'As soon as they can hold a glass, they begin taking alcohol': a qualitative study on early childhood substance use in Mbale District, Uganda.

BACKGROUND: Globally, substance use is a leading contributor to the burden of disease among young people, with far reaching social, economic and health effects. Following a finding of harmful alcohol use among 5-8-year-old children in Mbale District, Uganda, this study aims to investigate community members' views on early childhood substance use among children below the age of 10 years. METHODS: In 2016, we conducted eight focus group discussions with 48 parents and 26 key informant interviews with teachers, health workers, alcohol distributors, traditional healers, religious leaders, community leaders and youth workers. We used thematic content analysis. Four participants and two research assistants reviewed and confirmed the findings. RESULTS: Alcohol in everyday life: 'Even children on laps taste alcohol': Almost all participants confirmed the existence of and concern for substance use before age 10. They described a context where substance use was widespread in the community, especially intake of local alcoholic brews. Children would access substances in the home or buy it themselves. Those living in poor neighbourhoods or slums and children of brewers were described as particularly exposed. Using substances to cope: 'We don't want them to drink': Participants explained that some used substances to cope with a lack of food and resources for childcare, as well as traumatic experiences. This made children in deprived families and street-connected children especially vulnerable to substance use. Participants believed this was a result of seeing no alternative solution. CONCLUSIONS: To our knowledge, this is the first study to describe the context and conditions of childhood substance use before age 10 in Mbale District, Uganda. The study shows that community members attributed early childhood substance use to a social context of widespread use in the community, which was exacerbated by conditions of material and emotional deprivation. These social determinants for this practice deserve public health attention and intervention.

'There is nowhere to take the child': a qualitative study of community members' views on managing early childhood substance use in Mbale, Uganda.

BACKGROUND: Harmful alcohol use by 5-8-year-old children has been identified in Mbale District, Uganda. To further examine this finding, the present study explores the experiences and perceptions of community members regarding how childhood substance use (before age 10) is managed in this area. METHODS: We conducted eight focus group discussions with 48 parents of children aged < 10 years and 26 key informant interviews with teachers, health workers, child protection workers, police, local stakeholders, brewers, and others. Thematic content analysis was performed. RESULTS: Three main themes were identified: 'We don't talk about it': Despite concern, childhood substance use was not addressed in the community. Participants attributed this to three main factors related to a lack of leadership in addressing it, changing acceptability for peer parental interference, and uncertainty about repercussions related to children's rights. 'There is nowhere to take the child': Schools, police, and remand homes were intuitively considered appropriate arenas for managing childhood substance use but were considered inaccessible, unresponsive, and inadequate due to insufficient resources, competence, and training. Since substance use was not considered a medical problem, help from the health sector was only sought for adverse consequences, such as injury. This left the participants with the experience that there was in effect nowhere to take the child. 'The government has not done so much': The participants called for government action and clear laws that would regulate the availability of alcohol and other substances to children, but they had limited trust in the capacity and commitment of the government to act. CONCLUSIONS: The participants were concerned about childhood alcohol and substance use, but the complexity and magnitude of the problem left them feeling incapacitated in responding. Relevant factors were identified on the community, institutional, and the government level, such as a lack of leadership in addressing it, a loss of mandate to interfere in child-rearing, inadequate services, weak legal structures, and missing government action. A strengthening of collective agency and public policy is necessary to prevent and address childhood alcohol and substance use.

The Uganda version of the Pediatric Evaluation of Disability Inventory (PEDI). Part I: Cross-cultural adaptation.

BACKGROUND: The Pediatric Evaluation of Disability Inventory (PEDI) was developed and standardized to measure functional performance in American children. So far, no published study has examined the use of the PEDI in sub-Saharan Africa. This study describes the adaptation, translation, and validation process undertaken to develop a culturally relevant PEDI for Uganda (PEDI-UG). METHOD: The cross-cultural adaptation and translation of the PEDI was performed in a series of steps. A project manager and a technical advisory group were involved in all steps of adaptation, translation, cognitive debriefing, and revision. Translation and back-translation between English and Luganda were performed by professional translators. Cognitive debriefing of two subsequent adapted revisions was performed by a field-testing team on a total of 75 caregivers of children aged 6 months to 7.5 years. RESULTS: The PEDI-UG was established in both English (the official language) and Luganda (a local language) and comprises 185 items. Revisions entailed deleting irrelevant items, modifying wording, inserting new items, and incorporating local examples while retaining the meaning of the original PEDI. Item statements were rephrased as questions. Seven new items were inserted and 19 items deleted. To accommodate major differences in living conditions between rural and urban areas, 10 alternative items were provided. CONCLUSIONS: The PEDI-UG is to be used to measure functional limitations in both clinical practice and research, in order to assess and evaluate rehabilitative procedures in children with developmental delay and disability in Uganda. In this study, we take the first step by translating and adapting the original PEDI version to the culture and life conditions in both rural and urban Uganda. In subsequent studies, the tool's psychometric properties will be examined, and the tool will be tested in children with developmental delay and disability.

The Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG). Part II: Psychometric properties.

BACKGROUND: The Pediatric Evaluation of Disability Inventory (PEDI) has been recommended as a gold standard in paediatric rehabilitation. A Ugandan version of PEDI (PEDI-UG) has been developed by culturally adapting and translating the original PEDI. The aim of this study was to investigate the psychometric properties of the PEDI-UG in Ugandan children by testing the instrument's rating scale functioning, internal structure, and test-retest reliability. METHODS: Two hundred forty-nine Ugandan children (125 girls) aged 6 months to 7.5 years (Mean = 3.4, SD = 1.9) with typical development were tested using the PEDI-UG. Forty-nine children were tested twice to assess test-retest reliability. Validity was investigated by Rasch analysis and reliability by intraclass correlation coefficient. RESULTS: The PEDI-UG domains showed good unidimensionality based on principal component analysis of residuals. Most activities (95%) showed acceptable fit to the Rasch model. Six misfit items were deleted from the Functional Skills scales and one from the Caregiver Assistance scales. The category steps on the Caregiver Assistance scales' rating scale were reversed but functioned well when changed from a 6-point to 4-point rating scale. The reliability was excellent; intraclass correlation coefficient was 0.87-0.92 for the domains of the Functional Skills scales and 0.86-0.88 for the domains of the Caregiver Assistance scales. CONCLUSION: The PEDI-UG has good to excellent psychometric properties and provides a valid measure of the functional performance of typically developing children from the age of 6 months to 7.5 years in Uganda. Further analysis of all items, including misfit and deleted items, in children with functional disability is recommended.

[Determinants of low birth weight among newborns to HIV-infected mothers not eligible for antiretroviral treatment in Africa]. / Déterminants du faible poids de naissance chez des enfants nés de mères séropositives pour le VIH, non éligibles au traitement antirétroviral, en Afrique.

BACKGROUND: Low birth weight (LBW) increases the risk of infant death, but little is known about its rate and determinants among babies born to HIV-infected mothers in sub-Saharan Africa. METHODS: This study was conducted in South Africa, Burkina Faso, Uganda and Zambia, during the recruitment process of the PROMISE-PEP (ANRS 12174) clinical trial. The study sample included 1196 subjects screened between August 2009 and December 2011, respectively 254 in South Africa, 221 in Burkina Faso, 197 in Uganda and 524 in Zambia, all ineligible for antiretroviral therapy. Data were collected during ANRS12174 clinical trial antenatal and postnatal screening visits, and during an inclusion visit for completion of an electronic case report form (eCRF). RESULTS: The mean (±SD) age of mothers was 27±5years and their mean CD4 count was 576±195cells/µL. Most mothers lived in a couple (78.7%), had no employment (72.3%) and had a good level of education (74% had gone to school). Male newborns predominated (51.7%). The mean birth weight was 3043g±435g, and 7.8% ([95%CI: 6.3%-9.3%]) of newborns weighed less than 2500g. In univariate analyses, being married or cohabiting, body mass index, WHO HIV disease stage II, female newborn and low gestational age were associated with risk of LBW. In multivariate regression model, low gestational age (aOR=3.74, P<0.0001) and female newborn (aOR=1.63, P=0.04) were significantly associated with LBW. CONCLUSION: The risk factors for LBW found in HIV-infected women ineligible for antiretroviral therapy were the same as in the general population. There was no evidence of additional risk factors associated with HIV infection.

Faecal calprotectin in HIV-infected, HAART-naïve Ugandan children.

OBJECTIVES: Calprotectin is a calcium- and zinc-binding protein and a marker in faeces of gastrointestinal inflammation. Reference values have been established in children older than 4 years. The aim of the present study was to determine the concentration of faecal calprotectin (FC) in human immunodeficiency virus (HIV)-infected, highly active antiretroviral therapy-naïve Ugandan children and compare it with the reference value. METHODS: We tested 193 HIV-infected children ages 0 to 12 years in a hospital-based survey for FC. A standardised interview with sociodemographic information and medical history was used to assess risk factors. A cluster of differentiation 4 (CD4) cell percentage was prevalent in all of the children. RESULTS: The median FC concentrations decreased with increasing age, as in healthy children. The median concentration was 208 mg/kg in infants 0 to 1 year, 171 mg/kg among toddlers 1 to 4 years, and 62 mg/kg for children 4 to 12 years. Children with advanced disease and a low CD4 cell percentage had significantly higher FC concentrations than those with a high CD4 cell percentage. Children older than 4 years with diarrhoea had significantly higher FC concentrations compared with those without diarrhoea. CONCLUSIONS: HIV-infected children older than 4 years had a median FC concentration above the reference value, and gut inflammation in the children with elevated values is likely. Children with more advanced disease had increased FC concentrations regardless of age.

Care-seeking in the development of severe community acquired pneumonia in Ugandan children.

BACKGROUND: Improved case management of paediatric pneumonia is recognised as a key strategy for pneumonia control. Since symptoms of pneumonia and malaria often overlap, there are concerns that children with pneumonia are treated with antimalarial drugs. There is a need to describe how children with severe pneumonia have been managed prior to their arrival at hospital, including possible risks of developing more severe disease. METHODS: A case-series study of 140 children, aged 2-59 months, with severe radiologically verified pneumonia at Mulago Hospital, Kampala was undertaken. Caretakers were interviewed about initial symptoms, treatment given and care sought. Using WHO definitions, children were clinically classified as having severe or very severe pneumonia. RESULTS: The children had been ill for a median of 7 days before arrival at hospital, 90/140 (64%) had received treatment at home, and 72/140 (51%) had seen another health-care provider prior to presentation at hospital. Altogether, 32/140 (23%) children had reportedly received antibiotics only prior to admission, 18/140 (13%) had received anti-malarials only and 35/140 (25%) had received both. Being classified as very severe pneumonia was more common among children who had received anti-malarials only (OR 5.5, 1.8-16.4). CONCLUSIONS: Although the majority of caretakers were able to recognise the key symptoms of pneumonia, they did not respond with any immediate care-giving action. Since progression from first recognition of pneumonia symptoms to severe disease is rapid, management guidelines regarding timing of care-seeking need to be clearly defined. The reason why children who sought health facility care failed to improve should be investigated. Meanwhile, there is a need to increase caretakers' and health workers' awareness of the urgency to act promptly when key pneumonia symptoms are observed.

Knowledge gaps, attitude and beliefs of the communities about sickle cell disease in Eastern and Western Uganda.

BACKGROUND: The management of sickle cell disease (SCD) has remained insurmountable in developing countries such as Uganda, because most communities are not aware of it. OBJECTIVE: To determine knowledge gaps, attitudes and beliefs of the communities about sickle cell disease in Eastern and Western Uganda. DESIGN: Cross sectional descriptive study. SETTING: The districts of Sironko and Mbale in Eastern Uganda and Mbarara and Ntungamo in Western Uganda. SUBJECTS: Households, students and health workers. RESULTS: Household respondents from Eastern Uganda were more aware of SCD than those from Western (p < 0.001), with the majority reporting that they had seen more people with SCD in their communities than those from the West (p < 0.001). Fewer (< 1.9%) believed SCD was due to witch craft. Eight per cent of household respondents in Eastern believed it was a curse from God compared to 2% in the West. Less than 18% of the household respondents knew they could have children with SCD and (< 52%) of health workers knew SCD screening methods. Fewer (< 14%) of the health workers had participated in screening. Less than 20% of the respondents knew their sickle cell status. CONCLUSION: Respondents from Eastern Uganda were more aware of SCD than those from Western. Minority of the respondents knew their SCD status and few health staff knew how to screen it. There is need to sensitise communities and policy makers about prevention, screening and treatment of SCD.

Child mental illness and the help-seeking process: a qualitative study among parents in a Ugandan community.

BACKGROUND: Child mental illness contributes significantly to the burden of disease worldwide, and many are left untreated due to factors on both the provider and user side. Recognising this, the Ugandan Ministry of Health recently released the Child and Adolescent Mental Health (CAMH) Policy Guidelines. However, for implementation to be successful the suggested policy changes must resonate with the service users. To better understand the sociocultural factors influencing parental mental help-seeking, we sought insights from parents in the Mbale district of eastern Uganda. METHOD: In this qualitative study, eight focus group discussions were conducted with mothers and fathers in urban and rural communities. Parents of children younger than 10 years were purposively selected to discuss a vignette story about a child with symptoms of depression or ADHD as well as general themes relating to child mental illness. The data were analysed using qualitative content analysis. RESULTS: Descriptions of severe symptoms and epileptic seizures were emphasised when recognising problem behaviour as mental illness, as opposed to mere 'stubbornness' or challenging behaviour. A mixture of supernatural, biomedical, and environmental understandings as underlying causes was reflected in the help-seeking process, and different treatment providers and relevant institutions, such as schools, were contacted simultaneously. A notion of weakened community social support structures hampered access to care. CONCLUSION: Awareness of symptoms closer to normal behaviour must be increased in order to improve the recognition of common mental illnesses in children. Stakeholders should capitalise on the common recognition of the importance of the school when planning the upscaling of and improved access to services. Multifactorial beliefs within the spiritual and biomedical realms about the causes of mental illness lead to multisectoral help-seeking, albeit without collaboration between the various disciplines. The CAMH Policy Guidelines do not address traditional service providers or provide a strategy for better integration of services, which might mean continued fragmentation and ineffective service provision of child mental health care.

Bacterial aetiology and outcome in children with severe pneumonia in Uganda.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in the 'under-5s' and in Uganda accounts for 10-30% of childhood deaths. Antibiotic resistance is increasing. OBJECTIVE: To describe the bacterial aetiology, antimicrobial sensitivity and outcome of severe pneumonia among children aged 2-59 months admitted to the Acute Care Unit, Mulago Hospital, Uganda. METHODS: A total of 157 children aged 2-59 months with symptoms of severe pneumonia according to WHO guidelines were recruited over a 4-month period in 2005/2006. Blood and induced sputum were obtained for culture, and chest radiographs were undertaken. Children were clinically classified as having severe or very severe pneumonia and were followed up for a maximum of 7 days. RESULTS: Bacteraemia was detected in 15.9% of patients with Staphylococcus aureus (36%) and Streptococcus pneumoniae (28%) were the organisms most commonly isolated. Bacteria were isolated from sputum in half of the children, the commonest organisms being Streptococcus pneumoniae (45.9%), Haemophilus influenzae (23.5%) and Klebsiella species (22.4%). Staphylococcus aureus had only 33.3% sensitivity to chloramphenicol and H. influenzae isolates were completely resistant. S. pneumoniae was sensitive to chloramphenicol in 87.4% of cases. The case fatality rate was 15.5%. Independent predictors of death were very severe pneumonia (OR 12.9, CI 2.5-65.8), hypoxaemia (SaO(2) <92%, OR 4.9, CI 1.2-19.5) and severe malnutrition (OR 16.5, CI 4.2-65.5). CONCLUSION: S. aureus, S. pneumoniae and H. influenzae are common bacterial causes of severe pneumonia. Chloramphenicol, the current first-line antibiotic for treating severe pneumonia in Ugandan children, is useful in pneumonia caused by S. pneumoniae but other common bacteria show resistance. The presence of severe malnutrition, hypoxaemia and very severe pneumonia increase the risk of death and should be considered in case management protocols.

Diet and socio-economic factors and their association with the nutritional status of pre-school children in a low income suburb of Kampala City, Uganda.

OBJECTIVE: To establish dietary and socio-economic factors and their association with the nutritional status of pre-school children in a poor suburb of Kampala city, Uganda. DESIGN: A cross-sectional study. SETTING: Three nursery schools in a low income suburb of Kampala city, Uganda. SUBJECTS: A sub-sample of forty one randomly selected pre-school children (three to six years of age) from a larger intervention study, participated in the present investigation. RESULTS: The results reveal high levels of chronic malnutrition (stunting and underweight) among the children. Almost half (46.3%) and one third (29.3%) of the children had height-for-age and weight-for-age centiles, respectively, below the 20th centile. The father's educational status was significantly (p = 0.017) associated with the children's nutritional status with all the children whose fathers had tertiary education and above having better weight-for-age centiles (above the 50th). Economic status too was significantly (p = 0.026) associated with the nutritional status of the children with children from the upper and mid-upper socio-economic classes having better weight-for-age centiles than children from the lower socio-economic status. Analysis of the diet showed a significant association between the nutrition status of the children and some of the foods consumed. Children who were above the 50th weight-for-age centiles consumed significantly more bread (p = 0.008) and light-green-leafy vegetables (p = 0.020) than those who had lower weight-for-age centiles. Children who were above their 50th height-for-age centiles consumed significantly (p = 0.049) more soybeans than children who had lower height-for-age centiles. CONCLUSION: Socio-economic as well as dietary factors were found to be inextricably linked and have been shown to be significantly associated with the nutritional status in this group of suburban pre-school children in Kampala city, Uganda.

Effect of zinc supplementation on growth and body composition of Ugandan preschool children: a randomized, controlled, intervention trial.

BACKGROUND: Despite ample food supplies, the incidence of childhood underweight and stunting remains high in Uganda. Many factors contribute to this situation, but the role of low zinc intakes has not been adequately explored. OBJECTIVE: Our objective was to study the effect of zinc supplementation on growth and body composition of preschool children by using the outcome measures of weight, height, and midupper arm circumference (MUAC). DESIGN: The study was randomized, double-blind, placebo-controlled, parallel, and 8 mo long, and incorporated 6 mo of zinc supplementation. Children (n = 153) aged 55.8 +/- 11.2 mo from 3 randomly selected nursery schools of medium, low, and very low socioeconomic status in a suburb of Kampala took part. The intervention comprised 10 mg Zn (as ZnSO4) or placebo daily in freshly prepared fruit juice, Monday to Friday inclusive. RESULTS: Zinc supplementation increased MUAC by the end of the study (P = 0.029) and led to greater weight gain in children from the school of medium socioeconomic status at 3 and 8 mo (P = 0.019 and P = 0.038, respectively). There was no effect on weight gain of the children from the other schools. Zinc supplementation had no influence on height. Infection rates (of which 82% were recorded as malaria) were lower in the zinc-supplemented group than in control subjects (P = 0.063). CONCLUSIONS: Zinc supplementation may counter the age-related decrease in MUAC often observed in preschool children in developing countries. The study provides evidence that zinc may not be the most limiting nutrient for weight gain in children of poor nutritional status, but may become so as nutritional status improves.

Measles control in a rural area in Zimbabwe.

In the rural district of Chimanimani in Zimbabwe, the Expanded Programme on Immunisation (EPI) which started in January 1982 has achieved measles coverage of between 50 and 80% in the 12-23 months age group, from 1984 to 1988, through 65 outreach centres, and 15 static health centres serving 93985 people in 119 villages. Facility based data as well as community based surveys have failed to show serious measles transmission in children under nine months of age, a common observation in high population density urban areas in Africa. Instead there has been a reduction in measles incidence and age distribution of measles has shifted to older children. The lowest measles incidence rate of 0.8 per 100 children occurred in the 0-5 months age group and the highest incidence rate of 4.0 per 100 children in the 48-59 months of age group. Only 7.9% of measles cases occurred in children under nine months of age. The high vaccination coverage rates were made possible by the post-independence government commitment, community involvement and dedicated staff. Our observations support the current one-dose 9 months minimum age measles vaccination policy for the low density rural areas in the developing countries.

PIP: In the rural district of Chimanimani in Zimbabwe, the Expanded Program on Immunization (EPI) which began in January 1982 has achieved measles coverage of between 50-80% in the 12-23 month age group. This was achieved between 1984-88 through 65 outreach centers and 15 static health centers serving 93,985 people in 119 villages. Facility based data as well as community based surveys have failed to show serious measles transmission in children under 9 months of age, a common observation in high population density urban areas in Africa. Instead, there has been a reduction in measles incidence and age distribution of measles has shifted to an older age group among children. The lowest measles incidence rate of 0.8/100 children occurred in the 0-5 month age group and the highest incidence rate of 4.0/100 children in the 48-59 month age group. Only 7.9% of measles cases occurred in children under 9 months of age. The high vaccination coverage rates were made possible by the postindependence government commitment, community involvement, and dedicated staff. The authors' observations support the current 1 dose 9-month minimum age measles vaccination policy for the low density rural areas in developing countries.

Lung abscess in children in Harare, Zimbabwe.

Despite the rarity of lung abscess in children, 24 patients were treated at Harare Central Hospital during the 10 year period (1979 to 1988). The bacteriology and clinical findings of the 24 patients are presented. Bacteria were isolated from 18 patients. The most frequent isolates were Staphylococcus aureus, group A beta haemolytic streptococci, and Pseudomonas aeroginosa. Most of the abscesses followed measles, empyema or an episode of aspiration. The patients were managed with bronchoscopy, physiotherapy, and appropriate antibiotics, and had a mortality of 25%. Efforts at controlling measles as well as early and appropriate management of empyema are likely to reduce the number of lung abscesses in children.

PIP: The clinical features, microbiology, treatment, and outcome in 24 children diagnosed with lung abscess at Harare Central Hospital during 1979-88 were reviewed retrospectively. This condition is rare in children, and the present study is the first to address lung abscess in Zimbabweans. 17 (71%) of the 24 patients were male and their mean age was 4.9 years. The most common presenting symptoms were fever, cough, and breathlessness. Abnormal chest signs (e.g., localized dull percussion note, with amphoric or bronchial breathing) were detected in 18 cases. Foremost among the predisposing factors were measles (25%), empyema thoraxis (17%), and unconsciousness (13%). Bacteria were isolated from 18 children, with Staphylococcus aureus (8 cases), group A beta hemolytic streptococci (4 cases), and Pseudomonas aeruginosa (3 cases) the most common. Treatment consisted of bronchoscopy to aspirate pus from the bronchus and exclude foreign bodies as well as antibiotic administration. There were 6 deaths (25% case fatality rate). The prevention or prompt treatment of measles is urged to reduce further the incidence of this rare health condition. However, the spread of human immunodeficiency virus infection among children in sub-Saharan Africa is likely to be accompanied by pediatric lung abscess cases secondary to pneumonia.

Measles in Chimanimani Zimbabwe.

A mini outbreak of measles in Chimanimani District in Zimbabwe where the measles immunisation coverage is about 79% is reported. Although many of the cases occurred in susceptible non-immunised children of the vaPostori (Apostolic) religious sects, a large number was in teenagers and adults. The importance of health education in increasing community participation in immunisation is emphasised. There is need to chart out a strategy to deal with a projected pool of persons susceptible to measles as our coverage rates continue to increase.

Nutrition status of children in Kasese district at the Uganda-Congo border.

OBJECTIVE: To establish the magnitude and risk factors for malnutrition in Kasese district at the Uganda-Congo border. DESIGN: Cross sectional nutrition survey. METHODS: Thirty clusters were selected. The height, weight, and mid upper arm circumference of at least 31 children per cluster were measured. Data on food frequency, prevalence of cough, fever and diarrhoea was also collected. RESULTS: Half of the 932 children (49.8%) were stunted, and 21.9% were severely stunted. While 17.4% of the children were under weight, 1.29% were wasted and 3.7% had MUAC <12.5 cm. Risk factors for stunting included not consuming milk, fathers' low formal education, having no immunisation card, and not breast feeding among 12-23 months old. Risk factors for underweight included fathers' and mothers' low education level, consumption of legumes, and fever or diarrhoea two weeks before the survey. For wasting the risk factors were consumption of vegetables, legumes or starchy foods. Those not consuming high-energy or animal foods including milk were likely to be severely wasted as were those not breast feeding in the 12-23 months age group. Fever or a diarrhoea episode two weeks preceding the survey and living in a female-headed household, were also risk factors for severe wasting. CONCLUSION: Attention to education, poverty alleviation, appropriate feeding practices, prevention and treatment of infections might assist in combating malnutrition in this district.

Immediate outcome of babies with low Apgar score in Mulago Hospital, Uganda.

BACKGROUND: Birth asphyxia contributes significantly to perinatal morbidity and mortality especially in resource poor countries. Although the Apgar score has been in use for over 50 years, the prevalence of low Apgar score and attendant risk factors and outcome have not been established in many sub-Saharan countries including Uganda. OBJECTIVE: To determine the prevalence of low Apgar score and establish immediate outcome and possible risk factors for poor outcome in babies with low Apgar score. SETTING: Labour wards, operating theatres and special baby care unit, Mulago Teaching and referral Hospital, Uganda. SUBJECTS: Babies delivered in Mulago Hospital between September and October 1999. Those with low Apgar scores, together with an equal number of babies with normal scores matched for sex as controls, were followed up for 48 hours. MEASUREMENTS: Clinical features, anthropometry, gestational age, oxygen saturation, blood glucose and autopsy of babies who died. MAIN OUTCOME MEASURES: Clinical improvement, death, complications such as HIE, RDS, aspiration pneumonia, hypoglycaemia, hypothermia, hypotension and hypoxaemia. RESULTS: The prevalence of low Apgar score at one and five minutes was 8.4% and 2.8% respectively. Adverse outcome was seen in 57.3% of cases: death in 12.1% and clinical complications in 45.2%. HIE occurred in 21.8%, hypoxaemia in 12.9%, hypoglycaemia in 16.9% and aspiration pneumonia in 4.8%. Maternal factors significantly associated with low Apgar scores included primiparity, abnormal delivery, age and medical diseases during pregnancy, while birth injuries and cord accidents were the baby factors. Poor outcome was associated with birth injury, hypothermia, hypoglycaemia, hypotension, aspiration pneumonia, hypoxaemia and severe birth asphyxia. CONCLUSION: Even though the prevalence of low Apgar was only 8.4%, adverse outcomes associated with it were observed in more than half the patients. Therefore there is need to carefully evaluate and monitor babies with low Apgar scores immediately after birth.

Socio-economic risk factors for severe protein energy malnutrition among children in Mulago Hospital, Kampala.

BACKGROUND: Despite Uganda's recent economic success, malnutrition is still an important public health problem and little information is available on socio-economic risk factors for severe protein energy malnutrition. OBJECTIVE: To determine socio-economic risk factors for severe protein energy malnutrition among children aged 0-60 months. DESIGN: A case control study. SETTING: Mulago Referral and Teaching Hospital, Kampala, Uganda. PATIENTS: Sixty six severely malnourished children (age 0-60 months) were matched, for age and sex, with 66 well nourished controls, and socio-economic, demographic, health facility utilisation and feeding practices were compared between the two groups. RESULTS: Severe protein energy malnutrition was associated with young age of the caretaker (p = 0.005), living in a mud walled house (OR 2.44, CI 1.13-5.32), lack of breast feeding (OR 3.22, CI 1.31-8.02), failure to complete immunisation (OR 3.68, CI 1.53-9.011), no land ownership (OR 4.62, CI 2.09-10.3), and no ownership of livestock (OR 13.65, CI 3.60-60.84), by the caretaker. The level of formal education of the caretaker was not associated with severe malnutrition. CONCLUSION: There seems to be a strong association between severe malnutrition and some indicators of poverty, lack of breastfeeding, and failure to complete immunisation. Programmes aimed at poverty alleviation, promotion of breastfeeding and immunisation, will go a long way in preventing malnutrition.

Missed opportunities and caretaker constraints to childhood vaccination in a rural area in Uganda.

BACKGROUND: Despite concerted support to vaccination programmes, coverage remains low. While health service reasons for this are known, there is little information on caretaker constraints to vaccination in Africa. OBJECTIVE: To establish the prevalence of missed vaccination opportunities and caretaker constraints to childhood vaccinations. DESIGN: Cross-sectional descriptive study. SUBJECTS: Caretakers of 408 children aged 12-23 months were interviewed. SETTING: Kiyeyi, a rural area in Eastern Uganda. RESULTS: Complete vaccination coverage by card was 26.7% while by history and card it was 44.6%. Of the 215 eligible children who sought treatment in a health facility where vaccination could be offered, 59.6% missed an opportunity to be vaccinated while 24.4% of the children missed an opportunity during routine vaccination sessions. Reasons for non-completion of vaccination included caretaker 'not bothered', being busy, or ill and fear of rude health workers. While most caretakers were aware of vaccination and its benefits, none knew the immunisation schedule. The major caretaker constraints were low level of formal education, fear of vaccine side effects, and perceived contraindications to vaccinations. CONCLUSION: Promotion of formal education for girls and educating mothers and health workers on the timing of vaccinations, their side effects and management might contribute to higher vaccination coverage.