p=0.001), oral-dental OR=0.1(95% CI: 0.03,0.3) and urogenital infections OR=0.3(95% CI: 0.1,0.95) and the prescribing of penicillins (p=0.001) or combination antibiotics and amphenicols were independent predictors of compliance to the NSTGs. The main behaviours associated with antibiotic prescribing were patient influences, clinical state, and access to guidelines. Conclusions: Compliance with NSTGs is suboptimal. Prescribing of combination antibiotics, penicillins and diagnosis of oral dental, genitourinary and ear, nose and throat infections were important predictors for NSTG compliance. There is a need to implement antibiotic indicators and stewardship programmes, and ensure access to NSTGs, to improve future antibiotic prescribing in Namibia.

Initiatives across countries to reduce antibiotic utilization and resistance patterns: impact and implications

Introduction: Greater accessibility to antibiotics has resulted in their excessive use, leading to increasing antimicrobial resistance (AMR) and strains on healthcare systems, with only a limited number of patients in ambulatory care treated according to guidelines. High rates of AMR are now seen across countries and continents, resulting in AMR becoming one of the most critical issues facing healthcare systems. It is estimated that AMR could potentially cause over 10 million deaths per year by 2050 unless addressed, resulting in appreciable economic consequences. There are also concerns with under-treatment especially if patients are forced to fund more expensive antibiotics as a result of AMR to first-line antibiotics and do not have available funds. Overprescribing of antibiotics is not helped by patient pressure even when physicians are aware of the issues. There is also extensive dispensing of antibiotics without a prescription, although this is now being addressed in some countries. Aim: Review interventions that have been instigated across continents and countries to reduce inappropriate antibiotic prescribing and dispensing, and associated AMR, to provide future guidance. Method: Narrative case history approach. Findings: A number of successful activities have been instigated to reduce inappropriate prescribing and dispensing of antibiotics across sectors. These include the instigation of quality indicators, suggested activities of pharmacists as well as single and multiple interventions among all key stakeholder groups. Multiple interlinking strategies are typically needed to enhance appropriate antibiotic prescribing and dispensing. The impact of ongoing activities need to be continually analysed to provide future direction if AMR rates, and their impact on subsequent morbidity, mortality and costs, are to be reduced.

Liver enzyme elevations in a cohort of HIV/AIDS patients on first-line antiretroviral therapy in Namibia: Findings and implications

Highlights • All antiretroviral therapies (ARTs) are potentially toxic to the liver. The rising incidence of ART induced adverse events has led to guideline revision.• The rising incidence of ART induced adverse events has led to guideline revision. Limited studies to date evaluating ART induced liver injury in these countries. This need to be addressed to guide future clinical practice.• Majority of patients developed significant ALT elevation within 3 months of ART initiation. No significant difference between mean ALT levels at baseline and month 6.• Patients with high risk of hepatocellular damage, female sex, and > grade 2 ALT elevations, and patients who test positive for HBV/HCV, should be monitored for at least 6 months after initiation of NVP and EFV based ART. Abstract Introduction All antiretroviral therapies (ARTs) are potentially toxic to the liver. In sub-Saharan Africa, the rising incidence of ART induced adverse events has complicated treatment leading to recent revisions of Namibian ART guidelines. Unfortunately there have been limited studies to date evaluating ART induced liver injury in Namibia to guide further revisions if needed. Objective Determine the current patterns and grades of ALT elevation in Namibia’s HIV/AIDS. Methods Retrospective cohort analysis. Patterns of alanine amino transferase (ALT) liver enzyme elevation were determined in a cohort of ART naïve HIV patients on firstline ART regimen in a referral hospital in Namibia over a 1 year treatment period. Patterns of ALT changes at baseline, 3 months and 6 months were analyzed using ANOVA and Bonferroni test for pairwise comparisons. Results Of 79 eligible patients, 72 developed significant ALT elevation within 3 months of ART initiation (F (3, 76) = 6.4, p = 0.002, η2 = 0.193). Four 4 (5.6%) and 1 (1.38%) patient respectively developed grade 2 and grade 3 ALT elevation by month 3. There was no significant difference between mean ALT levels at baseline and month 6. A CD4 count of <350 cells/mm3; female gender and age over 40 years were the main factors associated with moderate or severe ALT elevation. Conclusions First line ART commonly induces mild self-limiting liver enzyme elevation in Namibian HIV patients especially in the first 3 months. Consequently, there is a need to monitor ALT levels for at least 3 months after initiation mainly in high risk patients to reduce side-effect concerns. This is already happening.

Teaching Pharmaceutical Care to Pharmacists and Other Health Professionals

Educating pharmacists about pharmaceutical care begins with re-orientating them to the provision of care rather than the supply of a medicine. Then the pharmacist’s knowledge and understanding must be developed and tailored to the steps of providing care; assessing the problem, identifying and prioritizing problems, planning the interventions, implementing changes, monitoring, and follow-up. In order to do this, it is necessary to have integrated academic and work-based learning with appropriately qualified and experienced professionals who take on the roles of facilitators, supervisors, mentors, and coaches as necessary. Suitable methods of assessment help the learner to gage their progression.

Validity of World Health Organisation prescribing indicators in Namibia's primary health care: findings and implications

OBJECTIVE World Health Organization/International Network of Rational use of Drugs (WHO/INRUD) indicators are widely used to assess medicine use. However, there is limited evidence on their validity in Namibias primary health care (PHC) to assess the quality of prescribing. Consequently, our aim was to address this. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS An analytical cross-sectional survey design was used to examine and validate WHO/INRUD indicators in out-patient units of two PHC facilities and one hospital in Namibia from 1 February 2015 to 31 July 2015. The validity of the indicators was determined using two-by-two tables against compliance to the Namibian standard treatment guidelines (NSTG). The receiver operator characteristics for the WHO/INRUD indicators were plotted to determine their accuracy as predictors of compliance to agreed standards. A multivariate logistic model was constructed to independently determine the prediction of each indicator. MAIN OUTCOMES AND RESULTS Out of 1243 prescriptions; compliance to NSTG prescribing in ambulatory care was sub-optimal (target was >80%). Three of the four WHO/INRUD indicators did not meet Namibian or WHO targets: antibiotic prescribing, average number of medicines per prescription and generic prescribing. The majority of the indicators had low sensitivity and/or specificity. All WHO/INRUD indicators had poor accuracy in predicting rational prescribing. The antibiotic prescribing indicator was the only covariate that was a significant independent risk factor for compliance to NSTGs. CONCLUSION WHO/INRUD indicators showed poor accuracy in assessing prescribing practices in ambulatory care in Namibia. There is need for appropriate models and/or criteria to optimize medicine use in ambulatory care in the future.

Multidisciplinary and multisectoral coalitions as catalysts for action against antimicrobial resistance: Implementation experiences at national and regional levels

ABSTRACT The multi-faceted complexities of antimicrobial resistance (AMR) require consistent action, a multidisciplinary approach, and long-term political commitment. Building coalitions can amplify stakeholder efforts to carry out effective AMR prevention and control strategies. We have developed and implemented an approach to help local stakeholders kick-start the coalition-building process. The five-step process is to (1) mobilise support, (2) understand the local situation, (3) develop an action plan, (4) implement the plan, and (5) monitor and evaluate. We first piloted the approach in Zambia in 2004, then used the lessons learned to expand it for use in Ethiopia and Namibia and to the regional level through the Ecumenical Pharmaceutical Network [EPN]. Call-to-action declarations and workshops helped promote a shared vision, resulting in the development of national AMR action plans, revision of university curricula to incorporate relevant topics, infection control activities, engagement with journalists from various mass media outlets, and strengthening of drug quality assurance systems. Our experience with the coalition-building approach in Ethiopia, Namibia, Zambia, and with the EPN shows that coalitions can form in a variety of ways with many different stakeholders, including government, academia, and faith-based organisations, to organise actions to preserve the effectiveness of existing antimicrobials and contain AMR.

Predictors of tuberculosis treatment success under the DOTS program in Namibia

ABSTRACT Objectives: Optimal treatment success rates are critical to end tuberculosis in Namibia. Despite the scale-up of high quality directly observed therapy short-course strategy (DOTS) in Namibia, treatment success falls short of the global target of 90%. The objective of this study was to ascertain the predictors of treatment success rates under DOTS in Namibia to provide future direction. Methods: A nation-wide comparative analysis of predictors of treatment success was undertaken. Tuberculosis cases in the electronic tuberculosis register were retrospectively reviewed over a 10-year period, 2004–2016. The patient, programmatic, clinical, and treatment predictors of treatment success were determined by multivariate logistic regression modeling using R software. Results: 104,603 TB cases were registered at 300 DOTS sites in 37 districts. The 10-year period treatment success rate was 80%, and varied by region (77.2%–89.2%). The patient’s sex and age were not significant predictors. The independent predictors for treatment success as were: Region of DOTS implementation (p=0.001), type of directly observed treatment (DOT) supporter (p<0.001), sputum conversion at 2 months (p=0.013), DOT regimen (p<0.001), cotrimoxazole prophylaxis (p=0.002), and HIV co-infection (p=0.001). Conclusion: Targeted programmatic, clinical and treatment interventions are required to enhance DOTS treatment success in Namibia. These are now ongoing.