Edward Galiwango

Delayed care seeking for fatal pneumonia in children aged under five years in Uganda: a case-series study

OBJECTIVE To review individual case histories of children who had died of pneumonia in rural Uganda and to investigate why these children did not survive. METHODS This case-series study was done in the Iganga/Mayuge demographic surveillance site, Uganda, where 67 000 people were visited once every 3 months for population-based data and vital events. Children aged 1-59 months from November 2005 to August 2007 were included. Verbal and social autopsies were done to determine likely cause of death and care-seeking actions. FINDINGS Cause of death was assigned for 164 children, 27% with pneumonia. Of the pneumonia deaths, half occurred in hospital and one-third at home. Median duration of pneumonia illness was 7 days, and median time taken to seek care outside the home was 2 days. Most first received drugs at home: 52% antimalarials and 27% antibiotics. Most were taken for care outside the home, 36% of whom first went to public hospitals. One-third of those reaching the district hospital were referred to the regional hospital, and 19% reportedly improved after hospital treatment. The median treatment cost for a child with fatal pneumonia was US

Discontinuation of cost sharing in Uganda

5.8. CONCLUSION There was mistreatment with antimalarials, delays in seeking care and likely low quality of care for children with fatal pneumonia. To improve access to and quality of care, the feasibility and effect on mortality of training community health workers and drug vendors in pneumonia and malaria management with prepacked drugs should be tested.

Spatial analysis of determinants of choice of treatment provider for fever in under-five children in Iganga, Uganda

OBJECTIVE To assess the effects of ending cost sharing on use of outpatient services and how this was perceived by health workers and members of a health unit management committee. METHODS From 10 districts across Uganda, 78 health facilities were selected. Attendance at these facilities was assessed for eight months before and 12 months after cost sharing ended. The data represented 1 966 522 outpatient visits. Perceptions about the impact of ending cost sharing were obtained from the 73 health workers and 78 members of the health unit management committee who were available. FINDINGS With the end of cost sharing, the mean monthly number of new visits increased by 17 928 (53.3%), but among children aged <5 years the increase was 3611 (27.3%). Mean monthly reattendances increased by 2838 (81.3%) among children aged <5 years and 1889 (24.3%) among all people. Attendances for immunizations, antenatal clinics, and family planning all increased, despite these services having always been free. Health workers reported a decline in morale, and many health unit management committees no longer met regularly. CONCLUSION Use of all services increased - even those that had never before been subject to fees. The loss of some autonomy by the health facility and diminished community governance of health facilities may have long term negative effects.

A new screening instrument for disability in low-income and middle-income settings: application at the Iganga-Mayuge Demographic Surveillance System (IM-DSS), Uganda

Although health facilities and drug shops are the main alternatives to home management of fever in children in Uganda, the influence of distance on the choice of treatment provider by caretakers is still unclear. We examined the spatial distribution of choice of treatment provider for fever in under-five children and the influence of household and geographical factors. Spatial and regression analysis of choices of treatment provider was done using data from a 2-week recall survey conducted in the Iganga-Mayuge Health and Demographic Surveillance Site. Of 3483 households with febrile children, 45% of caretakers treated the child at home, 33% took the child to a health facility, and 22% obtained treatment at drug shops. The distance to access care outside the home was crucial as seen in the greater preference for treatment at home or at drug shops among caretakers living more than 3 km from health facilities. The influence of proximity to health facilities in the choice of treatment provider highlights the need for greater access to health care services. The current Uganda Ministry of Health threshold of 5 km for access to health facilities needs to be reviewed for rural areas.

Characterizing disability at the Iganga-Mayuge Demographic Surveillance System (IM-DSS), Uganda.

Objective The measurement of disability in low-income countries is recognised as a major deficiency in health information systems, especially in Africa. The Iganga and Mayuge Demographic Surveillance System (IM-DSS) in Uganda provides a special opportunity to develop population-based data to inform national health policies and evaluate innovations in assessing the burden of disability in Uganda. In this study, we apply a new instrument to screen for physical disabilities at the IM-DSS. The study utilised a modified version of the short set of questions proposed by the Washington Group on Disability Statistics. The instrument was applied at the household level and information was collected on all individuals over the age of 5, who were residents of the IM-DSS. Setting The study was based at the IM-DSS, which covers the parts of Iganga and Mayuge districts in Eastern Uganda. Participants 57 247 individuals were included in the survey, with 51% of the study population being women. Primary outcomes Activity limitations Results The overall prevalence of physical disability at the IM-DSS was 9.4%, with vision being the most common type of difficulty reported in this population, and communication being least prevalent. Disability was less likely to be observed among males than their female counterparts (OR 0.75; 95% CI 0.71 to 0.81; p<0.001). Statistically significant associations were found between disability and increasing age, as well as disability and decreasing household wealth status. Conclusions This study shows that the modified short set of questions can be readily applied in a DSS setting to obtain estimates on the prevalence and types of disability at the population level. This instrument could be adapted for use to screen for disability in other LMIC settings, providing estimates that are comparable across different global regions and populations.

Caregiving for Uganda's elders with disability: Using cross-sectional surveillance data to identify healthcare service gaps in low- and middle-income settings

Abstract Purpose: There is a need to better measure disability as an outcome to understand the magnitude of the problem and its impact on health and socio-economic status. The aim of this study was to characterize the physical disabilities present at the Iganga-Mayuge Demographic Surveillance Site (IM-DSS) in Uganda. Methods: WHODAS 2.0 was used to examine the consequences of disability on activity limitations and participation in society. One thousand five hundred and fourteen individuals over the age of 18 at the IM-DSS with previously identified physical disabilities were included. Total and domain scores were calculated, and regression analyses examined differences by age, sex, education, occupation and SES. Results: The mean total score was 40.72. Domain 2 – getting around, had the highest mean score (57.21), followed by household activities (55.18). Domains 5.2 (work/school activities) and 6 (participation in society) also had relatively high mean scores – 47.71 and 49.44, respectively. Conclusion: This study serves as an indication of what the major limitations are among individuals in rural Uganda with physical disabilities. In general, individuals with disabilities had the most trouble on getting around, life activities and participation in society. This can guide public health planners and policy-makers on priorities to ameliorate the impact of disabilities in this population. Implications for Rehabilitation This study found that in general, individuals with disabilities had the most trouble on getting around, life activities and participation in society. This can guide public health planners and policy-makers on rehabilitation priorities to ameliorate the impact of disabilities in this population. Efforts can be made to develop and implement rehabilitation programs that cater to the needs of vulnerable populations including females and older individuals. Programs that focus on education and employment for physically disabled individuals ought to be given priority. These could include legislative changes, and modification of the physical environment, among others.

Prevention of mother-to-child transmission of HIV in rural Uganda: Modelling effectiveness and impact of scaling-up PMTCT services

BACKGROUND Disability is highly prevalent in low-and-middle-income countries (LMICs), but there is a relative dearth of disability and caregiving research from LMICs. OBJECTIVE To examine type and severity of disability experienced by individuals 60 years and older, caregivers and type of caregiving assistance, and the interrelationships between sociodemographic factors involved in Uganda. METHODS Data was collected from two Eastern Ugandan districts using the WHO Disability Assessment Schedule 2.0. Data on availability of caregiver was analyzed for 816 participants with disability. Group comparisons and regression analyses examined differences based on caregiver availability. RESULTS Approximately 66% of individuals with disability had a caregiver. The mean age of those with a caregiver (74.7 ± 8.9 years) was statistically significantly (p = .0004) higher than that of individuals without caregiver (72.4 ± 8.2 years). Significant differences based on caregiver availability were found relative to sex (p = .009), age (p≤.001), education level (p≤.001), occupation (p≤.001) and head of household status (p≤.001). The most frequent types of disability were related to vision (78.4%) and ambulation (71.7%). Caregiving most often fell to family members. Logistic regression results showed that individuals over the age of 80 years were 2.51 times more likely to have a caregiver compared to those 60-69 years (p≤.001). Those in the highest wealth quintile were 1.77 times more likely to have a caregiver. CONCLUSIONS Findings demonstrate gaps in caring for aging individuals with disabilities in LMICs and highlight the importance of understanding caregiver access in generating effective healthy aging initiatives and long-term care systems.

The effect of community dialogues and sensitization on patient reporting of adverse events in rural Uganda: uncontrolled before-after study

Background The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010. However, the coverage estimate is subject to overestimations since it only considers enrolment and not completion of the PMTCT programme. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care (ANC), HIV testing, and ARVs for the woman and the baby. Objective The objective was to estimate the number of children infected with HIV in a district population, using empirical data on uptake of PMTCT components combined with data on MTCT rates. Design This study is based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008-2010. We later modelled different scenarios assuming increased uptake of specific PMTCT components to estimate the impact on MTCT for each scenario. Results In this setting, HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction. Conclusions Our results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT. Further, to determine the effectiveness of PMTCT programmes in different settings, it is crucial to analyse at what stages of the PMTCT cascade that dropouts occur to target interventions accordingly.Background The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010. However, the coverage estimate is subject to overestimations since it only considers enrolment and not completion of the PMTCT programme. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care (ANC), HIV testing, and ARVs for the woman and the baby. Objective The objective was to estimate the number of children infected with HIV in a district population, using empirical data on uptake of PMTCT components combined with data on MTCT rates. Design This study is based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008–2010. We later modelled different scenarios assuming increased uptake of specific PMTCT components to estimate the impact on MTCT for each scenario. Results In this setting, HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction. Conclusions Our results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT. Further, to determine the effectiveness of PMTCT programmes in different settings, it is crucial to analyse at what stages of the PMTCT cascade that dropouts occur to target interventions accordingly.

Assessing feasibility of resources at health facilities in Uganda to diagnose pregnancy and neonatal outcomes

Background The patients that experience adverse events are in the best position to report them, only if they were empowered to do so. Systematic community engagement and support to patients in a rural setting to monitor any potential harm from medicines should provide evidence for patient safety. Methods This paper describes an uncontrolled before and after study aimed at assessing the effect of a community engagement strategy, the Community Dialogues and Sensitization (CDS) intervention between January and April 2017, on the knowledge, attitude and practice of reporting adverse drug events by community members in the two eastern Ugandan districts. A representative cross-sectional baseline household survey was done prior to the intervention in September 2016 (n=1034) and the end-line survey (n=827) in July 2017. Results After implementation of the CDS intervention, there was an overall 20% (95% CI=16- 25) increase in awareness about adverse drug events in the community. The young people (15- 24 years) demonstrated a 41% (95% CI =31-52) increase and the un-educated showed a 50% (95% CI=37-63) increase in awareness about adverse drug events. The attitudes towards reporting increased overall by 5% in response to whether there was a need to report ADEs (95% CI =3-7). An overall 115% (95% CI =137-217) increase in the population that had ever experienced ADEs was also reported. Conclusion Our evaluation shows that the CDS intervention increases knowledge, improves attitudes by catalyzing discussions among community members and health workers on health issues and monitoring safety of medicines.

Adverse perinatal events, treatment gap, and positive family history linked to the high burden of active convulsive epilepsy in Uganda: A population‐based study

BACKGROUND Standardized case definitions for obstetric and neonatal outcomes were developed by the Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project. These definitions can facilitate comparable assessment of maternal immunization safety surveillance and research. This study assessed the capabilities of health centers (HC) in Uganda to implement these definitions in a low income country, which has not been explored. METHODS Healthcare practitioners at 15 government-accredited health centers and one government-funded district hospital in the Iganga-Mayuge Health and Demographic Surveillance Site (IMHDSS) in Uganda were interviewed about the facilitys clinical diagnostic and laboratory capabilities. Five obstetric and five neonatal case definitions were evaluated. Definitions with the highest diagnostic certainty were designated as level 1, while definitions that decreased in certainty were designated as level 2 or 4. HCs were evaluated on diagnostic and laboratory capabilities to apply the GAIA definitions. RESULTS Higher-level facilities in the IMHDSS demonstrated the ability to diagnose more specific levels of the GAIA obstetric and neonatal outcomes than lower-level facilities. Furthermore, for the neonatal outcome assessment, there was an increased ability to diagnose outcomes moving from GAIA level 1 to level 3. CONCLUSIONS The ability of health centers to implement globally standardized definitions is promising for implementation of standardized data collection methods for global vaccine safety surveillance and research.