Uganda

It is well known that safe delivery in a health facility reduces the risks of maternal and infant mortality resulting from perinatal complications. What is less understood are the factors associated with safe delivery practices. We investigated factors influencing health facility delivery practices while adjusting for multiple other factors simultaneously, spatial heterogeneity, and trends over time. We fitted a logistic regression model to Lot Quality Assurance Sampling (LQAS) data from Uganda in a framework that considered individual-level covariates, geographical features, and variations over five time points. We showed that ease of access, maternal age and education are strongly associated with delivery in a health facility; after accounting for this, there remains a significant trend towards greater uptake over time. We used this model together with known demographics to formulate a nascent early warning system that identifies candidate districts expected to have low prevalence of facility-based delivery in the immediate future. We provided a statistical method for using inexpensive and routinely collected monitoring and evaluation data to answer complex epidemiology and public health questions in a resource-poor setting.

Half of the Ugandan population obtains medicines from the public sector. Yet, we found only 3/5 of 455 inspected public health facilities meet Good Pharmacy Practice (GPP) standards. Facilities using SPARS (the Supervision, Performance Assessment, and Recognition Strategy) tended to perform better than unsupervised facilities, substantiating the value of supporting supervision interventions in GPP areas that need strengthening. Non-compliant indicators can be improved through practices and behavioral changes; some require infrastructure investments. We conclude that regular National Drug Authority inspections of public sector pharmacies in conjunction with interventions to improve GPP adherence can revolutionize patient care in Uganda.

A cross-sectional survey was performed in 24 systems of care providing antiretroviral medications in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda to examine current practices in monitoring rates of treatment adherence and defaulting. Only 20 of 48 facilities reported routinely measuring individual patient adherence levels; only 12 measured rates of adherence for the clinic population. The rules for determining which patients were included in the calculation of rates were unclear. Fourteen different definitions of treatment defaulting were in use. Facilities routinely gather potentially useful data, but the frequency of doing so varied widely. Individual and program treatment adherence and defaulting are not routinely monitored; when done, the operational definitions and methods varied widely, making comparisons across programs unreliable. There is a pressing need to determine which measures are the most feasible and reliable to collect, the most useful for clinical counseling, and most informative for program management.

This paper explores HIV patients’ adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.

The objective of this survey was to develop an indicator-based tool for systematic assessment and reporting of good pharmacy practice (GPP). The tool comprises a) a set of indicators, b) an indicator and survey manual, c) a data collection sheet, and d) Microsoft Excel based data collection and analysis tool. We developed a set of 34 pharmacy practice (PP) indicators using an iterative process to test their functionality in various pharmacy practice settings in Ethiopia, Uganda and Zimbabwe. The indicator-based survey assessed five components of PP: system, storage, services, dispensing and rational drug use. The new GPP indicator-based assessment tool proved to be an easily applicable tool for uniform assessments of pharmacy practices and identification of problem areas. It allows for both intra- and inter-country comparison and for self-assessment. However, the indicators need to be further developed to test their applicability in developed countries.

This hospital-based study aimed to examine patient and primary healthcare factors and stage at diagnosis in women with cervical cancer in Northern Uganda in order to identify factors associated with advanced stages, to inform policies to improve survival from cervical cancer in low income and middle income countries. Of 166 patients attending care, 149 were enrolled and analysed. Most women were diagnosed at stages III (45%) or IV (21%). Understanding individual patient factors, patients' behavioural characteristics and healthcare factors associated with advanced stage at diagnosis is essential for targeted effective public health interventions to promote prompt health seeking, diagnosis at early stage and improved survival from cervical cancer.

We assessed community awareness about cervical cancer risk factors and symptoms and perceptions about prevention and cure of cervical cancer in order to contribute data to inform interventions to improve cervical cancer survival. In Gulu, a post-conflict district of Uganda, most participants (444/448) had heard about cervical cancer. Known risk factors, including multiple sexual partners, human papillomavirus infection, and early onset of sexual activity, were recognized by 88%, 82%, and 78% of respondents respectively. Targeted interventions including increasing availability of HPV vaccination, population-based cervical screening and diagnostic services can translate high awareness into actual benefits.

Retreatment ‘others’ refer to all TB cases who were previously treated but with unknown outcome of that previous treatment or who have returned to treatment with bacteriologically negative pulmonary or extra-pulmonary TB. This study was conducted in 11 regional referral hospitals (RRHs) serving high burden TB districts in Uganda to determine the profile and treatment success of TB retreatment ‘others’ in comparison with the classical retreatment cases. Of the 6244 TB cases registered at the study sites, 733 (11.7 %) were retreatment cases. Retreatment ‘others’ constituted 45.5 % of retreatment cases. Co-infection with HIV was higher among retreatment ‘others’ (70.9 %) than classical retreatment cases (53.5 %). Treatment was successful in 410 (56.2 %) retreatment cases. Retreatment ‘others’ were associated with reduced odds of success compared to classical cases. There is a need to review the diagnosis and management of retreatment ‘others’.

In Uganda, the child TB cases reported in 2012 made up less than 3 % of the total cases while recent modelling estimates it at 15–20 % of adult cases. Mapping of these cases in Kampala District, especially for the children under five year, would reflect recent transmission in the various communities in the district. We therefore conducted a retrospective study of reported child TB cases in Kampala district Uganda for 2009–2010 to provide an estimate of child TB incidence and map the cases. There was a higher child TB incidence of 56 per 100,000 in 2009 compared with 44 per 100,000 in 2010. The percentage of child TB cases was much higher at 7.5 % of all the reported TB cases than the WHO reported national average. For the review period, the TB cases clustered in particular slums in Kampala district.

We assessed adherence to standards of HIV care among health workers in the West Nile Region of Uganda. We conducted a cross-sectional study in nine health facilities and assessed records of a cohort of 270 HIV clients that enrolled on ART 12 months prior. The performance of each health facility on the different indicators of standards of HIV/AIDS care was determined and compared with the recommended national guidelines. Adherence to standards of HIV/AIDS care at facilities was inadequate. Performance was better at the start of ART but declined during the follow-up period. Higher level facilities were more likely to adhere to standards like CD4 monitoring and maintaining HIV clients on a standard ARV regimen. Efforts geared towards strengthening the health system, including support supervision and provision of care guidelines and job aides are needed, especially for lower level facilities.

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