Viewpoint: Antimicrobial Resistance Diagnostics Use Accelerator: Qualitative Research on Adherence to Prescriptions.

In this Viewpoint, the authors explore the determinants of patients' prescription adherence behaviors as part of FIND's Advancing Access to Diagnostic Innovation essential for Universal Health Coverage and AMR Prevention (ADIP) trials (ClinicalTrials.gov identifier: NCT04081051). Research findings from Burkina Faso, Ghana, and Uganda show that basic knowledge and understanding of prescription instructions are essential for adherence and can be improved through better communication. However, there are a range of other factors that influence adherence, some of which can be influenced through tailored communication messages from healthcare workers. These messages may contribute to changes in adherence behavior but may require other reinforcing interventions to be effective. Finally, there are some drivers of nonadherence centered around costs and time pressure that require other forms of intervention.

A Qualitative Assessment of a Training and Communication Intervention on Antibiotic Prescription Practices Among Health Workers and Outpatients at Public Health Facilities in Uganda.

BACKGROUND: Antibiotic prescribing practices are 1 of the contributing causes of antimicrobial resistance (AMR). The study explored the key drivers and barriers to adherence to prescribing instructions among healthcare workers and outpatient attendees with the aim of developing a training and communication intervention to improve adherence to prescription. METHODS: Prior to randomized trials at 3 health centers in Uganda (Aduku, Kihihi, and Nagongera), a pre-intervention qualitative assessment was conducted to explore behavioral drivers for adherence to prescriptions and the communication of adherence messages. Based on the findings, a training and communication package was developed for healthcare workers and patients at Day 0 of the trial. During the trial's Day 7 patient follow-up, in-depth interviews were conducted to further investigate adherence behaviors. RESULTS: Five main themes were identified that acted as drivers or barriers to prescription adherence. Key drivers included: drug availability at health facility, health worker knowledge, and communication to patients. Barriers included: care-seeker use of treatment resorts and an inability by care-seeker to buy drugs. CONCLUSIONS: The T&C appeared to influence both health workers' and patients' behavior and improve adherence to prescription.The adapted T&C should be considered a toolkit to improve antibiotic use across health facilities accompanied with appropriate guidelines to mitigate AMR.

Impact of the Introduction of a Package of Diagnostic Tools, Diagnostic Algorithm, and Training and Communication on Outpatient Acute Fever Case Management at 3 Diverse Sites in Uganda: Results of a Randomized Controlled Trial.

BACKGROUND: Increasing trends of antimicrobial resistance are observed around the world, driven in part by excessive use of antimicrobials. Limited access to diagnostics, particularly in low- and middle-income countries, contributes to diagnostic uncertainty, which may promote unnecessary antibiotic use. We investigated whether introducing a package of diagnostic tools, clinical algorithm, and training-and-communication messages could safely reduce antibiotic prescribing compared with current standard-of-care for febrile patients presenting to outpatient clinics in Uganda. METHODS: This was an open-label, multicenter, 2-arm randomized controlled trial conducted at 3 public health facilities (Aduku, Nagongera, and Kihihi health center IVs) comparing the proportions of antibiotic prescriptions and clinical outcomes for febrile outpatients aged ≥1 year. The intervention arm included a package of point-of-care tests, a diagnostic and treatment algorithm, and training-and-communication messages. Standard-of-care was provided to patients in the control arm. RESULTS: A total of 2400 patients were enrolled, with 49.5% in the intervention arm. Overall, there was no significant difference in antibiotic prescriptions between the study arms (relative risk [RR]: 1.03; 95% CI: .96-1.11). In the intervention arm, patients with positive malaria test results (313/500 [62.6%] vs 170/473 [35.9%]) had a higher RR of being prescribed antibiotics (1.74; 1.52-2.00), while those with negative malaria results (348/688 [50.6%] vs 376/508 [74.0%]) had a lower RR (.68; .63-.75). There was no significant difference in clinical outcomes. CONCLUSIONS: This study found that a diagnostic intervention for management of febrile outpatients did not achieve the desired impact on antibiotic prescribing at 3 diverse and representative health facility sites in Uganda.

Conducting Social Science Research During Epidemics and Pandemics: Lessons Learnt.

The COVID-19 pandemic has had a significant impact on how field-based research is being conducted globally. Given the challenges of undertaking fieldwork during epidemics and the need for mixed methods research to address the social, political, and economic issues related to epidemics, there is a small but growing body of evidence in this area. To contribute to the logistical and ethical considerations for conducting research during a pandemic, we draw on the challenges and lessons learnt from adapting methods for two research studies conducted in 2021 during the COVID-19 pandemic in low- and middle-income country (LMIC) settings: (1) in-person research in Uganda and (2) combined remote and in-person research in South and Southeast Asia. Our case studies focus on data collection and demonstrate the feasibility of conducting mixed methods research, even with many logistical and operational constraints. Social science research is often used to identify the context of specific issues, to provide a needs assessment, or inform longer-term planning; however, these case studies have shown the need to integrate social science research from the start of a health emergency and in a systematic way. Social science research during future health emergencies can also inform public health responses during the emergency. It is also crucial to collect social science data after health emergencies to inform future pandemic preparedness. Finally, researchers need to continue research on other public health issues that are ongoing even during a public health emergency.

Putting global health high on the agenda of medical schools.

In this opinion paper, we reflect on global health and global health education as well as challenges that the coming generation are likely to face. As the field is rapidly changing, it is vital to critically reflect categories of "global south" and "global north" as geographical boundaries, and rather think in terms of inequalities that are present in all countries. Global perspectives on health are useful to analyze structural challenges faced in all health care systems and help understand the diversity of cultures and patients' concepts of disease. We first discuss burning questions and important challenges in the field and how those challenges are tackled. Rather than going into detail on topical issues, we reflect on approaches and attitudes that we think are important in global health education and present opportunities and challenges for young scholars who are interested in working in this field.

Effectiveness of a mobile antiretroviral pharmacy and HIV care intervention on the continuum of HIV care in rural Uganda.

Adherence to antiretroviral therapy (ART) is critical in order to achieve viral suppression. We designed an intervention, Mobile Antiretroviral Therapy and HIV care (MAP-HC) in rural southwestern Uganda aimed to reduce travel distance and hypothesized that MAP-HC would improve ART adherence and rates of viral load suppression. The study was conducted at two district hospitals, among patients who lived >5 km from the hospital. For each hospital, we identified 4 health centers in the catchment area to serve as site for the mobile pharmacy. Each site was visited once a month to provide ART refills and adherence counseling. We measured patient waiting time, adherence and viral load suppression before and after the intervention. The proportion of patients who missed an ART dose in the last 30 days dropped from 20% to 8.5% at 12 months post-intervention (p = 0.009) and those with detectable viral load dropped from 19.9% to 7.4% (p = 0.001), however, mean waiting time increased from 4.48 to 4.76 h (p = 0.13). Mobile pharmacy intervention in rural Uganda is feasible and resulted in improvement in adherence and viral load suppression. Although it did not reduce patient waiting time at the clinic, we recommend scale-up in rural areas where patients face transportation challenges.

Routines, Hope, and Antiretroviral Treatment among Men and Women in Uganda.

Antiretroviral treatment programs, despite biomedical emphases, require social understanding and transformations to be successful. In this article, we draw from a qualitative study of HIV treatment seeking to examine the drug-taking routines and health-related subjectivities of men and women on antiretroviral treatment (ART) at two sites in Uganda. We show that while not all participants in ART programs understand clinical protocols in biomedical terms, they adopt treatment-taking strategies to integrate medication into daily practices and social spaces. In turn, these embedded practices and understandings shape long-term hopes and fears for living with HIV, including the possibility of a cure. More significant than new forms of citizenship or sociality, we suggest that quotidian dimensions of treatment normalization shape the long-term experience of medication and outlook for the future.

The first mile: community experience of outbreak control during an Ebola outbreak in Luwero District, Uganda.

BACKGROUND: A major challenge to outbreak control lies in early detection of viral haemorrhagic fevers (VHFs) in local community contexts during the critical initial stages of an epidemic, when risk of spreading is its highest ("the first mile"). In this paper we document how a major Ebola outbreak control effort in central Uganda in 2012 was experienced from the perspective of the community. We ask to what extent the community became a resource for early detection, and identify problems encountered with community health worker and social mobilization strategies. METHODS: Analysis is based on first-hand ethnographic data from the center of a small Ebola outbreak in Luwero Country, Uganda, in 2012. Three of this paper's authors were engaged in an 18 month period of fieldwork on community health resources when the outbreak occurred. In total, 13 respondents from the outbreak site were interviewed, along with 21 key informants and 61 focus group respondents from nearby Kaguugo Parish. All informants were chosen through non-probability sampling sampling. RESULTS: Our data illustrate the lack of credibility, from an emic perspective, of biomedical explanations which ignore local understandings. These explanations were undermined by an insensitivity to local culture, a mismatch between information circulated and the local interpretative framework, and the inability of the emergency response team to take the time needed to listen and empathize with community needs. Stigmatization of the local community--in particular its belief in amayembe spirits--fuelled historical distrust of the external health system and engendered community-level resistance to early detection. CONCLUSIONS: Given the available anthropological knowledge of a previous outbreak in Northern Uganda, it is surprising that so little serious effort was made this time round to take local sensibilities and culture into account. The "first mile" problem is not only a question of using local resources for early detection, but also of making use of the contextual cultural knowledge that has already been collected and is readily available. Despite remarkable technological innovations, outbreak control remains contingent upon human interaction and openness to cultural difference.

A consortium approach to competency-based undergraduate medical education in Uganda: process, opportunities and challenges.

BACKGROUND: Uganda, like the rest of Africa, is faced with serious health challenges including human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), other infectious diseases and increasing non-communicable diseases, yet it has a significant shortage of health workers. Even the few health workers available may lack desired competencies required to address current and future health challenges. Reducing Uganda's disease burden and addressing health challenges requires Ugandan medical schools to produce health workers with the necessary competencies. This study describes the process which a consortium of Ugandan medical schools and the Medical Education Partnership for Equitable Services to all Ugandans (MESAU) undertook to define the required competencies of graduating doctors in Uganda and implement competency-based medical education (CBME). METHODS: A retrospective qualitative study was conducted in which document analysis was used to collect data employing pre-defined checklists, in a desktop or secondary review of various documents. These included reports of MESAU meetings and workshops, reports from individual institutions as well as medical undergraduate curricula of the different institutions. Thematic analysis was used to extract patterns from the collected data. RESULTS: MESAU initiated the process of developing competencies for medical graduates in 2011 using a participatory approach of all stakeholders. The process involved consultative deliberations to identify priority health needs of Uganda and develop competencies to address these needs. Nine competence domain areas were collaboratively identified and agreed upon, and competencies developed in these domains. DISCUSSION: Key successes from the process include institutional collaboration, faculty development in CBME and initiating the implementation of CBME. The consortium approach strengthened institutional collaboration that led to the development of common competencies desired of all medical graduates to address priority health challenges in Uganda. It is important that the MESAU consortium continues engaging all stakeholders in medical education to support the implementation and sustainability of CBME in Uganda.

Experiences and responses of child protection professionals during COVID-19: Lessons learned from professionals around the globe.

BACKGROUND: COVID-19 significantly worsened already challenging circumstances for children and their families and globally increased the likelihood of child maltreatment. This risk heightened the urgency of child protection professionals in preventing child maltreatment and defending children's rights. The vast and growing body of research on protecting children from child maltreatment during COVID-19 has emphasized practitioners' tremendous difficulty in this arena. OBJECTIVE: The current international study sought to identify the experiences and responses of child protection professionals to child maltreatment during COVID-19. PARTICIPANTS AND SETTING: Five real-time, virtual focus groups were conducted among professionals who work with children from countries around the globe. METHOD: Reflexive thematic analysis was employed to analyze the focus group transcripts. RESULTS: The participants identified their experiences and challenges in performing their role of protecting children. Additionally, they shared context-adapted and innovative responses to child maltreatment, while emphasizing self-care and their mental health. CONCLUSIONS: The results highlighted that child protection was significantly more challenging during the COVID-19 pandemic. Furthermore, they underlined the importance of establishing practices and policies for child protection in crisis times as well as ensuring both children's and professionals' well-being and mental health.

The remote work of child protection professionals during COVID-19: A scoping review and thematic analysis.

BACKGROUND: The COVID-19 pandemic created new challenges and barriers for the work of child protection professionals (CPPs) and intensified existing hardships for families and children, increasing the risk of child maltreatment. As new restrictions and precautions were implemented by governments worldwide to stop the virus from spreading, CPPs had to adapt to a new reality of working remotely. However, limited research has investigated how remote work impacted CPPs and child protection work and how CPPs handled this alternative work style. OBJECTIVE: This review aims to address gaps in the research to reveal the creative and effective approaches CPPs developed to overcome the challenges presented by COVID-19, defined as the 'positive legacy' of CPPs, particularly in adapting to remote work challenges. METHOD: This review was conducted using a scoping review, followed by two rounds of thematic analysis. The scoping review was conducted in six languages: Hebrew, Arabic, French, Portuguese, Spanish, and English. RESULTS: The first round of thematic analysis found 18 articles relevant to this review. The second round extracted two main themes: 1) the challenges of remote work and 2) overcoming the challenges of no contact. CONCLUSIONS: The findings of this review may be used to inform future strategies for child protection during a pandemic. They also provide an opportunity to rethink the relationship child protection work has with technology to systematically reform current and future protection policies and practices, including outside of a pandemic.

Genetic and Genomic Researchers' Perspectives on Biological Sample Sharing in Collaborative Research in Uganda: A Qualitative Study.

Numerous ethical, legal, and social issues arise with biological sample sharing. The study explored the perspectives of genetic and genomic researchers on the sharing of biological samples in international collaborative research. Qualitative in-depth interviews were conducted with 15 researchers. Participants expressed positive attitudes towards biobanking and appreciated the benefits of cross-border sharing of biological samples but noted that this practice had adversely affected local capacity building efforts. There was limited understanding of the ethical and regulatory frameworks governing sample sharing. Researchers emphasized the importance of respecting cultural values in biobanking research. Issues concerning poor governance and inequitable benefit sharing were also raised. There is a need for fair and equitable international collaborations where all researchers are treated with respect and as equal partners.

Perceptions about and reasons for participation in research bronchoscopy in Uganda: A qualitative analysis.

This study sought to assess perceptions towards and reasons for participation in research bronchoscopy studies in a high TB burden urban setting. Additionally, the study aimed to identify areas of pre- and post-procedural concern among healthy adults approached to participate in research bronchoscopy. A cross sectional qualitative study was undertaken at the Uganda-Case Western Reserve University Collaboration Tuberculosis Research Project Clinic at Mulago National Referral Hospital in Kampala, Uganda. In-depth interviews were conducted with participants at their pre-bronchoscopy visit (n = 17) and after they had undergone bronchoscopy (n = 23) to examine their perceptions and experiences with the procedure. Following consent, all interviews were audio recorded and later transcribed and typed in MS WORD. Local language interviews were translated into English by the social science interviewers. Qualitative analysis was performed manually following an inductive and emergent approach typical in thematic analysis. This study was approved by the Makerere University School of Social Sciences Research Ethics Committee (MAKSS REC 09.18.220) and registered with the Uganda National Council for Science and Technology (UNCST SS4785). Overall willingness to participate in bronchoscopy was high as many participants viewed the study as primarily a means of getting free health checks and determining their health status. Notably, despite extensive face to face counseling for this study coupled with the fact that our participants had been involved in prior research at the site, therapeutic misconception still played a pivotal role in willingness to participate in research bronchoscopy. Therapeutic misconception has important ethical and research implications in clinical research, which requires strategies to tackle it, even among a pool of potential participants who are knowledgeable about a disease or clinical care procedures. Continuous awareness and knowledge building about the difference between being a trial participant and therapeutic misconception must become a mainstay in trials to improve the process of informed consent for future research bronchoscopy studies.

Risk perception of Ebola virus disease and COVID-19 among transport drivers living in Ugandan border districts.

Background: Cross-border movements between districts bordering Uganda and the Democratic Republic of Congo (DRC) are common due to the interdependence between populations on either side, though this increases the risk of the international spread of infectious diseases. Due to the nature of their work, boda boda drivers (motorcycle taxis), taxis and truck drivers continue to cross the border during epidemics. However, perceived risk of contracting and spreading communicable diseases may be influenced by several factors such as the level of education, packaging and perception of health care messages, limited interaction with local socio-cultural dynamics or personal experiences. This study aims to explore differences in movement patterns and risk perceptions as factors for transmission among transport drivers in Ugandan border districts during the 2018-2020 Ebola Virus Disease (EVD) epidemic and the current COVID-19 pandemic. Methods: Between May and June 2021, in-depth interviews and focus group discussions were conducted with transport drivers in three Ugandan districts bordering DRC (Kasese, Kisoro and Hoima). Participants were asked about their knowledge and beliefs about EVD and COVID-19, perceived risk during epidemics, reasons for, and travel patterns during the EVD epidemic and COVID- 19 pandemic. A thematic content analysis was applied. Results: Participants' awareness of EVD was higher than that of COVID-19 however, the risk of transmission of Ebola virus was perceived as a remote threat. Measures restricting mobility during the COVID-19 pandemic had a greater impact on transport drivers compared to those implemented during the EVD epidemic, and were perceived as prohibitive rather than protective, largely due to fear of reprisals by security officers. Despite this, drivers were unlikely to be able to comply with the restrictions as they relied on their work as a source of income. Conclusion: The vulnerabilities of transport drivers should be considered in the context of epidemics such EVD and COVID-19 in Uganda. Policy makers should address these particularities and assess the impact of public health measures on transport drivers' mobility and involve them in designing of mobility-relatedpolicies.

Gendered care at the margins: Ebola, gender, and caregiving practices in Uganda's border districts.

In July 2019, Ebola in the Democratic Republic of Congo (DRC) was declared a public health emergency of international concern and neighbouring countries were put on high alert. This paper examines the intersections of gender, caregiving, and livelihood practices in Uganda's border districts that emerged as key factors to consider in preparedness and response. This paper is based on an anthropological study of the Ebola context among Bantu cultures. We report on data from focus group discussions and key informant interviews with various sectors of the community. The study identified intersecting themes reported here: (1) women as primary caregivers in this context; and (2) women as providers, often in occupations that increase vulnerability to Ebola. Findings demonstrate the role that women play inside and outside the home as caregivers of the sick and during burials, and intersections with livelihood-seeking strategies. Because women's caregiving is largely unpaid, women face a double burden of work as they seek other livelihood strategies that sometimes increase vulnerability to Ebola. Epidemic response should address these intersections and the context-specific vulnerabilities of caregivers; it should also be localised and community-centred and able to attend to the cultural as well as the economic needs of a community.

Experiences and practices of key research team members in obtaining informed consent for pharmacogenetic research among people living with HIV: a qualitative study.

This study aimed to explore experiences and practices of key research team members in obtaining informed consent for pharmacogenetics research and to identify the approaches used for enhancing understanding during the consenting process. Data collection involved 15 qualitative, in-depth interviews with key researchers who were involved in obtaining informed consent from HIV infected individuals in Uganda for participation in pharmacogenetic clinical trials. The study explored two prominent themes: approaches used to convey information and enhance research participants' understanding and challenges faced during the consenting process. Several barriers and facilitators for obtaining consent were identified. Innovative and potentially effective consenting strategies were identified in this study that should be studied and independently verified.

Child protective services during COVID-19 and doubly marginalized children: International perspectives.

BACKGROUND: Alongside deficits in children's wellbeing, the COVID-19 pandemic has created an elevated risk for child maltreatment and challenges for child protective services worldwide. Therefore, some children might be doubly marginalized, as prior inequalities become exacerbated and new risk factors arise. OBJECTIVE: To provide initial insight into international researchers' identification of children who might have been overlooked or excluded from services during the pandemic. PARTICIPANTS AND SETTING: This study was part of an international collaboration involving researchers from Brazil, Canada, Colombia, Israel, South Africa, Uganda, the UK and the USA. Researchers from each country provided a written narrative in response to the three research questions in focus, which integrated the available data from their countries. METHOD: Three main questions were explored: 1) Who are the children that were doubly marginalized? 2) What possible mechanisms may be at the root? and 3) In what ways were children doubly marginalized? The international scholars provided information regarding the three questions. A thematic analysis was employed using the intersectional theoretical framework to highlight the impact of children's various identities. RESULTS: The analysis yielded three domains: (1) five categories of doubly marginalized children at increased risk of maltreatment, (2) mechanisms of neglect consisting of unplanned, discriminatory and inadequate actions, and (3) children were doubly marginalized through exclusion in policy and practice and the challenges faced by belonging to vulnerable groups. CONCLUSION: The COVID-19 pandemic can be used as a case study to illustrate the protection of children from maltreatment during worldwide crises. Findings generated the understanding that child protective systems worldwide must adhere to an intersectionality framework to protect all children and promote quality child protection services.

Experiences and ways PLWHA deal with their lives.

The issue of HIV and AIDS and people living with HIV and AIDS is very sensitive which needs great attention. The population of infected individuals seems not to seek help and health services due to their illness. The barriers which prevent this population experience the meaning of social construction of their illness. The main objective of this study is to understand the day-to-day lives and the ways PLWHA deals with their lives. Qualitative method and participatory action research were used to gather information. The study found out that PLWHA have much to fight for in the complex and frightening areas of HIV research and treatment. Though there have been lacking scientific skills, all PLWHA can bring unique experiences and perspectives to an open discussion. The study concluded that facing the challenges of working with HIV and AIDS -individuals; consider the participatory research approach because it can reach out to individuals, groups and organizations. It was recommended that the ultimate goals of AIDS treatment and research activism are to accelerate scientific research knowledge that contributes towards cure, and to win an early widespread access to treatment for everyone infected with HIV. Developing a well-designed research can help PLWHA learn how to ask themselves different questions and ask if the medical and research establishments will address their concerns.