Perspectives of stakeholders regarding the value of maternal and newborn health interventions and practices supported by UNICEF and other partners in the West Nile region of Uganda: a qualitative study.

INTRODUCTION: Uganda has high maternal, neonatal, and under-five mortality rates. This study documents stakeholder perspectives on best practices in a maternal and newborn health (MNH) quality-improvement programme implemented in the West Nile region of Uganda to improve delivery and utilisation of MNH services. METHODS: This exploratory cross-sectional qualitative study, conducted at the end of 2021, captured the perspectives of stakeholders representing the different levels of the healthcare system. Data were collected in four districts through: interviews with key informants working at all levels of the health system; focus group discussions with parents and caretakers and with community health workers; and interviews with individual community members whose lives had been impacted by the MNH programme. The initial content analysis was followed by a deductive synthesis pitched according to the different levels of the health system and the health-systems building blocks. RESULTS: The findings are summarised according to the health-systems building blocks and an account is given of three of the interventions most valued by participants: (1) data use for evidence-based decision making (with regard to human resources, essential reproductive health commodities, and financing); (2) establishment of special newborn care units and high-dependency maternity units at district hospitals and training of the health workforce (also with reference to other infrastructural improvements such as the provision of water, sanitation and hygiene facilities at health facilities); and (3) community referral of pregnant women through a commercial motorcycle voucher referral system. CONCLUSION: The MNH programme in the West Nile region adopted a holistic and system-wide approach to addressing the key bottlenecks in the planning, delivery, and monitoring of quality MNH services. There was general stakeholder appreciation across the board that the interventions had the potential to improve quality of care and newborn and maternal health outcomes. However, as the funding was largely donor-driven, questions about government ownership and sustainability in the context of limited resources remain.

Perspectives of health care providers on the provision of intermittent preventive treatment in pregnancy in health facilities in Malawi.

BACKGROUND: Nearly 20 years after the adoption by the government of Malawi of the provision of intermittent preventive treatment in pregnancy (IPTp) for malaria, only 55% of pregnant women received at least two doses of sulfadoxine-pyrimethamine (SP) in 2010. Although several reasons for the low coverage have been suggested, few studies have examined the views of health care providers. This study examined the experiences of the nurses and midwives in providing antenatal care (ANC) services. METHODS: This study was conducted in health facilities in Malawi that provide routine ANC services. Providers of ANC in Malawi were selected from in eight health care facilities of Malawi. Selected providers were interviewed using a semi-structured interview guide designed to address a series of themes related to their working conditions and their delivery of IPTp. RESULTS: Nurses displayed detailed knowledge of ANC services and the rationale behind them. Nurses understood that they should provide two doses of IPTp during a pregnancy, but they did not agree on the timing of the doses. Nurses gave SP as directly observed therapy (DOT) at the clinic. Nurses did not give SP pills to women to take home with them because they did not trust that women would take the pills. Women who resisted taking SP explained they do not take drugs if they had not eaten, or they feared side effects, or they were not sick. Reasons for not giving the first or second dose of SP included a delay in the first ANC visit, testing positive for HIV, and presenting with malaria. None of the nurses were able to show any specific written guidelines on when to give SP. The challenges faced by the nurses include being overworked and persuading women to take SP under observation. CONCLUSION: The findings show that the nurses had gained the knowledge and technical skills to provide appropriate ANC services. With regard to IPTp, nurses need guidelines that would be available at the health facility about how and when to give SP. The adoption of the WHO guidelines and their diffusion to health care facilities could help increase the coverage of IPTp2 (at least two doses of sulfadoxine-pyrimethamine) in Malawi.

Political economy analysis of subnational health management in Kenya, Malawi and Uganda.

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers' ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.

How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana.

District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national- and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decision-makers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs' decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.

Mistrust in marriage--reasons why men do not accept couple HIV testing during antenatal care- a qualitative study in eastern Uganda.

BACKGROUND: A policy for couple HIV counseling and testing was introduced in 2006 in Uganda, urging pregnant women and their spouses to be HIV tested together during antenatal care (ANC). The policy aims to identify HIV-infected pregnant women to prevent mother-to-child transmission of HIV through prophylactic antiretroviral treatment, to provide counseling, and to link HIV-infected persons to care. However, the uptake of couple testing remains low. This study explores men's views on, and experiences of couple HIV testing during ANC. METHODS: The study was conducted at two time points, in 2008 and 2009, in the rural Iganga and Mayuge districts of eastern Uganda. We carried out nine focus group discussions, about 10 participants in each, and in-depth interviews with 13 men, all of whom were fathers. Data were collected in the local language, Lusoga, audio-recorded and thereafter translated and transcribed into English and analyzed using content analysis. RESULTS: Men were fully aware of the availability of couple HIV testing, but cited several barriers to their use of these services. The men perceived their marriages as unstable and distrustful, making the idea of couple testing unappealing because of the conflicts it could give rise to. Further, they did not understand why they should be tested if they did not have symptoms. Finally, the perceived stigmatizing nature of HIV care and rude attitudes among health workers at the health facilities led them to view the health facilities providing ANC as unwelcoming. The men in our study had several suggestions for how to improve the current policy: peer sensitization of men, make health facilities less stigmatizing and more male-friendly, train health workers to meet men's needs, and hold discussions between health workers and community members. CONCLUSIONS: In summary, pursuing couple HIV testing as a main avenue for making men more willing to test and support PMTCT for their wives, does not seem to work in its current form in this region. HIV services must be better adapted to local gender systems taking into account that incentives, health-seeking behavior and health system barriers differ between men and women.

Use of drugs, perceived drug efficacy and preferred providers for febrile children: implications for home management of fever.

BACKGROUND: Community distribution of anti-malarials and antibiotics has been recommended as a strategy to reduce the under-five mortality due to febrile illnesses in sub-Saharan Africa. However, drugs distributed in these interventions have been considered weak by some caretakers and utilization of community medicine distributors has been low. The aim of the study was to explore caretakers' use of drugs, perceptions of drug efficacy and preferred providers for febrile children in order to make suggestions for community management of pneumonia and malaria. METHODS: The study was conducted in eastern Uganda using four focus group discussions with fathers and mothers of children under five; and eight key informant interviews with health workers in government and non-governmental organization facilities, community medicine distributors, and attendants in drug shops and private clinics. Caretakers were asked the drugs they use for treatment of fever, why they considered them efficacious, and the providers they go to and why they go there. Health providers were interviewed on their opinions of caretakers' perceptions of drugs and providers. Analysis was done using content analysis. RESULTS: Drugs that have been phased out as first-line treatment for malaria, such as chloroquine and sulphadoxine/pyrimethamine, are still perceived as efficacious. Use of drugs depended on perception of the disease, cost and drug availability. There were divergent views about drug efficacy concerning drug combinations, side effects, packaging, or using drugs over time. Bitter taste and high cost signified high efficacy for anti-malarials. Government facilities were preferred for conducting diagnostic investigations and attending to serious illnesses, but often lacked drugs and did not treat people fast. Drug shops were preferred for having a variety of drugs, attending to clients promptly and offering treatment on credit. However, drug shops were considered disadvantageous since they lacked diagnostic capability and had unqualified providers. CONCLUSION: Community views about drug efficacy are divergent and some may divert caretakers from obtaining efficacious drugs for febrile illness. Interventions should address these perceptions, equip community medicine distributors with capacity to do diagnostic investigations and provide a constant supply of drugs. Subsidized efficacious drugs could be made available in the private sector.

Home-based management of fever in rural Uganda: community perceptions and provider opinions.

BACKGROUND: Uganda was the first country to scale up Home Based Management of Fever/Malaria (HBM) in 2002. Under HBM pre-packaged unit doses with a combination Sulphadoxine/Pyrimethamin (SP) and Chloroquine (CQ) called "HOMAPAK" are administered to all febrile children by community selected voluntary drug distributors (DDs). In this study, community perceptions, health worker and drug provider opinions about the community based distribution of HOMAPAK and its effect on the use of other antimalarials were assessed. METHODS: In 2004, four focus group discussions with mothers and 11 key informant interviews with drug sellers, drug distributors and health workers were conducted in Kasese district, western Uganda. This was complemented by three months of field observations. RESULTS: Caretakers concurred that they were benefiting from the programme. However, according to the information from the DDs and health workers, many caretakers perceived HOMAPAK as a drug of lower quality only meant for first aid. Caretakers also expressed need for other drugs to treat other childhood diseases. The introduction of HOMAPAKs was said not to affect the sale of other allopathic antimalarial drugs in the community. DDs expressed concerns about lack of incentives and facilitation such as torches, gumboots and diagnostic equipment to improve their performance. CONCLUSION: HBM is well appreciated by the community. However, more efforts are needed to improve uptake of the strategy through systematic community sensitization and community dialogue. This study highlights the potential of community based volunteers if well trained, facilitated and integrated into a functioning local health system.

Local illness concepts--implications for management of childhood pneumonia in eastern Uganda.

BACKGROUND: Pneumonia is one of the major killers of children under 5 years. Prompt and appropriate management is crucial; yet, the care a sick child receives depends on caretakers' perception of illness and action taken. Hence, understanding of local illness concepts on pneumonia and caretakers' response is crucial for interventions aimed at improved management. OBJECTIVE: To elucidate local illness concepts involving childhood fever, cough and difficult/fast breathing and how these concepts' influence management of children with potential pneumonia. METHODS: Key informant interviews with eight health workers and eight traditional healers and five focus group discussions, including presentation of a DVD showing children suffering from respiratory problems, with mothers of children under 5 years old in Iganga/Mayuge Demographic Surveillance Site (DSS) in eastern Uganda. RESULTS: Many terminologies were used to refer to symptoms of pneumonia. Difficult/fast breathing was considered severe but was not presented among common childhood illnesses. Mothers were likely to interpret any condition involving fever as malaria and had different preferred actions for difficult/fast breathing in their children. Although mothers mentioned using drugs at home for pneumonia related symptoms, they gave examples only of antipyretics. Health workers said mothers would use antimalarials and sometimes antibiotics to treat breathing problems. CONCLUSIONS: There is a community knowledge gap on symptoms and biomedical treatment for pneumonia. To promote appropriate management of childhood fever, pneumonia and malaria as two separate illnesses should be highlighted, the role of antibiotics must be emphasized and local illness concepts should be addressed in behaviour change communication.

Promoting unity of purpose in district health service delivery in Uganda through partnerships, trust building and evidence-based decision-making.

CONTEXT: The Uganda Program for Human and Holistic Development (UPHOLD), a USAID-funded project which supports health services in 34 Ugandan districts, was conceived at a time when promising interventions could not be expanded due to fragmented systems. This paper focuses on how the program addressed fragmentation to improve service delivery in the health sector. APPROACH: UPHOLD achieved results by utilizing grants and technical support to strengthen capacity in a decentralized setting to foster institutional behavior change, promote strengthened partnerships among stakeholders in health, and produce increased transparency and accountability. In addition, the Lot Quality Assurance Sampling (LQAS) survey methodology was institutionalized to promote a culture of evidence-based decision-making at the district level. RESULTS: Evidence-based decision-making and partnership-oriented implementation led to programmatic results and institutional behavior change in districts through synergetic relationships between local governments and Civil Society Organizations. The use of Insecticide Treated Nets increased from 11.2% in 2004 to 17.2% in 2005, clients utilizing HIV/AIDS counselling and testing services increased from 6,205 in 2004 to 85 947 in 2005 and using Lot Quality Assurance Sampling methodology has begun to positively influence district and national staff mind sets leading to more evidence-based planning and decision-making. CONCLUSION: The pillars of 'evidence-based decision-making' and 'partnerships', together with approaches which strengthen existing synergies, produced more results, faster. Programs designed to work with fragmented settings should consider using the same pillars and blocks to ultimately make a difference in the lives of program beneficiaries.

Can community health workers and caretakers recognise pneumonia in children? Experiences from western Uganda.

Acute respiratory infections (ARI) are leading killers of children. Case management using community health workers (CHW) has halved ARI mortality in children in Asia. WHO/UNICEF recommend integrating pneumonia into Home Management of Malaria strategies. However, in sub-Saharan Africa, CHW's performance to recognise pneumonia is rarely demonstrated. We evaluated the ability of CHWs to assess rapid breathing in under 5 year olds and explored caretaker interpretation of pneumonia symptoms. Ninety-six CHWs were evaluated for their skills to count and classify breathing rate in inpatient children. Respiratory illness concepts and actions were obtained from focus group discussions with mothers, video probing and key informant interviews. Of the CHW assessments, 71% were within +/-5 breaths/min from the gold standard. The sensitivity of CHW classification was 75% and the specificity was 83%. Many local terms existed for ARIs, such as "quick breathing" and "groaning breathing". There was consistency in the interpretation of severity, cause and treatment, most being related to fever and treated with antimalarials. Given the ability of CHWs to classify pneumonia, their skills should be tested in real life. To minimise failure to treat and overtreatment, context-specific communication strategies that improve care-seeking and increase illness prevalence among patients assessed by CHWs are needed. A toolkit including a set of methods for this purpose is proposed.

'Better medicines for children' within the Integrated Management of Childhood Illness framework: a qualitative inquiry in Uganda.

BACKGROUND: The Integrated Management of Childhood Illnesses is the main approach for treating children in more than 100 low income countries worldwide. In 2007, the World Health Assembly urged countries to integrate 'better medicines for children' into their essential medicines lists and treatment guidelines. WHO regularly provides generic algorithms for IMCI and publishes the Model Essential Medicines List with child-friendly medicines based on new evidence for member countries to adopt. However, the status of 'better medicines for children' within the Integrated Management of Childhood Illnesses approach in Uganda has not been studied. METHODS: Qualitative interviews were conducted with: two officials from the ministry of health; two district health officials and, 22 health workers from public health facilities. Interview transcripts were manually analyzed for manifest and latent content. RESULTS: Child-appropriate dosage formulations were not included in the package for the Integrated Management of Childhood Illnesses and ministry officials attributed this to resource constraints and lack of initial guidance from the World Health Organization. Underfunding reportedly undercut efforts to: orient health workers; do support supervision and update treatment guidelines to reflect 'better medicines for children'. Health workers reported difficulties in administering tablets and capsules to under-five children and that's why they preferred liquid oral dosage formulations, suppositories and injections. CONCLUSIONS: The IMCI strategy in Uganda was not revised to reflect child-appropriate dosage formulations - a missed opportunity for improving the quality of management of childhood illnesses. Funding was an obstacle to the integration of child-appropriate dosage formulations. Ministry of health should prioritize funding for the Integrated Management of Childhood Illnesses and revising the Essential Medicines and Health Supplies List of Uganda, the Uganda Clinical Guidelines and, the Treatment Charts for the Integrated Management of Childhood Illnesses to reflect child-appropriate dosage formulations.

Coping with paediatric referral--Ugandan parents' experience.

Referral of severely ill children to hospital is key in the Integrated Management of Childhood Illness (IMCI). In rural Uganda, we documented the caretakers' ability to complete referral to hospital from 12 health facilities. Of 227 children, only 63 (28%) had completed referral after 2 weeks, at a median cost of 8.85 US dollars (range 0.40-89.00). Failure to attend hospital resulted from lack of money (139 children, 90%), transport problems (39, 26%), and responsibilities at home (26, 17%). Children with incomplete referral continued treatment at referring health centres (87, 54%) or in the private sector (45, 28%). Our results show that cost of referral must decrease to make paediatric referral realistic. When referral is difficult, more specific IMCI referral criteria should be used and first-level health workers should be empowered to manage severely ill children.

Explaining the slow transition of child-appropriate dosage formulations from the global to national level in the context of Uganda: a qualitative study.

BACKGROUND: In 2007, the Sixtieth World Health Assembly (WHA) passed a resolution entitled "Better medicines for children" and subsequently the World Health Organization (WHO) recommended the inclusion of child-appropriate dosage formulations in the essential medicines lists of member countries. However, child-appropriate dosage formulations are not highlighted in the Essential Medicines and Health Supplies List of Uganda (EMHSLU) 2012 and they are still limited in availability in public health facilities. Several stakeholders influenced the status of child-appropriate dosage formulations in the EMHSLU 2012. OBJECTIVE: To explore stakeholders' views about the relevance of the globally recommended child-appropriate dosage formulations in the context of Uganda. METHODS: The findings derive from thirty three in-depth interviews with stakeholder representatives and the results of a follow up validation meeting where preliminary findings were shared with stakeholders. Policy analysis and policy transfer theories were used to guide a deductive analysis for manifest and latent content. RESULTS: According to stakeholders, the transition to the globally recommended child-appropriate dosage formulations has been slow in Uganda due to a number of factors. These factors include resource constraints at the global and national levels, lack of Ministry of Health (MOH) formal commitment to the adoption of the child-appropriate dosage formulations policy and a lack of consensus between those who advocated for the availability of liquid oral dosage formulations for easy administration and effectiveness and those who were more convinced by economic arguments and preferred the procurement of solid oral dosage formulations intended for adults. CONCLUSIONS: The global policy for child-appropriate dosage formulations still remains to be implemented in Uganda and other low income countries. This has been due to lack of resources that hindered formal transfer of the policy from the global to the local level. To achieve this transfer there is a need for resource mobilisation at both the international and local levels, together with the revitalisation of UMTAC to enable it to take on a leadership role of the coalitions supporting child-appropriate dosage formulations.

The "child size medicines" concept: policy provisions in Uganda.

BACKGROUND: In 2007, the World Health Organization (WHO) launched the 'make medicines child size' (MMCS) campaign by urging countries to prioritize procurement of medicines with appropriate strengths for children's age and weight and, in child-friendly formulations of rectal and flexible oral solid formulations. This study examined policy provisions for MMCS recommendations in Uganda. METHODS: This was an in-depth case study of the Ugandan health policy documents to assess provisions for MMCS recommendations in respect to oral and rectal medicine formulations for malaria, pneumonia and diarrhea, the major causes of morbidity and mortality among children in Uganda- diseases that were also emphasized in the MMCS campaign. Asthma and epilepsy were included as conditions that require long term care. Schistomiasis was included as a neglected tropical disease. Content analysis was used to assess evidence of policy provisions for the MMCS recommendations. RESULTS: For most medicines for the selected diseases, appropriate strength for children's age and weight was addressed especially in the EMHSLU 2012. However, policy documents neither referred to 'child size medicines' concept nor provided for flexible oral solid dosage formulations like dispersible tablets, pellets and granules- indicating limited adherence to MMCS recommendations. Some of the medicines recommended in the clinical guidelines as first line treatment for malaria and pneumonia among children were not evidence-based. CONCLUSION: The Ugandan health policy documents reflected limited adherence to the MMCS recommendations. This and failure to use evidence based medicines may result into treatment failure and or death. A revision of the current policies and guidelines to better reflect 'child size', child appropriate and evidence based medicines for children is recommended.

Availability and utilization of the WHO recommended priority lifesaving medicines for under five-year old children in public health facilities in Uganda: a cross-sectional survey.

OBJECTIVES: To explore the availability and utilization of the World Health Organization (WHO) recommended priority life-saving medicines for children under five in public health facilities in Uganda. METHODS: We conducted a cross sectional survey in 32 lower level public facilities in Jinja district of Uganda. A proportionate number of facilities were randomly selected in each stratum following a hierarchy of Health Centers (HC) defined according to the level of care they provide: 17 HC IIs, 10 HC IIIs and 5 HC IVs. In the facilities, we verified the availability of the WHO recommended priority medicines for diarrhea, sepsis, pneumonia and malaria. 81 health workers from the facilities reported what they prescribed for children with the above diseases. RESULTS: Oral rehydration salt (ORS) and zinc sulphate dispersible tablets for diarrhea were available in all HC IIs and IIIs and in only 60% of HC IVs. Procaine benzyl penicillin injection powder for treatment of sepsis was available in the majority of all HCs with: 100% of HC of IVs, 83% of HC IIIs and 82% of HC IIs. Medicines for pneumonia were limited across all the HCs with: Amoxicillin dispersible tablets in only 30% of the HC IIs and 40% of the HC IVs. The most uncommon were child-friendly priority medicines for malaria with: Artesunate injection in only 6% of HC IIs, 14% of HC IIIs and 20% of HC IVs; Artemether lumefantrine dispersible tablets and rectal artesunate were missing in all the 32 HCs. Less than a third of the health workers reported prescribing zinc sulphate and ORS for diarrhea, 86% reported procaine benzyl penicillin injection powder for sepsis, and 57% reported amoxicillin dispersible tablets for pneumonia. None reported prescribing Artemether lumefantrine dispersible tablets and rectal artesunate for malaria. CONCLUSIONS: There is low availability and utilization of life-saving priority medicines for pneumonia and malaria in public health facilities in Uganda. However, the priority medicines for diarrhea and sepsis are available and highly prescribed by the health workers.

Hurdles and opportunities for newborn care in rural Uganda.

INTRODUCTION: A set of evidence-based delivery and neonatal practices have the potential to reduce neonatal mortality substantially. However, resistance to the acceptance and adoption of these practices may still be a problem and challenge in the rural community in Uganda. OBJECTIVES: To explore the acceptability and feasibility of the newborn care practices at household and family level in the rural communities in different regions of Uganda with regards to birth asphyxia, thermo-protection and cord care. METHODS: A qualitative design using in-depth interviews and focus group discussions were used. Participants were purposively selected from rural communities in three districts. Six in-depth interviews targeting traditional birth attendants and nine focus group discussions composed of 10-15 participants among post childbirth mothers, elderly caregivers and partners or fathers of recently delivered mothers were conducted. All the mothers involved has had normal vaginal deliveries in the rural community with unskilled birth attendants. Latent content analysis was used. FINDINGS: Two main themes emerged from the interviews: 'Barriers to change' and 'Windows of opportunities'. Some of the recommended newborn practices were deemed to conflict with traditional and cultural practices. Promotion of delayed bathing as a thermo-protection measure, dry cord care were unlikely to be accepted and spiritual beliefs were attached to use of local herbs for bathing or smearing of the baby's skin. However, several aspects of thermo-protection of the newborn, breast feeding, taking newborns for immunisation were in agreement with biomedical recommendations, and positive aspects of newborn care were noticed with the traditional birth attendants. CONCLUSIONS: Some of the evidence based practices may be accepted after modification. Behaviour change communication messages need to address the community norms in the country. The involvement of other newborn caregivers than the mother at the household and the community early during pregnancy may influence change of behaviour related to the adoption of the recommended newborn care practices.

Inadequate pre-antiretroviral care, stock-out of antiretroviral drugs and stigma: policy challenges/bottlenecks to the new WHO recommendations for earlier initiation of antiretroviral therapy (CD<350 cells/microL) in eastern Uganda.

OBJECTIVE: This study explores reasons for late ART initiation among known HIV positive persons in care from a client/caretaker perspective in eastern Ugandan where ART awareness is presumably high yet AIDS related mortality is a common function of late initiation of ARVs. METHODS: In Iganga, Uganda we conducted in-depth interviews with clients who started ART at 50-200 CD4 cells/microL and those initiated very late at CD4<50 cells/microL. Focus-group discussions were also conducted with caretakers of clients on ART. Content analysis was performed to identify recurrent themes. RESULTS: ARV stock-outs, inadequate pre-antiretroviral care and lack of staff confidentiality were system barriers to timely ART initiation. Weak social support and prevailing stigma and misconceptions about ARVs as drugs designed to kill, cause cancer, infertility or impotence were other important factors. CONCLUSION: If the new WHO recommendations (start ART at CD4 350 cells/microL) should be feasible, PLHIV/communities need sensitization about the importance of regular pre-ARV care through the local media and authorities. The ARV supply chain and staff attitudes towards client confidentiality must also be improved in order to encourage timely ART initiation. PLHIV/communities should be sensitization about drug package labeling and the use and importance of ARVs. Stronger social support structures must be created through public messages that fight stigma, enhance acceptance of PLHIV and encourage timely ART initiation.

Policy and practice, lost in transition: Reasons for high drop-out from pre-antiretroviral care in a resource-poor setting of eastern Uganda.

OBJECTIVE: This study explores reasons for drop-out from pre-ARV care in a resource-poor setting where premature death is a common consequence of delayed ARV initiation. METHODS: In Iganga, Uganda, we conducted key informant interviews with staff at the pre-ARV clinic, focus group discussions with persons who looked after people living with HIV (PLWH) and in-depth interviews with PLWH half of whom had dropped out of pre-ARV care. Content data analysis was done to identify recurrent themes. RESULTS: Reasons cited for dropping out of pre-ARV care include: inadequate post-test counseling due to staff work overload, competition from the holistic and less stigmatizing traditional/spiritual healers. Others were transportation costs, long waiting time lack of incentives to seek pre-ARV care by healthy looking PLWH and gender inequalities. CONCLUSIONS: Pre-ARV adherence counseling should be improved through recruitment of counselors or multi-skilling in counseling skills for the available staff to reduce on the work load. Traditional/ spiritual healers should be integrated and supervised to offer pre-ARV care. Door step supply of cotrimoxazole using agents could reduce transport costs, waiting time and increase access to pre-ARV. Women should be sensitized on comprehensive HIV care through the local media and local leaders to address gender inequalities.

Local fever illness classifications: implications for home management of malaria strategies.

BACKGROUND: The Ugandan Ministry of Health has adopted the WHO Home Based Fever Management strategy (HBM) to improve access to antimalarial drugs for prompt (<24 h) presumptive treatment of all fevers in children under 5 years. Village volunteers will distribute pre-packed antimalarials free of charge to caretakers of febrile children 2 months to 5 years ('Homapaks'). OBJECTIVE: To explore the local understanding and treatment practices for childhood fever illnesses and discuss implications for the HBM strategy. METHODS: Focus Group Discussions were held with child caretakers in three rural communities in Kasese district, West Uganda, and analysed for content in respect to local illness classifications and associated treatments for childhood fevers. RESULTS: Local understanding of fever illnesses and associated treatments was complex. Some fever illness classifications were more commonly mentioned, including 'Fever of Mosquito', 'Chest Problem', 'the Disease', 'Stomach Wounds' and 'Jerks', all of which could be biomedical malaria. Although caretakers refer to all these classifications as 'fever' treatment differed; some were seen as requiring urgent professional western treatment and others were considered severe but 'non-western' and would preferentially be treated with traditional remedies. CONCLUSIONS: The HBM strategy does not address local community understanding of 'fever' and its influence on treatment. While HBM improves drug access, Homapaks are likely to be used for only those fevers where 'western' treatment is perceived appropriate, implying continued delayed and under-treatment of potential malaria. Hence, HBM strategies also need to address local perceptions of febrile illness and adapt information and training material accordingly.