Self-care and healthcare seeking practices among patients with hypertension and diabetes in rural Uganda.

BACKGROUND: Implementing effective self-care practices for non-communicable diseases (NCD) prevents complications and morbidity. However, scanty evidence exists among patients in rural sub-Saharan Africa (SSA). We sought to describe and compare existing self-care practices among patients with hypertension (HTN) and diabetes (DM) in rural Uganda. METHODS: Between April and August 2019, we executed a cross-sectional investigation involving 385 adult patients diagnosed with HTN and/or DM. These participants were systematically randomly selected from three outpatient NCD clinics in the Nakaseke district. Data collection was facilitated using a structured survey that inquired about participants' healthcare-seeking patterns, access to self-care services, education on self-care, medication compliance, and overall health-related quality of life. We utilized Chi-square tests and logistic regression analyses to discern disparities in self-care practices, education, and healthcare-seeking actions based on the patient's conditions. RESULTS: Of the 385 participants, 39.2% had only DM, 36.9% had only HTN, and 23.9% had both conditions (HTN/DM). Participants with DM or both conditions reported more clinic visits in the past year than those with only HTN (P = 0.005). Similarly, most DM-only and HTN/DM participants monitored their weight monthly, unlike those with only HTN (P<0.0001). Participants with DM or HTN/DM were more frequently educated about their health condition(s), dietary habits, and weight management than those with only HTN. Specifically, education about their conditions yielded adjusted odds ratios (aOR) of 5.57 for DM-only and 4.12 for HTN/DM. Similarly, for diet, aORs were 2.77 (DM-only) and 4.21 (HTN/DM), and for weight management, aORs were 3.62 (DM-only) and 4.02 (HTN/DM). Medication adherence was notably higher in DM-only participants (aOR = 2.19). Challenges in self-care were significantly more reported by women (aOR = 2.07) and those above 65 years (aOR = 5.91), regardless of their specific condition(s). CONCLUSION: Compared to rural Ugandans with HTN-only, participants with DM had greater utilization of healthcare services, exposure to self-care education, and adherence to medicine and self-monitoring behaviors. These findings should inform ongoing efforts to improve and integrate NCD service delivery in rural SSA.

Does mHealth influence community health worker performance in vulnerable populations? A mixed methods study in a multinational refugee settlement in Uganda.

Community Health Workers (CHWs) provide healthcare in under-served communities, including refugee settlements, despite various challenges hindering their performance. Implementers have adopted mobile wireless technologies (m-Health) to improve the performance of CHWs in refugee settlements. We assessed the CHWs' performance and associated factors in a multi-national refugee settlement, operating mHealth and paper-based methods. This cross-sectional study employed quantitative and qualitative data collection methods. Data for 300 CHWs was collected from implementing partners' (IPs) databases. Nine focus group discussions (FGDs) with the CHWs and community members, two in-depth interviews (IDIs) with CHW leaders, and eight key informant interviews (KIIs) with six IPs and two local leaders were conducted. The qualitative data were analysed thematically using AtlasTi version 9 while the quantitative data were analysed at the univariate, bivariate and multivariable levels using Stata version14. The study found that only 17% of the CHWs performed optimally. The factors that significantly influenced CHW performance included education level: secondary and above (APR: 1.83, 95% CI: 1.02-3.30), having a side occupation (APR: 2.02, 95% CI: 1.16-3.52) and mHealth use (APR: 0.06, 95% CI: 0.02-.0.30). The qualitative data suggested that performance was influenced by the number of households assigned to CHWs, monetary incentives, adequacy of materials and facilitation. Particularly, mHealth was preferred to paper-based methods. Overall, the CHWs' performance was sub-optimal; only 2 in 10 performed satisfactorily. The main factors that influenced performance included the level of education, use of mHealth, having another occupation, workload and incentivisation. CHWs and IPs preferred mHealth to paper-based methods. IPs should work to improve refugee settlement working conditions for the CHWs and adopt mHealth to improve CHW performance.

Design Research to Embed mHealth into a Community-Led Blood Pressure Management System in Uganda: Protocol for a Mixed Methods Study.

BACKGROUND: Uncontrolled hypertension is a leading risk factor for cardiovascular diseases. In Uganda, such diseases account for approximately 10% of all deaths, with 1 in 5 adults having hypertension (>90% of the hypertensive cases are uncontrolled). Although basic health care in the country is available free of cost at government facilities, regularly accessing medication to control hypertension is difficult because supply chain challenges impede availability. Clients therefore frequently suspend treatment or buy medication individually at private facilities or pharmacies (incurring significant costs). In recent years, mobile health (mHealth) interventions have shown increasing potential in addressing health system challenges in sub-Saharan Africa, but the acceptability, feasibility, and uptake conditions of mobile money approaches to chronic disease management remain understudied. OBJECTIVE: This study aims to design and pilot-test a mobile money-based intervention to increase the availability of antihypertensive medication and lower clients' out-of-pocket payments. We will build on existing local approaches and assess the acceptability, feasibility, and uptake of the designed intervention. Furthermore, rather than entering the study setting with a ready-made intervention, this research will place emphasis on gathering applied ethnographic insights early, which can then inform the parameters of the intervention prototype and concurrent trial. METHODS: We will conduct a mixed methods study following a human-centered design approach. We will begin by conducting extensive qualitative research with a range of stakeholders (clients; health care providers; religious, cultural, and community leaders; academics; and policy makers at district and national levels) on their perceptions of hypertension management, money-saving systems, and mobile money in the context of health care. Our results will inform the design, iterative adaptation, and implementation of an mHealth-facilitated pooled financing intervention prototype. At study conclusion, the finalized prototype will be evaluated quantitatively via a randomized controlled trial. RESULTS: As of August 2023, qualitative data collection, which started in November 2022, is ongoing, with data analysis of the first qualitative interviews underway to inform platform and implementation design. Recruitment for the quantitative part of this study began in August 2023. CONCLUSIONS: Our results aim to inform the ongoing discourse on novel and sustainable pathways to facilitate access to medication for the management of hypertension in resource-constrained settings. TRIAL REGISTRATION: German registry of clinical trials DRKS00030922; https://drks.de/search/en/trial/DRKS00030922. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46614.

Principles for task shifting hypertension and diabetes screening and referral: a qualitative study exploring patient, community health worker and healthcare professional perceptions in rural Uganda.

BACKGROUND: A shortage of healthcare workers in low- and middle-income countries (LMICs) combined with a rising burden of non-communicable diseases (NCDs) like hypertension and diabetes mellitus has resulted in increasing gaps in care delivery for NCDs. As community health workers (CHWs) often play an established role in LMIC healthcare systems, these programs could be leveraged to strengthen healthcare access. The objective of this study was to explore perceptions of task shifting screening and referral for hypertension and diabetes to CHWs in rural Uganda. METHODS: This qualitative, exploratory study was conducted in August 2021 among patients, CHWs and healthcare professionals. Through 24 in-depth interviews and ten focus group discussions, we investigated perceptions of task shifting to CHWs in the screening and referral of NCDs in Nakaseke, rural Uganda. This study employed a holistic approach targeting stakeholders involved in the implementation of task shifting programs. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically guided by the framework method. RESULTS: Analysis identified elements likely to be required for successful program implementation in this context. Fundamental drivers of CHW programs included structured supervision, patients' access to care through CHWs, community involvement, remuneration and facilitation, as well as building CHW knowledge and skills through training. Additional enablers comprised specific CHW characteristics such as confidence, commitment and motivation, as well as social relations and empathy. Lastly, socioemotional aspects such as trust, virtuous behavior, recognition in the community, and the presence of mutual respect were reported to be critical to the success of task shifting programs. CONCLUSION: CHWs are perceived as a useful resource when task shifting NCD screening and referral for hypertension and diabetes from facility-based healthcare workers. Before implementation of a task shifting program, it is essential to consider the multiple layers of needs portrayed in this study. This ensures a successful program that overcomes community concerns and may serve as guidance to implement task shifting in similar settings.

The effect of blister packaging Iron and Folate on adherence to medication and hemoglobin levels among pregnant women at National Referral Hospital antenatal clinics in a low to middle income country: a Randomised Controlled Trial (The IFAd Trial).

INTRODUCTION: Anemia in pregnancy is an important global public health problem. It is estimated that 38% of pregnant women worldwide are anemic. In Africa, literature from observational studies show 20% of maternal deaths are attributed to anemia. In Uganda, 50% of pregnant women have iron deficiency anaemia. The proportion of pregnant women receiving Iron-Folic acid (IFA) supplementation has improved. However, the number of IFA pills consumed is still low. We carried out a randomized controlled trial to determine the effect of dispensing blister and loose packaged IFA pills on adherence measured by count on next return visit and hemoglobin levels among pregnant women at two National Referral Hospitals in Kampala, Uganda. METHODS: This trial was conducted between April and October 2016. Nine hundred fifty pregnant women at ≤28 weeks were randomized to either the blister (intervention arm) or loose (control arm) packaged IFA. The participants completed the baseline measurements and received 30 pills of IFA at enrolment to swallow one pill per day. We assessed adherence by pill count and measured hemoglobin at four and 8 weeks. The results were presented using both intention-to-treat and per-protocol analysis. RESULTS: There were 474 participants in the control and 478 in the intervention arms. Adherence to IFA intake was similar in the two groups at 4th week (40.6 and 39.0%, p = 0.624) and 8th week (51.9 and 46.8%, p = 0.119). The mean hemoglobin level at 4 weeks was higher in the blister than in the loose packaging arms (11.9 + 1.1 g/dl and 11.8 + 1.3 g/dl, respectively; p = 0.02), however, similar at week 8 (12.1 + 1.2 and 12.0 + 1.3, respectively; p = 0.23). However, over the 8-week period blister packaging arm had a higher change in hemoglobin level compared to loose package (blister package 0.6 ± 1.0; loose packaging 0.2 ± 1.1; difference: 0.4 g/dL (95% CI: 0.24-0.51 g/dL); p = 0.001. There were no serious adverse events. CONCLUSIONS: Our results showed no effect of blister packaging on IFA adherence among pregnant women. However, our findings showed that blister packaged group had a higher hemoglobin increase compared to loose iron group. TRIAL REGISTRATION: No. PACTR201707002436264 (20 /07/ 2017).

Social Support for Self-Care: Patient Strategies for Managing Diabetes and Hypertension in Rural Uganda.

Background: Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings. Objective: We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda. Methods: Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes. Results: Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities. Conclusion: Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients' social support networks.

Accessing medicines for non-communicable diseases: Patients and health care workers' experiences at public and private health facilities in Uganda.

BACKGROUND: Non-communicable diseases (NCDs) are increasingly prevalent in low- and middle-income countries. Successful management requires consistent access to appropriate medicines. Availability of NCD medicines is generally low, especially in the public sector, however, little is known about other factors affecting access. We explored barriers and facilitators of access to medicines for diabetes and hypertension at public and private health facilities in Uganda. METHODS: We conducted a qualitative descriptive study at six public hospitals and five private health facilities in different regions of Uganda. Data collection included 36 in-depth interviews and 14 focus group discussions (n = 128) among purposively selected adult outpatients with diabetes and/or hypertension and 26 key informant interviews with healthcare workers and patient association leaders. Transcripts were coded and emerging themes identified using the Framework method. RESULTS: Four main themes emerged: Stocking of medicines and supplies, Financial factors, Individual behaviour and attitudes, and Service delivery at health facilities. Stocking of medicines and supplies mainly presented barriers to access at public facilities including frequent stockouts, failure to stock certain medicines and low quality brands often rejected by patients. Financial factors, especially high cost of medicines and limited insurance coverage, were barriers in private facilities. Free service provision was a facilitator at public facilities. Patients' confusion resulting from mixed messages and their preference for herbal treatments were cross-sector barriers. While flexibility in NCD service provision was a facilitator at private facilities, provider burnout and limited operating hours were barriers in public facilities. Patient-driven associations exist at some public facilities and help mitigate inadequate medicine stock. CONCLUSION: Access to NCD medicines in Uganda is influenced by both health system and patient factors. Some factors are sector-specific, while others cross-cutting between public and private sectors. Due to commonalities in barriers, potential strategies for overcoming them may include patient-driven associations, public-private partnerships, and multi-modal health education platforms.

Pregnancy Planning among Female Sex Workers in Uganda: Evaluation of the Psychometric Properties of the London Measure of Unplanned Pregnancy.

The aim of the study was to evaluate the psychometric properties of the London Measure of Unplanned Pregnancy (LMUP) among female sex workers (FSWs) in Uganda. The LMUP was translated into Luganda and adapted for use with FSWs and underwent cognitive testing and two field tests. From the final Luganda LMUP, three other language versions were created (Acholi, Lugisu and Runyakole), and preliminary field test data were collected. Final data were collected from 819 FSWs attending the 'Most at Risk Population Initiative' clinics. The Luganda field testing showed that there were no missing data, the scale was well targeted, Cronbach's alpha was 0.82, weighted Kappa was 0.78, measurement was unidimensional, and all construct validity hypotheses were met. Likewise, with the Acholi, Lugisu, and Runyankole translations, field testing showed that there were no missing data, the scales were well targeted, Cronbach's alpha were<0.70, and measurement was unidimensional. We concluded that the Luganda LMUP is a valid and reliable tool for assessing pregnancy planning among FSWs in Uganda and that the Acholi, Lugisu, and Runyankole versions of the LMUP also had good initial psychometric properties.

Newborn Care Practices among Adolescent Mothers in Hoima District, Western Uganda.

INTRODUCTION: Adolescent childbearing remains a major challenge to improving neonatal mortality especially in Sub Saharan countries which are still struggling with high neonatal mortality rates. We explored essential newborn care practices and associated factors among adolescent mothers in Western Uganda. METHODS: Data were collected among 410 adolescent mothers with children aged one to six months in Hoima district. Three composite variables (appropriate neonatal breastfeeding, cord care and thermal protection) were derived by combining related practices from a list of recommended newborn care practices. Logistic regression analysis was conducted to identify factors independently associated with practice of essential newborn care. RESULTS: Appropriate newborn feeding, optimal thermal protection and dry cord care were practiced by 60.5%, 67.2% and 31% of adolescent mothers respectively. Independent predictors' of cord care were: knowledge of cord care (AOR 5.34, 95% CI (1.51-18.84) and having delivered twins (AOR 0.04, 95% CI (0.01-0.22). The only predictor of thermal care was knowledge (AOR 25.15, 95% CI (7.01-90.20). Staying in a hospital for more than one day postpartum (AOR 2.45, 95%CI (1.23-4.86), knowledge of the correct time of breastfeeding initiation (AOR 14.71, 95% CI (5.20-41.58), predicted appropriate neonatal feeding, whereas; adolescent mothers who had had a caesarean delivery (AOR 0.19, 95% CI (I 0.04-0.96) and a male caretaker in the postnatal period (AOR 0.18, 95% CI (0.07-0.49) were less likely to practice the recommended newborn feeding. CONCLUSION: Sub optimal essential newborn care practice was noted especially suboptimal cord care. Adolescent mothers should be a focus of strategies to improve maternal and neonatal health.

Implementation of infection control in health facilities in Arua district, Uganda: a cross-sectional study.

BACKGROUND: At least 1.4 million people are affected globally by nosocomial infections at any one time, the vast majority of these occurring in low-income countries. Most of these infections can be prevented by adopting inexpensive infection prevention and control measures such as hand washing. We assessed the implementation of infection control in health facilities and determined predictors of hand washing among healthcare workers (HCWs) in Arua district, Uganda. METHODS: We interviewed 202 HCWs that included 186 randomly selected and 16 purposively selected key informants in this cross-sectional study. We also conducted observations in 32 health facilities for compliance with infection control measures and availability of relevant supplies for their implementation. Quantitative data underwent descriptive analysis and multiple logistic regressions at 95 % confidence interval while qualitative data was coded and thematically analysed. RESULTS: Most respondents (95/186, 51 %) were aware of at least six of the eight major infection control measures assessed. Most facilities (93.8 %, 30/32) lacked infection control committees and adequate supplies or equipment for infection control. Respondents were more likely to wash their hands if they had prior training on infection control (AOR = 2.71, 95 % CI: 1.03-7.16), had obtained at least 11 years of formal education (AOR = 3.30, 95 % CI: 1.44-7.54) and had reported to have acquired a nosocomial infection (AOR = 2.84, 95 % CI: 1.03-7.84). CONCLUSIONS: Healthcare workers are more likely to wash their hands if they have ever suffered from a nosocomial infection, received in-service training on infection control, were educated beyond ordinary level, or knew hand washing as one of the infection control measures. The Uganda Ministry of Health should provide regular in-service training in infection control measures and adequate necessary materials.

'As soon as the umbilical cord gets off, the child ceases to be called a newborn': sociocultural beliefs and newborn referral in rural Uganda.

BACKGROUND: The first week of life is the time of greatest risk of death and disability, and is also associated with many traditional beliefs and practices. Identifying sick newborns in the community and referring them to health facilities is a key strategy to reduce deaths. Although a growing area of interest, there remains a lack of data on the role of sociocultural norms and practices on newborn healthcare-seeking in sub-Saharan Africa and the extent to which these norms can be modified. OBJECTIVE: This study aimed to understand the community's perspective of potential sociocultural barriers and facilitators to compliance with newborn referral. METHOD: In this qualitative study, focus group discussions (n=12) were conducted with mothers and fathers of babies aged less than 3 months. In addition, in-depth interviews (n=11) were also held with traditional birth attendants and mothers who had been referred by community health workers to seek health-facility-based care. Participants were purposively selected from peri-urban and rural communities in two districts in eastern Uganda. Data were analysed using latent content analysis. RESULTS: The community definition of a newborn varied, but this was most commonly defined by the period between birth and the umbilical cord stump falling off. During this period, newborns are perceived to be vulnerable to the environment and many mothers and their babies are kept in seclusion, although this practice may be changing. Sociocultural factors that influence compliance with newborn referrals to seek care emerged along three sub-themes: community understanding of the newborn period and cultural expectations; the role of community health actors; and caretaker knowledge, experience, and decision-making autonomy. CONCLUSION: In this setting, there is discrepancy between biomedical and community definitions of the newborn period. There were a number of sociocultural factors that could potentially affect compliance to newborn referral. The widely practised cultural seclusion period, knowledge about newborn sickness, individual experiences in households, perceived health system gaps, and decision-making processes were facilitators of or barriers to compliance with newborn referral. Designers of newborn interventions need to address locally existing cultural beliefs at the same time as they strengthen facility care.

Modelling the potential impact and cost of scaling-up male circumcision in resource poor settings: A case of Uganda.

This study modelled estimates of the cost and impact of male circumcision (MC) under different scenarios using the Decision Maker's Program Planning Tool on data from Uganda. Results showed that the number of new adult HIV infections could be reduced by 23 000 if MC could be increased from the current 25% to 80% by 2015. The incidence of HIV could be reduced by 0.2 percentage points over the same period. If a scale up programme is to meet a target of 80% by 2015 then the annual number of MCs performed should be over twice as many as those performed in 2011. The discounted net cost per infection averted would be US$559 for the period 2011-2015 and the country would save US$6 841 per infection. A scale up of MC will reduce HIV prevalence and incidence substantially and it would be highly cost effective. The government should mobilise funding to meet high MC targets that would deliver the desired reduction in prevalence and incidence in a short period of time.