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BACKGROUND: Immunisation remains the most cost-effective public health intervention in preventing morbidity and mortality due to Vaccine-Preventable Diseases (VPDs). The study aims to compare the differences in immunisation coverage amongst children aged 0 to 23 months living in slums of Kampala city and Iganga as rural districts in Uganda. METHODS: This study utilises data from a cross-sectional survey done in 2019 in the slums of Kampala City and the rural district of Iganga within the Health and Demographic Surveillance Site (HDSS). It included 1016 children aged 0-23 months and their parents. A logistic regression model was used to analyse the relationship between multiple independent variables and the binary dependent variables (fully immunised) using Stata statistical software. The measures of association were odds ratios reported with a corresponding 95% confidence interval. RESULTS: Out of the 1016 participants, 544 participants live in the rural area and 472 participants in the slums. Slums had 48.9% (n = 231) of fully immunised children whilst rural areas had 43.20% (n = 235). The multivariate analysis showed that children living in slums are more likely to be fully immunised as compared to their counterparts in rural areas (Odds ratio:1.456; p = 0.033; CI:1.030-2.058). Immunisation coverage for BCG (98.9%), Polio 0 (88.2%), Penta1 (92.7%), and Pneumo1 (89.8%) were high in both settlements. However, the dropout rate for subsequent vaccines was high 17%, 20% and 41% for Penta, pneumococcal and rota vaccines respectively. There was poor uptake of the new vaccines with slums having 73.4% and 47.9% coverage for pneumococcal and rota vaccines respectively and rural areas had 72.1% and 7.5% for pneumococcal and rota vaccines respectively. CONCLUSION: The low full immunisation status in this study was attributed to the child's residence and the occupation of the parents. Lack of education and poor access to messages on immunisation (inadequate access to mass media) are other contributing factors. Educational messages on the importance of immunisation targeting these underserved populations will improve full immunisation coverage.
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Imunização , Áreas de Pobreza , Humanos , Criança , Lactente , Estudos Transversais , Uganda/epidemiologia , Vacinas PneumocócicasRESUMO
BACKGROUND: Efforts aimed at reducing morbidity and mortality associated with pneumonia in children aged five years and below largely depend on caretakers. This study aimed to assess the factors associated with knowledge, attitudes, and practices of caretakers regarding pneumonia. METHODS: This was a cross-sectional study carried out within Iganga and Mayuge health and demographic surveillance site (IMHDSS) cohort in Eastern Uganda. Caretakers of children under the age of five years were assessed for knowledge, attitudes, and practices using a set of indicators. The caretaker characteristics as determinants for knowledge, attitude, and practices in relation to pneumonia management were assessed for association. Logistic regression was used to assess the factors associated with caretaker knowledge, attitudes and practices. RESULTS: A total of 649 caretakers of children five years and below of age were interviewed. Caretakers knew pneumonia as one of the childhood diseases, but were less knowledgeable about its transmission, signs and symptoms, risk factors and treatment. Overall, 28% had good knowledge, 36% had moderate knowledge and 35% had poor knowledge. The caretaker attitude was good for more than a half of the respondents (57%), while majority reported good practices (74.1%). Older age (OR = 1.63, 95% CI (1.05-2.51)), Tertiary education (OR = 4.92, 95% CI (2.5-9.65)), being married (OR = 1.82, 95% CI (1.05-3.15)) were associated with having good knowledge. Age above 35 years (aOR = 1.48, 95% CI (1.03-2.11)), and main source of livelihood were associated with good attitude and lastly being female (OR = 2.3, 95% CI (1.23-4.37)), being a Muslim (aOR = 0.5, 95% CI (0.35-0.75)), and being a farmer (OR = 0.5, 95% CI (0.33-0.85)) were associated with being a good caretaker practice. CONCLUSIONS: The caretakers of children five years and below, have relatively adequate knowledge about the signs and symptoms of pneumonia, risk factors and treatment measures. Higher education, being married, and being a salary earner were associated with better knowledge about pneumonia, while being female, being a Muslim, and being a peasant farmer were associated with good practice. Targeted interventions to equip caretakers with relevant and adequate skills and knowledge for lower-income and less educated caretakers, considering cultural and religious beliefs about childhood pneumonia identification and management are required.
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Conhecimentos, Atitudes e Prática em Saúde , Pneumonia , Criança , Humanos , Feminino , Masculino , Uganda/epidemiologia , Estudos Transversais , Pneumonia/terapia , População Rural , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Monitoring essential health services coverage is important to inform resource allocation for the attainment of the Sustainable Development Goal 3. The objective was to assess service, effective and financial coverages of maternal healthcare services and their equity, using health and demographic surveillance site data in eastern Uganda. METHODS: Between Nov 2018 and Feb 2019, 638 resident women giving birth in 2017 were surveyed. Among them, 386 were randomly sampled in a follow-up survey (Feb 2019) on pregnancy and delivery payments and contents of care. Service coverage (antenatal care visits, skilled birth attendance, institutional delivery and one postnatal visit), effective coverage (antenatal and postnatal care content) and financial coverage (out-of-pocket payments for antenatal and delivery care and health insurance coverage) were measured, stratified by socio-economic status, education level and place of residence. RESULTS: Coverage of skilled birth attendance and institutional delivery was both high (88%), while coverage of postnatal visit was low (51%). Effective antenatal care was lower than effective postnatal care (38% vs 76%). Financial coverage was low: 91% of women made out-of-pocket payments for delivery services. Equity analysis showed coverage of institutional delivery was higher for wealthier and peri-urban women and these women made higher out-of-pocket payments. In contrast, coverage of a postnatal visit was higher for rural women and poorest women. CONCLUSION: Maternal health coverage in eastern Uganda is not universal and particularly low for postnatal visit, effective antenatal care and financial coverage. Analysing healthcare payments and quality by healthcare provider sector is potential future research.
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Serviços de Saúde Materna , Estudos Transversais , Parto Obstétrico , Feminino , Humanos , Gravidez , Cuidado Pré-Natal , Fatores Socioeconômicos , Uganda , Cobertura Universal do Seguro de SaúdeRESUMO
BACKGROUND: Birth registration is a child's first right. Registration of live births, stillbirths and deaths is foundational for national planning. Completeness of birth registration for live births in low- and middle-income countries is measured through population-based surveys which do not currently include completeness of stillbirth or death registration. METHODS: The EN-INDEPTH population-based survey of women of reproductive age was undertaken in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017-2018). In four African sites, we included new/modified questions regarding registration for 1177 stillbirths and 11,881 livebirths (1333 neonatal deaths and 10,548 surviving the neonatal period). Questions were evaluated for completeness of responses, data quality, time to administer and estimates of registration completeness using descriptive statistics. Timing of birth registration, factors associated with non-registration and reported barriers were assessed using descriptive statistics and logistic regression. RESULTS: Almost all women, irrespective of their baby's survival, responded to registration questions, taking an average of < 1 min. Reported completeness of birth registration was 30.7% (6.1-53.5%) for babies surviving the neonatal period, compared to 1.7% for neonatal deaths (0.4-5.7%). Women were able to report age at birth registration for 93.6% of babies. Non-registration of babies surviving the neonatal period was significantly higher for home-born children (aOR 1.43 (95% CI 1.27-1.60)) and in Dabat (Ethiopia) (aOR 4.11 (95% CI 3.37-5.01)). Other socio-demographic factors associated with non-registration included younger age of mother, more prior births, little or no education, and lower socio-economic status. Neonatal death registration questions were feasible (100% women responded; only 1% did not know), revealing extremely low completeness with only 1.2% of neonatal deaths reported as registered. Despite > 70% of stillbirths occurring in facilities, only 2.5% were reported as registered. CONCLUSIONS: Questions on birth, stillbirth and death registration were feasible in a household survey. Completeness of birth registration is low in all four sites, but stillbirth and neonatal death registration was very low. Closing the registration gap amongst facility births could increase registration of both livebirths and facility deaths, including stillbirths, but will require co-ordination between civil registration systems and the often over-stretched health sector. Investment and innovation is required to capture birth and especially deaths in both facility and community systems.
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Morte Perinatal , Natimorto , Criança , Confiabilidade dos Dados , Coleta de Dados , Escolaridade , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Masculino , Gravidez , Natimorto/epidemiologiaRESUMO
BACKGROUND: Preterm birth (gestational age (GA) <37 weeks) is the leading cause of child mortality worldwide. However, GA is rarely assessed in population-based surveys, the major data source in low/middle-income countries. We examined the performance of new questions to measure GA in household surveys, a subset of which had linked early pregnancy ultrasound GA data. METHODS: The EN-INDEPTH population-based survey of 69,176 women was undertaken (2017-2018) in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda. We included questions regarding GA in months (GAm) for all women and GA in weeks (GAw) for a subset; we also asked if the baby was 'born before expected' to estimate preterm birth rates. Survey data were linked to surveillance data in two sites, and to ultrasound pregnancy dating at <24 weeks in one site. We assessed completeness and quality of reported GA. We examined the validity of estimated preterm birth rates by sensitivity and specificity, over/under-reporting of GAw in survey compared to ultrasound by multinomial logistic regression, and explored perceptions about GA and barriers and enablers to its reporting using focus group discussions (n = 29). RESULTS: GAm questions were almost universally answered, but heaping on 9 months resulted in underestimation of preterm birth rates. Preference for reporting GAw in even numbers was evident, resulting in heaping at 36 weeks; hence, over-estimating preterm birth rates, except in Matlab where the peak was at 38 weeks. Questions regarding 'born before expected' were answered but gave implausibly low preterm birth rates in most sites. Applying ultrasound as the gold standard in Matlab site, sensitivity of survey-GAw for detecting preterm birth (GAw <37) was 60% and specificity was 93%. Focus group findings suggest that women perceive GA to be important, but usually counted in months. Antenatal care attendance, women's education and health cards may improve reporting. CONCLUSIONS: This is the first published study assessing GA reporting in surveys, compared with the gold standard of ultrasound. Reporting GAw within 5 years' recall is feasible with high completeness, but accuracy is affected by heaping. Compared to ultrasound-GAw, results are reasonably specific, but sensitivity needs to be improved. We propose revised questions based on the study findings for further testing and validation in settings where pregnancy ultrasound data and/or last menstrual period dates/GA recorded in pregnancy are available. Specific training of interviewers is recommended.
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Nascimento Prematuro , Criança , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Pobreza , Gravidez , Nascimento Prematuro/epidemiologia , Cuidado Pré-Natal , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The UNICEF/Washington Group Child Functioning Module (CFM) assesses child functioning among children between 5 and 17 years of age. This study adapted and validated the CFM at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Uganda. METHODS: This cross-sectional study was conducted between September 2018-January 2019 at the IM-HDSS. Respondents were caregivers of children between 5 and 17 years of age who were administered modified Washington Group short set (mWG-SS) and CFM. The responses were recorded on a 4-point Likert scale. Descriptive analysis was conducted on child and caregiver demographic characteristics. Exploratory factor analysis (EFA) assessed underlying factor structure, dimensionality and factor loadings. Cronbach's alpha was reported as an assessment of internal consistency. Face validity was assessed during the translation process, and concurrent validity of CFM was assessed through comparison with disability short form. RESULTS: Out of 1842 caregivers approached, 1439 (78.1%) participated in the study. Mean age of children was 11.06 ± 3.59 years, 51.4% were males, and 86.1% had a primary caregiver. Based on EFA, vision, hearing, walking, self-care, communication, learning, remembering, concentrating, accepting change, behavior control, and making friends loaded on factor 1 - "Motor and Cognition," while anxiety and depression loaded on factor 2 - "Mood". Cronbach's alpha for the overall CFM was 0.899 (good internal consistency). Cronbach's alpha for each extracted factor was excellent, motor and cognition (0.904), and mood (0.902). CFM had acceptable face validity. Spearman's rank correlation between scores of CFM and modified WG short set was 0.51 (p-value < 0.001). The overall mean CFM score was 2.47 ± 3.82 out of 39. The mean score for Mood (1.35 ± 1.42 out of 6) was higher compared to Motor and Cognition (1.12 ± 3.06 out of 33). Comparing modified WG short set and CFM Likert responses, the percent agreement was greatest for "cannot do at all." CONCLUSION: CFM is a two-factor, valid and reliable scale for assessing disability in Uganda and can be applied to other similar settings to contribute towards disability data from the region. It is an easy-to-administer tool that can help in deeper understanding of context-specific burden and extent of disability in children between 5 and 17 years of age.
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Afeto , Cognição , Avaliação da Deficiência , Crianças com Deficiência/estatística & dados numéricos , Atividade Motora , Adolescente , Adulto , Cuidadores , Criança , Estudos Transversais , Análise Fatorial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Uganda/epidemiologia , Nações UnidasRESUMO
BACKGROUND: Injectable artesunate (AS) is the World Health Organization (WHO) recommended medication for the treatment of severe malaria followed with an oral artemisinin-based combination therapy (ACT). There are few studies indicating how physicians prescribe injectable AS, injectable quinine (Q) or injectable artemether (AR) and ACT for severe malaria. This study was undertaken to evaluate prescription compliance to the WHO recommendation in 8 public health facilities in Ghana and Uganda. This was a modified cohort event monitoring study involving patients who were administered with injectable anti-malarial for treatment of presumed or confirmed severe malaria. Patients prescribed at least one dose of injectable artesunate, artemether or quinine qualified to enrol in the study. Patients were recruited at inpatient facilities and followed up in the hospital, by phone or at home. Following WHO recommendations, patients are to be prescribed 3 doses of injectable AS, Q or AR for at least 24 h followed with oral ACT. Compliance rate was estimated as the number of patient prescriptions that met the WHO recommendation for treatment of severe malaria divided by the total number of patients who completed the study by end of follow up. Log-binomial regression model was used to identify predictors for compliance. Based on the literature and limitations of available data from the patients' record, the diagnosis results, age, gender, weight, and country were considered as potential predictors of prescriber adherence to the WHO recommendations. RESULTS: A total of 1191 patients completed the study, of which 93% were prescribed injectable AS, 3.1% (injectable AR or Q) with 32.5% prescribed follow-on oral ACT and 26% on concomitant antibiotics. 391 (32.8%) were in Ghana and 800 (67.2%) in Uganda. There were 582 (48.9%) women. The median age was 3.9 years (IQR = 2, 9) and median weight was 13 kg (IQR = 10, 20). Of the 1191 patients, 329 of the prescriptions complied with the WHO recommendation (compliance rate = 27.6%; 95% CI = [25.2, 30.2]). Diagnostic results (Adjusted prevalence ratio (aPR) = 4.56; 95% = [3.42, 6.08]; p < 0.0001) and weight (20 + kg vs < 10 kg: aPR = 0.65; 95% = [0.44, 0.96]; p = 0.015) were identified as factors independently associated with compliance. CONCLUSION: Injectable AS is the most commonly prescribed medicine in the management of severe malaria in Ghana and Uganda. However, adherence to the WHO recommendation of at least 3 doses of injectable anti-malarial in 24 h followed by a full course of ACT is low, at less than 30%.
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Antimaláricos/uso terapêutico , Malária/tratamento farmacológico , Cooperação do Paciente/estatística & dados numéricos , Prescrições/estatística & dados numéricos , Competência Profissional/estatística & dados numéricos , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Gana , Guias como Assunto , Instalações de Saúde , Humanos , Masculino , Uganda , Organização Mundial da SaúdeRESUMO
BACKGROUND: With a view to improve neonatal survival, data on birth outcomes are critical for planning maternal and child health care services. We present information on neonatal survival from Ifakara Health and Demographic Surveillance System (HDSS) in Tanzania, regarding the influence of mother's age and other related factors on neonatal survival of first and second births. METHODS: The study conducted analysis using longitudinal health and demographic data collected from Ifakara HDSS in parts of Kilombero and Ulanga districts in Morogoro region. The analysis included first and second live births that occurred within six years (2004-2009) and the unit of observation was a live birth. A logistic regression model was used to assess the influence of socio-demographic factors on neonates' survival. RESULTS: A total of 18,139 first and second live births were analyzed. We found neonatal mortality rate of 32 per 1000 live births (95% CI: 29/1000-34/1000). Results from logistic regression model indicated increase in risk of neonatal mortality among neonates those born to young mothers aged 13-19 years compared with those whose mother's aged 20-34 years (aOR = 1.64, 95% CI = 1.34-2.02). We also found that neonates in second birth order were more likely to die than those in first birth order (aOR = 1.85: 95% CI = 1.52-2.26). The risk of neonatal mortality among offspring of women who had a partner co-resident was 18% times lower as compared with offspring of mothers without a partner co-resident in the household (aOR = 0.82: 95% CI = 0.66-0.98). Short birth interval (<33 months) was associated with increased risk of neonatal mortality (aOR = 1.50, 95% CI =1.16-1.96) compared with long birth interval (> = 33 months). Male born neonates were found to have an increased risk (aOR = 1.34, 95% CI =1.13- 1.58) of neonatal mortality as compared to their female counterparts. CONCLUSIONS: Delaying the age at first birth may be a valuable strategy to promote and improve neonatal health and survival. Moreover, birth order, birth interval, mother's partner co-residence and sex of the neonate appeared as important markers for neonatal survival.
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Intervalo entre Nascimentos , Ordem de Nascimento , Mortalidade Infantil , Idade Materna , Vigilância da População , População Rural/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Lactente , Recém-Nascido , Nascido Vivo , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Tanzânia/epidemiologia , Adulto JovemRESUMO
In light of the suboptimal noncommunicable disease (NCD) risk factor surveillance efforts, the study's main objectives were to: (i) characterize the epidemiological profile of NCD risk factors; (ii) estimate the prevalence of hypertension; and (iii) identify factors associated with hypertension in a peri-urban and rural Ugandan population. A population-based cross-sectional survey of adults was conducted at the Iganga-Mayuge Health and Demographic Surveillance System site in eastern Uganda. After describing sociodemographic characteristics, the prevalence of NCD risk factors and hypertension was reported. Prevalence ratios for NCD risk factors were calculated using weighted Poisson regression to identify factors associated with hypertension. Among 3220 surveyed respondents (mean age: 35.3 years (standard error: 0.1), 49.4% males), 4.4% were current tobacco users, 7.7% were current drinkers, 98.5% had low fruit and vegetable consumption, 26.9% were overweight, and 9.3% were obese. There was a high prevalence of hypertension and prehypertension, at 17.1% and 48.8%, respectively. Among hypertensive people, most had uncontrolled hypertension, at 97.4%. When we examined associated factors, older age (adjusted prevalence ratio (APR): 3.1, 95% CI: 2.2-4.4, APR: 5.2, 95% CI: 3.7-7.3, APR: 8.9, 95% CI: 6.4-12.5 among 30-44, 45-59, and 60+-year-old people than 18-29-year-olds), alcohol drinking (APR: 1.6, 95% CI: 1.3-2.0, ref: no), always adding salt during eating (APR: 1.6, 95% CI: 1.1-2.2, ref: no), poor physical activity (APR: 1.3, 95% CI: 1.1-1.6, ref: no), overweight (APR: 1.3, 95% CI: 1.1-1.5, ref: normal weight), and obesity (APR: 2.0, 95% CI: 1.6-2.4, ref: normal weight) had higher prevalence of hypertension than their counterparts. The high prevalence of NCD risk factors highlights the immediate need to implement and scale-up population-level strategies to increase awareness about leading NCD risk factors in Uganda. These strategies should be accompanied by concomitant investment in building health systems capacity to manage and control NCDs.
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The prevalence of non-communicable diseases (NCDs) is increasing in many low- and middle-income countries (LMICs). This study examined differences in the burden of NCDs and their risk factors according to geographic, sex, and sociodemographic characteristics in a rural and peri-urban community in Eastern Uganda. We compared the prevalence by sex, location, wealth, and education. Unadjusted and adjusted prevalence ratios (PR) were reported. Indicators related to tobacco use, alcohol use, salt consumption, fruit/vegetable consumption, physical activity, body weight, and blood pressure were assessed. Among 3220 people (53.3% males, mean age: 35.3 years), the prevalence of NCD burden differed by sex. Men had significantly higher tobacco (e.g., current smoking: 7.6% vs. 0.7%, adjusted PR (APR): 12.8, 95% CI: 7.4-22.3), alcohol use (e.g., current drinker: 11.1% vs. 4.6%, APR: 13.4, 95% CI: 7.9-22.7), and eat processed food high in salt (13.4% vs. 7.1, APR: 1.8, 95% CI: 1.8, 95% CI: 1.4-2.4) than women; however, the prevalence of overweight (23.1% vs 30.7%, APR: 0.7, 95% CI: 0.6-0.9) and obesity (4.1% vs 14.7%, APR: 0.3, 95% CI: 0.2-0.3) was lower among men than women. Comparing locations, peri-urban residents had a higher prevalence of current alcohol drinking, heavy episodic drinking, always/often adding salt while cooking, always eating processed foods high in salt, poor physical activity, obesity, prehypertension, and hypertension than rural residents (p<0.5). When comparing respondents by wealth and education, we found people who have higher wealth or education had a higher prevalence of always/often adding salt while cooking, poor physical activity, and obesity. Although the findings were inconsistent, we observed significant sociodemographic and socioeconomic differences in the burden of many NCDs, including differences in the distributions of behavioral risk factors. Considering the high burden of many risk factors, we recommend appropriate prevention programs and policies to reduce these risk factors' burden and future negative consequences.
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INTRODUCTION: Citizen science (CS) is an emerging approach in public health to harness the collective intelligence of individuals to augment traditional scientific efforts. However, citizens' viewpoint, especially the hard-to-reach population, is lacking in current outbreak-related literature. We aim to understand the awareness, readiness and feasibility of outbreak-related CS, including digitally enabled CS, in low-income and middle-income countries. METHODS: This mixed-method study was conducted in nine countries between October 2022 and June 2023. Recruitment through civil society targeted the general population, marginalised/indigenous groups, youth and community health workers. Participants (aged ≥18 years) completed a quantitative survey, and a subset participated in focus group discussions (FGDs). RESULTS: 2912 participants completed the survey and 4 FGDs were conducted in each country. Incorporating participants' perspectives, CS is defined as the practice of active public participation, collaboration and communication in all aspects of scientific research to increase public knowledge, create awareness, build trust and facilitate information flow between citizens, governments and scientists. In Bangladesh, Indonesia, the Philippines, Cameroon and Kenya, majority were unaware of outbreak-related CS. In India and Uganda, majority were aware but unengaged, while in Nepal and Zimbabwe, majority participated in CS before. Engagement approaches should consider different social and cultural contexts, while addressing incentivisation, attitudes and practicality factors. Overall, 76.0% expressed interest in digital CS but needed training to build skills and confidence. Digital CS was perceived as convenient, safer for outbreak-related activities and producing better quality and quantity of data. However, there were concerns over non-inclusion of certain groups, data security and unclear communication. CONCLUSION: CS interventions need to be relatable and address context-specific factors influencing CS participation. Digital CS has the potential to facilitate collaboration, but capacity and access issues must be considered to ensure inclusive and sustainable engagement.
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Ciência do Cidadão , Humanos , Adolescente , Adulto , Estudos de Viabilidade , Participação da Comunidade , Grupos Focais , Surtos de Doenças/prevenção & controleRESUMO
Multimorbidity is an emerging challenge for health systems globally. It is commonly defined as the co-occurrence of two or more chronic conditions in one person, but its meaning remains a lively area of academic debate, and the utility of the concept beyond high-income settings is uncertain. This article presents the findings from an interdisciplinary research initiative that drew together 60 academic and applied partners working in 10 African countries to answer the questions: how useful is the concept of multimorbidity within Africa? Can the concept be adapted to context to optimise its transformative potentials? During a three-day concept-building workshop, we investigated how the definition of multimorbidity was understood across diverse disciplinary and regional perspectives, evaluated the utility and limitations of existing concepts and definitions, and considered how to build a more context-sensitive, cross-cutting description of multimorbidity. This iterative process was guided by the principles of grounded theory and involved focus- and whole-group discussions during the workshop, thematic coding of workshop discussions, and further post-workshop development and refinement. Three thematic domains emerged from workshop discussions: the current focus of multimorbidity on constituent diseases; the potential for revised concepts to centre the priorities, needs, and social context of people living with multimorbidity (PLWMM); and the need for revised concepts to respond to varied conceptual priorities amongst stakeholders. These themes fed into the development of an expanded conceptual model that centres the catastrophic impacts multimorbidity can have for PLWMM, families and support structures, service providers, and health systems.
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BACKGROUND: Use of artemisinin-based combination therapy (ACT), such as artemether-lumefantrine (AL), requires a strict dosing schedule that follows the drugs' pharmacokinetic properties. The quality of malaria case management was assessed in two areas in rural Tanzania, to ascertain patient characteristics and facility-specific factors that influence correct dosing of AL for management of uncomplicated malaria. METHODS: Exit interviews were conducted with patients attending health facilities for initial illness consultation. Information about health workers' training and supervision visits was collected. Health facilities were inventoried for capacity and availability of medical products related to care of malaria patients. The outcome was correct dosing of AL based on age and weight. Logistic regression was used to assess health facility factors and patient characteristics associated with correct dosing of AL by age and weight. RESULTS: A total of 1,531 patients were interviewed, but 60 pregnant women were excluded from the analysis. Only 503 (34.2%) patients who received AL were assessed for correct dosing. Most patients who received AL (85.3%) were seen in public health facilities, 75.7% in a dispensary and 91.1% in a facility that had AL in stock on the survey day. Overall, 92.1% (463) of AL prescriptions were correct by age or weight; but 85.7% of patients received correct dosing by weight alone and 78.5% received correct dosing by age alone. In multivariate analysis, patients in the middle dosing bands in terms of age or weight, had statistically significant lower odds of correct AL dosing (p < 0.05) compared to those in the lowest age or weight group. Other factors such as health worker supervision and training on ACT did not improve the odds of correct AL dosing. CONCLUSION: Although malaria treatment guidelines indicate AL dosing can be prescribed based on age or weight of the patient, findings from this study show that patients within the middle age and weight dosing bands were least likely to receive a correct dose by either measure. Clinicians should be made aware of AL dosing errors for patients aged three to 12 years and advised to use weight-based prescriptions whenever possible.
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Antimaláricos/administração & dosagem , Artemisininas/administração & dosagem , Etanolaminas/administração & dosagem , Fluorenos/administração & dosagem , Malária/tratamento farmacológico , Adolescente , Combinação Arteméter e Lumefantrina , Criança , Pré-Escolar , Combinação de Medicamentos , Feminino , Humanos , Modelos Logísticos , Malária/epidemiologia , Masculino , Análise Multivariada , Tanzânia/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: Improving malaria case management is partially dependent on health worker compliance with clinical guidelines. This study assessed health worker factors associated with correct anti-malarial prescribing practices at two sites in rural Tanzania. METHODS: Repeated cross-sectional health facility surveys were conducted during high and low malaria transmission seasons in 2010 and collected information on patient consultations and health worker characteristics. Using logistic regression, the study assessed health worker factors associated with correct prescription for uncomplicated malaria defined as prescription of artemisinin-based combination therapy (ACT) for patients with fever and Plasmodium falciparum asexual infection based on blood slide or malaria rapid diagnostic test (RDT) according to national treatment guidelines. RESULTS: The analysis included 685 patients with uncomplicated malaria who were seen in a health facility with ACT in stock, and 71 health workers practicing in 30 health facilities. Overall, 58% of malaria patients were correctly treated with ACT. Health workers with three or more years' work experience were significantly more likely than others to prescribe correctly (adjusted odds ratio (aOR) 2.9; 95% confidence interval (CI) 1.2-7.1; p = 0.019). Clinical officers (aOR 2.2; 95% CI 1.1-4.5; p = 0.037), and nurse aide or lower cadre (aOR 3.1; 95% CI 1.3-7.1; p = 0.009) were more likely to correctly prescribe ACT than medical officers. Training on ACT use, supervision visits, and availability of job aids were not significantly associated with correct prescription. CONCLUSIONS: Years of working experience and health worker cadre were associated with correct ACT prescription for uncomplicated malaria. Targeted interventions to improve health worker performance are needed to improve overall malaria case management.
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Antimaláricos/uso terapêutico , Artemisininas/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Malária Falciparum/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude do Pessoal de Saúde , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , População Rural , Tanzânia , Adulto JovemRESUMO
BACKGROUND: Artemisinin-based combination treatment (ACT) has been widely adopted as one of the main malaria control strategies. However, its promise to save thousands of lives in sub-Saharan Africa depends on how effective the use of ACT is within the routine health system. The INESS platform evaluated effective coverage of ACT in several African countries. Timely access within 24 hours to an authorized ACT outlet is one of the determinants of effective coverage and was assessed for artemether-lumefantrine (Alu), in two district health systems in rural Tanzania. METHODS: From October 2009 to June 2011 we conducted continuous rolling household surveys in the Kilombero-Ulanga and the Rufiji Health and Demographic Surveillance Sites (HDSS). Surveys were linked to the routine HDSS update rounds. Members of randomly pre-selected households that had experienced a fever episode in the previous two weeks were eligible for a structured interview. Data on individual treatment seeking, access to treatment, timing, source of treatment and household costs per episode were collected. Data are presented on timely access from a total of 2,112 interviews in relation to demographics, seasonality, and socio economic status. RESULTS: In Kilombero-Ulanga, 41.8% (CI: 36.6-45.1) and in Rufiji 36.8% (33.7-40.1) of fever cases had access to an authorized ACT provider within 24 hours of fever onset. In neither of the HDSS site was age, sex, socio-economic status or seasonality of malaria found to be significantly correlated with timely access. CONCLUSION: Timely access to authorized ACT providers is below 50% despite interventions intended to improve access such as social marketing and accreditation of private dispensing outlets. To improve prompt diagnosis and treatment, access remains a major bottle neck and new more innovative interventions are needed to raise effective coverage of malaria treatment in Tanzania.
Assuntos
Antimaláricos/uso terapêutico , Artemisininas/uso terapêutico , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Malária/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Quimioterapia Combinada/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , População Rural , Tanzânia , Adulto JovemRESUMO
BACKGROUND: Successful implementation of malaria treatment policy depends on the prescription practices for patients with malaria. This paper describes prescription patterns and assesses factors associated with co-prescription of antibiotics and artemether-lumefantrine (AL) for patients presenting with fever in rural Tanzania. METHOD: From June 2009 to September 2011, a cohort event monitoring program was conducted among all patients treated at 8 selected health facilities in Ifakara and Rufiji Health and Demographic Surveillance System (HDSS). It included all patients presenting with fever and prescribed with AL. Logistic regression was used to model the predictors on the outcome variable which is co-prescription of AL and antibiotics on a single clinical visit. RESULTS: A cohort of 11,648 was recruited and followed up with 92% presenting with fever. Presumptive treatment was used in 56% of patients treated with AL. On average 2.4 (1 - 7) drugs was prescribed per encounter, indicating co-prescription of AL with other drugs. Children under five had higher odds of AL and antibiotics co-prescription (OR = 0.63, 95% CI: 0.46 - 0.85) than those aged more than five years. Patients testing negative had higher odds (OR = 2.22, 95% CI: 1.65 - 2.97) of AL and antibiotics co-prescription. Patients receiving treatment from dispensaries had higher odds (OR = 1.45, 95% CI: 0.84 - 2.30) of AL and antibiotics co-prescription than those served in health centres even though the deference was not statistically significant. CONCLUSION: Regardless the fact that Malaria is declining but due to lack of laboratories and mRDT in most health facilities in the rural areas, clinicians are still treating malaria presumptively. This leads them to prescribe more drugs to treat all possibilities.
Assuntos
Antibacterianos/uso terapêutico , Antimaláricos/uso terapêutico , Artemisininas/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Etanolaminas/uso terapêutico , Febre/tratamento farmacológico , Fluorenos/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Adolescente , Combinação Arteméter e Lumefantrina , Criança , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Combinação de Medicamentos , Feminino , Humanos , Malária/tratamento farmacológico , Masculino , Setor Público , Tanzânia , Adulto JovemRESUMO
BACKGROUND: The World Health Organization recommends parasitological confirmation of all malaria cases. Tanzania is implementing a phased rollout of malaria rapid diagnostic tests (RDTs) for routine use in all levels of care as one strategy to increase parasitological confirmation of malaria diagnosis. This study was carried out to evaluated artemisinin combination therapy (ACT) prescribing patterns in febrile patients with and without uncomplicated malaria in one pre-RDT implementation and one post-RDT implementation area. METHODS: A cross-sectional health facility surveys was conducted during high and low malaria transmission seasons in 2010 in both areas. Clinical information and a reference blood film on all patients presenting for an initial illness consultation were collected. Malaria was defined as a history of fever in the past 48 h and microscopically confirmed parasitaemia. Routine diagnostic testing was defined as RDT or microscopy ordered by the health worker and performed at the health facility as part of the health worker-patient consultation. Correct diagnostic testing was defined as febrile patient tested with RDT or microscopy. Over-testing was defined as a non-febrile patient tested with RDT or microscopy. Correct treatment was defined as patient with malaria prescribed ACT. Over-treatment was defined as patient without malaria prescribed ACT. RESULTS: A total of 1,247 febrile patients (627 from pre-implementation area and 620 from post-implementation area) were included in the analysis. In the post-RDT implementation area, 80.9% (95% CI, 68.2-89.3) of patients with malaria received recommended treatment with ACT compared to 70.3% (95% CI, 54.7-82.2) of patients in the pre-RDT implementation area. Correct treatment was significantly higher in the post-implementation area during high transmission season (85.9% (95% CI, 72.0-93.6) compared to 58.3% (95% CI, 39.4-75.1) in pre-implementation area (p = 0.01). Over-treatment with ACT of patients without malaria was less common in the post-RDT implementation area (20.9%; 95% CI, 14.7-28.8) compared to the pre-RDT implementation area (45.8%; 95% CI, 37.2-54.6) (p < 0.01) in high transmission. The odds of overtreatment was significantly lower in post- RDT area (adjusted Odds Ratio (OR: 95% CI) 0.57(0.36-0.89); and much higher with clinical diagnosis adjusted OR (95% CI) 2.24(1.37-3.67) CONCLUSION: Implementation of RDTs increased use of RDTs for parasitological confirmation and reduced over-treatment with ACT during high malaria transmission season in one area in Tanzania. Continued monitoring of the national RDT rollout will be needed to assess whether these changes in case management practices will be replicated in other areas and sustained over time. Additional measures (such as refresher trainings, closer supervisions, etc.) may be needed to improve ACT targeting during low transmission seasons.
Assuntos
Antimaláricos/uso terapêutico , Testes Diagnósticos de Rotina/métodos , Testes Diagnósticos de Rotina/estatística & dados numéricos , Malária/diagnóstico , Malária/tratamento farmacológico , Artemisininas/uso terapêutico , Pré-Escolar , Estudos Transversais , Quimioterapia Combinada/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Lactonas/uso terapêutico , Masculino , População Rural , TanzâniaRESUMO
BACKGROUND: Drug prescription practices depend on several factors related to the patient, health worker and health facilities. A better understanding of the factors influencing prescription patterns is essential to develop strategies to mitigate the negative consequences associated with poor practices in both the public and private sectors. METHODS: A cross-sectional study was conducted in rural Tanzania among patients attending health facilities, and health workers. Patients, health workers and health facilities-related factors with the potential to influence drug prescription patterns were used to build a model of key predictors. Standard data mining methodology of classification tree analysis was used to define the importance of the different factors on prescription patterns. RESULTS: This analysis included 1,470 patients and 71 health workers practicing in 30 health facilities. Patients were mostly treated in dispensaries. Twenty two variables were used to construct two classification tree models: one for polypharmacy (prescription of ≥3 drugs) on a single clinic visit and one for co-prescription of artemether-lumefantrine (AL) with antibiotics. The most important predictor of polypharmacy was the diagnosis of several illnesses. Polypharmacy was also associated with little or no supervision of the health workers, administration of AL and private facilities. Co-prescription of AL with antibiotics was more frequent in children under five years of age and the other important predictors were transmission season, mode of diagnosis and the location of the health facility. CONCLUSION: Standard data mining methodology is an easy-to-implement analytical approach that can be useful for decision-making. Polypharmacy is mainly due to the diagnosis of multiple illnesses.
Assuntos
Atitude do Pessoal de Saúde , Prescrições de Medicamentos/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Modelos Estatísticos , Adolescente , Adulto , Criança , Pré-Escolar , Estudos Transversais , Feminino , Instalações de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Lactente , Recém-Nascido , Masculino , População Rural , Tanzânia , Adulto JovemRESUMO
Background: Short-term experiences in global health (STEGHs) are an important part of global health degree programs. Due to the COVID-19 pandemic, travel was not possible for students planning to participate in the Johns Hopkins Center for Global Health's Global Health Established Field Placement (GHEFP) program in 2020. Working with willing faculty mentors, in-country collaborators, and students, the Center allowed students to complete their practicums remotely so that students could gain practicum experience despite not being able to travel, and faculty and collaborators could receive the planned support on their projects. Objectives: This evaluation aims to describe the experience of pivoting the GHEFP program from an in-person, in-country program to a remote practicum. Methods: We analyzed program evaluation data from 30 students, 20 faculty members, and 10 in-country collaborators. Surveys for each group consisted of multiple choice, scale rating, and open-ended questions. The quantitative data was analyzed using Microsoft Excel to calculate survey response frequencies. The open-ended responses were analyzed for emergent themes. Findings: The remote GHEFP experience enabled students to gain practice working on global health projects from a distance, but it came with challenges related to preparation, communication, shifting scopes of work, and contextualization. All participants would have preferred an in-person experience if given a choice, but most agreed that a remote practicum was better than not participating at all. Conclusions: The remote program served its purpose during the height of the pandemic. Given the hybrid nature of global health today, many aspects of the remote practicum experience are helpful for global health training. Future iterations of remote STEGHs should initially be designed for remote work to ensure meaningful scopes for students that are helpful to faculty mentors and collaborators. Hybrid models may also be useful. Mutually beneficial twinning relationships should also be incorporated into remote and in-person STEGHs to foster a more equitable global health training environment.
Assuntos
COVID-19 , Saúde Global , Humanos , COVID-19/epidemiologia , COVID-19/prevenção & controle , Pandemias/prevenção & controle , Docentes , MentoresRESUMO
INTRODUCTION: There is scarcity of data on children with disabilities living in low-and-middle-income countries, including Uganda. This study describes disability prevalence and explores factors associated with different disability categories. It highlights the value of using a standardized, easy-to-use tool to determine disability in children and contextualizing disability in children in light of their developmental needs. METHODS: A cross-sectional study was conducted between September 2018-January 2019 at the Iganga-Mayuge Health and Demographic Surveillance Site in Uganda. Respondents were caregivers of children between 5-17 years and were administered an in-depth Child Functioning Module (CFM). The outcome variable, disability, was defined as an ordered categorical variable with three categories-mild, moderate, and severe. Generalized ordered logit model was applied to explore factors associated with disability categories. RESULTS: Out of 1,842 caregivers approached for the study, 1,439 (response: 78.1%) agreed to participate in the study. Out of these 1,439, some level of disability was reported by 67.89% (n = 977) of caregivers. Of these 977 children with disability, 48.01% (n = 692) had mild disability and 15.84% (n = 228) had moderate disability, while 3.96% (n = 57) had severe disability. The mean (SD) score for mild disability was 2.22±1.17, with a median of 2. The mean and median for moderate disability was 5.26±3.28 and 4 (IQR:3-6), and for severe disability was 14.23±9.51 and 12 (IQR:6-22). The most common disabilities reported were depression (54.83%) and anxiety (50.87%). Statistically significant association was found for completion of immunization status and school enrollment when controlled for a child's age, sex, having a primary caregiver, age of mother at child's birth, family system, family size and household wealth quintile. CONCLUSION: This study suggests association between incomplete immunization status and school enrollment for children with disability. These are areas for further exploration to ensure inclusive health and inclusive education of children with disabilities in Uganda.