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.

A qualitative study of the development and utilization of health facility-based immunization microplans in Uganda.

BACKGROUND: In 2006, Uganda adopted the Reaching Every District strategy with the goal of attaining at least 80% coverage for routine immunizations in every district. The development and utilization of health facility/district immunization microplans is the key to the strategy. A number of reports have shown suboptimal development and use of microplans in Uganda. This study explores factors associated with suboptimal development and use of microplans in two districts in Uganda to pinpoint challenges encountered during the microplanning process. METHODS: A qualitative study was conducted comparing two districts: Kapchorwa, with low immunization coverage, and Luwero with high immunization coverage. Data were collected through multilevel observation of health facilities, planning sessions and planning meetings; records review of microplans, micromaps and meeting minutes; 57 interviews with health workers at the ministry level and lower-level health facility workers. Data were analysed using NVivo 8 qualitative text analysis software. Transcripts were coded, and memos and display matrices were developed to examine the process of developing and utilizing microplans, including experiences of health workers (implementers). RESULTS: Three key findings emerged from this study. First, there are significant knowledge gaps with regard to the microplanning process among health workers at all levels (community and district health facility and nationally). Limited knowledge about communities and programme catchment areas greatly hinders the planning process by limiting the ability to identify hard-to-reach areas and to prioritize areas according to need. Secondly, the microplanning tool is bulky and complex. Finally, microplanning is being implemented in the context of already overtasked health personnel who have to conduct several other activities as part of their daily routines. CONCLUSIONS: In order to achieve quality improvement as outlined in the Reaching Every District campaign, the microplanning process should be revised. Health workers' misunderstanding and limited knowledge about the microplanning process, especially at peripheral health facilities, coupled with the complex, bulky nature of the microplanning tool, reduces the effectiveness of microplanning in improving routine immunization in Uganda. This study reveals the need to reduce the complexity of the tool and to identify ways to train and support workers in the use of the revised tool, including support in incorporating the microplanning process into their busy schedules.

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.

Linking communities to formal health care providers through village health teams in rural Uganda: lessons from linking social capital.

BACKGROUND: Community-based programmes, particularly community health workers (CHWs), have been portrayed as a cost-effective alternative to the shortage of health workers in low-income countries. Usually, literature emphasises how easily CHWs link and connect communities to formal health care services. There is little evidence in Uganda to support or dispute such claims. Drawing from linking social capital framework, this paper examines the claim that village health teams (VHTs), as an example of CHWs, link and connect communities with formal health care services. METHODS: Data were collected through ethnographic fieldwork undertaken as part of a larger research program in Luwero District, Uganda, between 2012 and 2014. The main methods of data collection were participant observation in events organised by VHTs. In addition, a total of 91 in-depth interviews and 42 focus group discussions (FGD) were conducted with adult community members as part of the larger project. After preliminary analysis of the data, we conducted an additional six in-depth interviews and three FGD with VHTs and four FGD with community members on the role of VHTs. Key informant interviews were conducted with local government staff, health workers, local leaders, and NGO staff with health programs in Luwero. Thematic analysis was used during data analysis. RESULTS: The ability of VHTs to link communities with formal health care was affected by the stakeholders' perception of their roles. Community members perceive VHTs as working for and under instructions of "others", which makes them powerless in the formal health care system. One of the challenges associated with VHTs' linking roles is support from the government and formal health care providers. Formal health care providers perceived VHTs as interested in special recognition for their services yet they are not "experts". For some health workers, the introduction of VHTs is seen as a ploy by the government to control people and hide its inability to provide health services. Having received training and initial support from an NGO, VHTs suffered transition failure from NGO to the formal public health care structure. As a result, VHTs are entangled in power relations that affect their role of linking community members with formal health care services. We also found that factors such as lack of money for treatment, poor transport networks, the attitudes of health workers and the existence of multiple health care systems, all factors that hinder access to formal health care, cannot be addressed by the VHTs. CONCLUSIONS: As linking social capital framework shows, for VHTs to effectively act as links between the community and formal health care and harness the resources that exist in institutions beyond the community, it is important to take into account the power relationships embedded in vertical relationships and forge a partnership between public health providers and the communities they serve. This will ensure strengthened partnerships and the improved capacity of local people to leverage resources embedded in vertical power networks.

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.

Traditional birth attendants (TBAs) as potential agents in promoting male involvement in maternity preparedness: insights from a rural community in Uganda.

BACKGROUND: Since the 1994 International Conference on Population and Development, male involvement in reproductive health issues has been advocated as a means to improve maternal and child health outcomes, but to date, health providers have failed to achieve successful male involvement in pregnancy care especially in rural and remote areas where majority of the underserved populations live. In an effort to enhance community participation in maternity care, TBAs were trained and equipped to ensure better care and quick referral. In 1997, after the advent of the World Health Organization's Safe Motherhood initiative, the enthusiasm turned away from traditional birth attendants (TBAs). However, in many developing countries, and especially in rural areas, TBAs continue to play a significant role. This study explored the interaction between men and TBAs in shaping maternal healthcare in a rural Ugandan context. METHODS: This study employed ethnographic methods including participant observation, which took place in the process of everyday life activities of the respondents within the community; 12 focus group discussions, and 12 in-depth interviews with community members and key informants. Participants in this study were purposively selected to include TBAs, men, opinion leaders like village chairmen, and other key informants who had knowledge about the configuration of maternity services in the community. Data analysis was done inductively through an iterative process in which transcribed data was read to identify themes and codes were assigned to those themes. RESULTS: Contrary to the thinking that TBA services are utilized by women only, we found that men actively seek the services of TBAs and utilize them for their wives' healthcare within the community. TBAs in turn sensitize men using both cultural and biomedical health knowledge, and become allies with women in influencing men to provide resources needed for maternity care. CONCLUSION: In this study area, men trust and have confidence in TBAs; closer collaboration with TBAs may provide a suitable platform through which communities can be sensitized and men actively brought on board in promoting maternal health services for women in rural communities.

Undergraduate students' contributions to health service delivery through community-based education: A qualitative study by the MESAU Consortium in Uganda.

BACKGROUND: It has been realised that there is need to have medical training closer to communities where the majority of the population lives in order to orient the trainees' attitudes towards future practice in such communities. Although community based education (CBE) has increasingly been integrated into health professions curricula since the 1990s, the contribution students make to service delivery during CBE remains largely undocumented. In this study, we examined undergraduate health professions students' contribution to primary health care during their CBE placements. METHODS: This was a qualitative study involving the Medical Education for Equitable Services to All Ugandans consortium (MESAU). Overall, we conducted 36 Focus Group Discussions (FGDs): one each with youth, men and women at each of 12 CBE sites. Additionally, we interviewed 64 community key-informants. All data were audio-recorded, transcribed and analysed using qualitative data analysis software Atlas.ti Ver7. RESULTS: Two themes emerged: students' contribution at health facility level and students' contribution at community level. Under theme one, we established that students were not only learning; they also contributed to delivery of health services at the facilities. Their contribution was highly appreciated especially by community members. Students were described as caring and compassionate, available on time and anytime, and as participating in patient care. They were willing to share their knowledge and skills, and stimulated discussion on work ethics. Under the second theme, students were reported to have participated in water, sanitation, and hygiene education in the community. Students contributed to maintenance of safe water sources, educated communities on drinking safe water and on good sanitation practices (hand washing and proper waste disposal). Hygiene promotion was done at household level (food hygiene, hand washing, cleanliness) and to the public. Public health education was extended to institutions. School pupils were sensitised on various health-related issues including sexuality and sexual health. CONCLUSION: Health professions students at the MESAU institutions contribute meaningfully to primary health care delivery. We recommend CBE to all health training programs in sub-Saharan Africa.

Selection and performance of village health teams (VHTs) in Uganda: lessons from the natural helper model of health promotion.

BACKGROUND: Community health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion. METHODS: As part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members. RESULTS: The VHT selection process created distrust, damaging the programme's legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community's members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work. CONCLUSION: As the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.

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.

Practices and attitudes of herbalists regarding informed consent in Uganda: A qualitative study.

Background: Informed consent (IC) is a fundamental principle in medical ethics that upholds respect for patient autonomy. Although widely applied in healthcare, its feasibility and implementation in herbal medicine have been underexplored. This study therefore aimed to explore the practices and attitudes of herbalists regarding informed consent. Methods: To achieve these objectives, a qualitative cross-sectional study was conducted from June to December 2020. Twenty-one in-depth interviews with herbalists and four key informant interviews with leaders of the different traditional medicine organizations were also conducted. The data were analyzed thematically using NVivo version 12 software. Results: Sixteen of the twenty-one participants acquired oral herbal medicine knowledge from their relatives. Although a positive inclination toward obtaining IC was evident, the focus was on disclosing basic information. Discussions of alternative treatments and herbal specifics less frequent. Disease management decisions often involve shared responsibility within families or societies. Documented IC procedures are rare among herbalists, who deem consent forms unnecessary, although they recognize the potential benefits of IC in fostering trust and professionalism. Challenges hindering IC implementation included regulatory gaps, inadequate skills, and the absence of mechanisms to protect the intellectual property rights of herbal medicine. Conclusion: This study illuminates how educational, cultural, familial, and regulatory factors influence herbalists' practices and attitudes toward informed consent.

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.