Esther Buregyeya

Tuberculosis knowledge, attitudes and health-seeking behaviour in rural Uganda

OBJECTIVES To assess tuberculosis (TB) knowledge, attitudes and health-seeking behaviour to inform the design of communication and social mobilisation interventions. SETTING Iganga/Mayuge Demographic Surveillance Site, Uganda. DESIGN Between June and July 2008, 18 focus group discussions and 12 key informant interviews were conducted, including parents of infants and adolescents and key informant interviews with community leaders, traditional healers and patients with TB. RESULTS People viewed TB as contagious, but not necessarily an airborne pathogen. Popular TB aetiologies included sharing utensils, heavy labour, smoking, bewitchment and hereditary transmission. TB patients were perceived to seek care late or to avoid care. Combining care from traditional healers and the biomedical system was common. Poverty, drug stock-outs, fear of human immunodeficiency virus (HIV) testing and length of TB treatment negatively affect health-seeking behaviour. Stigma and avoidance of persons with TB often reflects an assumption of HIV co-infection. CONCLUSION The communitys concerns about pill burden, quality of care, financial barriers, TB aetiology, stigma and preference for pluralistic care need to be addressed to improve early detection. Health education messages should emphasise the curability of TB, the feasibility of treatment and the engagement of traditional healers as partners in identifying cases and facilitating adherence to treatment.

Implementation of tuberculosis infection control in health facilities in Mukono and Wakiso districts, Uganda

AbstractBackgroundTuberculosis infection control (TBIC) is rarely implemented in the health facilities in resource limited settings. Understanding the reasons for low level of implementation is critical. The study aim was to assess TBIC practices and barriers to implementation in two districts in Uganda.MethodsWe conducted a cross-sectional study in 51 health facilities in districts of Mukono and Wakiso. The study included: a facility survey, observations of practices and eight focus group discussions with health workers.ResultsQuantitative: Only 16 facilities (31%) had a TBIC plan. Five facilities (10%) were screening patients for cough. Two facilities (4%) reported providing masks to patients with cough. Ventilation in the waiting areas was inadequate for TBIC in 43% (22/51) of the facilities. No facility possessed N95 particulate respirators. Qualitative: Barriers that hamper implementation of TBIC elicited included: under-staffing, lack of space for patient separation, lack of funds to purchase masks, and health workers not appreciating the importance of TBIC.ConclusionTBIC measures were not implemented in health facilities in the two Ugandan districts where the survey was done. Health system factors like lack of staff, space and funds are barriers to implement TBIC. Effective implementation of TBIC measures occurs when the fundamental health system building blocks -governance and stewardship, financing, infrastructure, procurement and supply chain management are in place and functioning appropriately.

Occupational Health Hazards among Healthcare Workers in Kampala, Uganda

Objective. To assess the occupational health hazards faced by healthcare workers and the mitigation measures. Methods. We conducted a cross-sectional study utilizing quantitative data collection methods among 200 respondents who worked in 8 major health facilities in Kampala. Results. Overall, 50.0% of respondents reported experiencing an occupational health hazard. Among these, 39.5% experienced biological hazards while 31.5% experienced nonbiological hazards. Predictors for experiencing hazards included not wearing the necessary personal protective equipment (PPE), working overtime, job related pressures, and working in multiple health facilities. Control measures to mitigate hazards were availing separate areas and containers to store medical waste and provision of safety tools and equipment. Conclusion. Healthcare workers in this setting experience several hazards in their workplaces. Associated factors include not wearing all necessary protective equipment, working overtime, experiencing work related pressures, and working in multiple facilities. Interventions should be instituted to mitigate the hazards. Specifically PPE supply gaps, job related pressures, and complacence in adhering to mitigation measures should be addressed.

Delays in diagnosis and treatment of pulmonary tuberculosis in Wakiso and Mukono districts, Uganda

BackgroundDelay in tuberculosis (TB) diagnosis may worsen the disease and increase TB transmission. Therefore, timely diagnosis and treatment is critical in TB control. We aimed to assess the treatment delay of pulmonary TB and its determinants in two Ugandan districts where TB infection control (TBIC) guidelines were formerly implemented.MethodsA facility based cross-sectional study was conducted in Mukono and Wakiso districts. Adult pulmonary TB patients within three months of initiating treatment were included in the study. Delays were categorized into unacceptable patient delay (more than 3 weeks from the onset of cough and the first consultation with a health care provider), health service (more than one week from the first consultation to the initiation of TB treatment) and total delay (more than 4 weeks since the onset of cough). The prevalences as well as predictors for the three delays were determined.ResultsWe enrolled 158 sputum positive patients. Unacceptable patient delay was noted in 91 (58%) patients, a health service delay in 140 (88%) patients and a total delay in 140 (90%) patients. An independent predictor for patient delay was male gender (p < 0.001). First visiting a non-public health facility (p = 0.001) was an independent predictor of health service delay.ConclusionThere is still a significant TB diagnosis and treatment delay in Uganda. Most of the delay was caused by health system delay in the non-public health care sector. There is need for TB advocacy in the community, training of health workers in TBIC and strengthening public-private partnerships in TB control.

Utilization of HIV and tuberculosis services by health care workers in Uganda: implications for occupational health policies and implementation.

Background Access to HIV testing and subsequent care among health care workers (HCWs) form a critical component of TB infection control measures for HCWs. Challenges to and gaps in access to HIV services among HCWs may thus compromise TB infection control. This study assessed HCWs HIV and TB screening uptake and explored their preferences for provision of HIV and TB care. Methods A cross-sectional mixed-methods study involving 499 HCWs and 8 focus group discussions was conducted in Mukono and Wakiso districts in Uganda between October 2010 and February 2011. Results Overall, 5% of the HCWs reported a history of TB in the past five years. None reported routine screening for TB disease or infection, although 89% were willing to participate in a TB screening program, 77% at the workplace. By contrast, 95% had previously tested for HIV; 34% outside their workplace, and 27% self-tested. Nearly half (45%) would prefer to receive HIV care outside their workplace. Hypothetical willingness to disclose HIV positive status to supervisors was moderate (63%) compared to willingness to disclose to sexual partners (94%). Older workers were more willing to disclose to a supervisor (adjusted prevalence ratio [APR] = 1.51, CI = 1.16–1.95). Being female (APR = 0.78, CI = 0.68–0.91), and working in the private sector (APR = 0.81, CI = 0.65–1.00) were independent predictors of unwillingness to disclose a positive HIV status to a supervisor. HCWs preferred having integrated occupational services, versus stand-alone HIV care. Conclusions Discomfort with disclosure of HIV status to supervisors suggests that universal TB infection control measures that benefit all HCWs are more feasible than distinctions by HIVstatus, particularly for women, private sector, and younger HCWs. However, interventions to reduce stigma and ensuring confidentiality are also essential to ensure uptake of comprehensive HIV care including Isoniazid Preventive Therapy among HCWs.

Prescription for antibiotics at drug shops and strategies to improve quality of care and patient safety: a cross-sectional survey in the private sector in Uganda.

Objectives The main objective of this study was to assess practices of antibiotic prescription at registered drug shops with a focus on upper respiratory tract infections among children in order to provide data for policy discussions aimed at improving quality of care and patient safety in the private health sector in Uganda. Methods A survey was conducted within 57 parishes from August to October 2014 in Mukono District, Uganda. Data was captured on the following variables: drug shop characteristics, training of staff in management of pneumonia, availability of guidelines and basic equipment, available antibiotics, knowledge on treatment of pneumonia in children aged <5 years. The main study outcome was the proportion of private health facilities prescribing an antibiotic. Results A total of 170 registered drug shops were surveyed between August and October 2014. The majority of drug shops, 93.5% were prescribing antibiotics, especially amoxicillin and trimethoprim-sulfamethoxazole (septrin). The professional qualification of a provider was significantly associated with this practice, p=0.04; where lower cadre staff (nursing assistants and enrolled nurses) overprescribed antibiotics. A third, 29.4% of drug shop providers reported that antibiotics were the first-line treatment for children with diarrhoea; yet the standard guideline is to give oral rehydration salts and zinc tablets. Only few providers, 8.2%, had training on antibiotics, with 10.6% on pneumonia case management. Further to this, 7.1% drug shops had WHO-Integrated Management of Childhood Illness guidelines, and a negligible proportion (<1%) had respiratory timers and baby weighing scales. Although the majority of providers, 82.4%, knew severe signs and symptoms of pneumonia, few, 17.6%, knew that amoxicillin was the first-line drug for treatment of pneumonia in children according to the guidelines. Conclusions There is urgent need to regulate drug shop practices of prescribing and selling antibiotics, for the safety of patients seeking care at these outlets.

‘. . . if you bring the kit home, you [can] get time and test together with your partner’: Pregnant women and male partners’ perceptions regarding female partner-delivered HIV self-testing in Uganda – A qualitative study

In 2015, the World Health Organization reported that more than 60 million people were tested for HIV in 122 low- and middle-income countries between 2010 and 2014. Despite this level of progress, over 40% of people living with HIV remain unaware of their HIV status. This calls for innovative approaches to improve uptake of HIV testing services, including use of HIV self-test (HIVST) kits. We conducted a cross-sectional, qualitative study to assess pregnant women and their male partners’ perceptions regarding female partner-delivered HIVST kits. This study was conducted at two health facilities in Central Uganda between November and December 2015. Data were collected on pregnant women’s willingness to take HIVST kits to their male partners and other household members using eight focus group discussions and 30 in-depth interviews. Data were analyzed following a thematic framework approach. Overall, pregnant women were willing to take HIVST kits to their partners and other household members, with the exception of their cowives. Male partners were willing to use HIVST kits brought by their female partners. Our findings suggest that secondary distribution of HIVST kits through female partners is acceptable and has the potential to improve male partner and household-member HIV testing.

Prevalence of undiagnosed diabetes and pre-diabetes among hypertensive patients attending Kiambu district Hospital, Kenya: a cross-sectional study

Introduction Hypertension (HTN) and diabetes mellitus (DM) are two common non-communicable diseases (NCDs) that are closely linked: one cannot be properly managed without attention to the other. The aim of this study was to determine the prevalence of undiagnosed diabetic and pre-diabetic states that is abnormal glucose regulation (AGR) and factors associated with it among hypertensive patients in Kiambu Hospital, Kenya. Methods We conducted a cross-sectional study from February 2014 to April 2014. Hypertensive patients aged ≥18 attending the out-patient medical clinic were included in the study. Pregnant and known diabetic patients were excluded. Data was collected on socio-demographics, behavior, and anthropometrics. Diabetes status was based on a Glycated Haemoglobin (HbA1C) classification of ≥6.5% for diabetes, 6.0-6.4% for pre-diabetes and ≤6.0% for normal. AGR was the dependable variable and included two diabetic categories; diabetes and pre-diabetes. Results We enrolled 334 patients into the study: the mean age was 59 years (Standard deviation= 14.3). Of these patients 254 (76%) were women. Thirty two percent (107/334; 32%) were found to have AGR, with 14% (46) having un-diagnosed DM and 18%(61) with pre-diabetes. Factors associated with AGR were age ≥45 (OR = 3.23; 95% CI 1.37 ≥ 7.62), basal metabolic index (BMI) ≥ 25 Kg/m2 (OR= 3.13; 95% CI 1.53 - 6.41), low formal education (primary/none)(OR= 2; 95%CI 1.08 - 3.56) and family history of DM (OR = 2.19; 95%CI 1.16 - 4.15). Conclusion There was a high prevalence of undiagnosed AGR among hypertensive patients. This highlights the need to regularly screen for AGR among hypertensive patients as recommended by WHO.

Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: a qualitative study

ObjectivesThis study explored the acceptability of cough etiquette, wearing masks and separation by tuberculosis (TB) suspects and TB patients in two districts in Uganda.DesignThe study was conducted in Mukono and Wakiso districts in central Uganda. Eighteen in-depth interviews with patients and eight focus group discussions with health workers were conducted. Patients were asked for their opinions on cough etiquette, patient separation and wearing of masks.ResultsPatients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness. Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Good counseling and health education were suggested to improve patients’ adoption of separation and masking. However patients expressed concerns about equity, coercive and stigmatizing approaches. Universal precautions were more acceptable than targeted ones, with the exception of separating TB patients. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures.ConclusionScaling up effective TB infection control norms and behaviors requires a patient-centered, rights-based, and evidence-based approach. Socially acceptable measures like covering the mouth and nose with a handkerchief should be promoted. We recommend that further studies are needed to explore how community advocacy impacts on acceptability of masking. Furthermore, the efficacy of covering the mouth using a handkerchief or piece of cloth compared to wearing a mask in TB prevention needs to be evaluated.

Referral of children seeking care at private health facilities in Uganda

BackgroundIn Uganda, referral of sick children seeking care at public health facilities is poor and widely reported. However, studies focusing on the private health sector are scanty. The main objective of this study was to assess referral practices for sick children seeking care at private health facilities in order to explore ways of improving treatment and referral of sick children in this sector.MethodsA survey was conducted from August to October 2014 in Mukono district, central Uganda. Data was collected using a structured questionnaire supplemented by Focus Group Discussions and Key Informant interviews with private providers and community members.ResultsA total of 241 private health facilities were surveyed; 170 (70.5%) were registered drug shops, 59 (24.5%) private clinics and 12 (5.0%) pharmacies. Overall, 104/241 (43.2%) of the private health facilities reported that they had referred sick children to higher levels of care in the two weeks prior to the survey. The main constraints to follow referral advice as perceived by caretakers were: not appreciating the importance of referral, gender-related decision-making and negotiations at household level, poor quality of care at referral facilities, inadequate finances at household level; while the perception that referral leads to loss of prestige and profit was a major constraint to private providers.ConclusionIn conclusion, the results show that referral of sick children at private health facilities faces many challenges at provider, caretaker, household and community levels. Thus, interventions to address constraints to referral of sick children are urgently needed.