Cultural beliefs and practices on perinatal death: a qualitative study among the Lango community in Northern Uganda.

BACKGROUND: Perinatal death has profound psychosocial effects on women and their families. Sociocultural contexts influence the burden, rituals and bereaved's support. Little is known about cultural beliefs and practices related to perinatal death. This study explored the cultural perspectives of the Lango community on perinatal death. METHODS: This study utilised a focused ethnographic design anchored on a symbolic interactionist framework to understand the meanings attached to beliefs and practices on stillbirth or neonatal death among the Lango community in Lira District, Northern Uganda. Participants were sampled purposively for FGD while key informants were identified through snowballing technique. Data were audio recorded in Lango, transcribed, and later translated, a codebook was developed and data entered into Atlas. ti version 8.4.26 and then coded. It was analysed both deductively and inductively into themes. RESULTS: Stillbirth and early neonatal death both attract similar rituals as would an older child. Burial is not rushed and is attended by family members and close friends. Stillbirths and children that die before naming are buried without names. Bereaved families are comforted and encouraged about future pregnancies. Currently, Lango associates the deaths to biomedical explanations such as teenage pregnancies, inadequate pregnancy care, health system challenges and poor health-seeking behaviour, unlike previously when they were attributed to consequences of unacceptable social behaviours, superstitious beliefs and witchcraft. Antenatal care and health facility childbirths are currently preferred over traditional practices for good pregnancy outcomes. CONCLUSION: Stillbirth or early neonatal death is viewed as the death of a child, different from other settings. Thus, rituals are performed to honour, create memory, and maintain the connection with deceased babies. Bereaved parents are supported. Health care workers need to provide culturally sensitive support to parents after perinatal loss. The prevailing beliefs of perinatal death cause in terms of biomedical explanations consistent with known determinants and preference for health facility care for prevention creates an opportunity for improving perinatal health.

Child pedestrian crossing behaviour and associated risk factors in school zones: a video-based observational study in Kampala, Uganda.

BACKGROUND: Pedestrian crashes, often occurring while road crossing and associated with crossing behaviour, make up 34.8% of road casualties in Uganda. This study determined crossing behaviour and associated factors among child pedestrians around primary schools in Kampala, Uganda. METHODS: We conducted a cross-sectional study in 2022 among 2100 primary school children. Data on their crossing behaviour were collected using video recordings from cameras staged at the crossing points of 21 schools. We estimated prevalence ratios (PR) with their corresponding 95% CIs using a modified Poisson regression model for the association between unsafe behaviour and the predictors. RESULTS: The prevalence for each of 5 unsafe child pedestrian behaviour was 206 (25.8%) for crossing outside the crosswalk, 415 (19.8%) for failing to wait at the kerb, 238 (11.3%) for failing to look for vehicles, 361 (17.2%) for running and 235 (13%) for crossing between vehicles. There was a higher likelihood of crossing outside the crosswalk when an obstacle was present (adjusted PR (aPR) 1.8; 95% CI 1.40 to 2.27) and when children crossed alone (aPR 1.5; 95% CI 1.13 to 2.06). Children who crossed without a traffic warden (aPR 2; 95% CI 1.40 to 2.37) had a significantly higher prevalence of failing to wait at a kerb. CONCLUSION: These findings reveal the interaction between child pedestrians, vehicles and the environment at crossings. Some factors associated with unsafe child pedestrian behaviour were the presence of an obstacle, crossing alone and the absence of a traffic warden. These findings can help researchers and practitioners understand child pedestrian crossing behaviour, highlighting the need to prioritise targeted safety measures.

"Your heart keeps bleeding": lived experiences of parents with a perinatal death in Northern Uganda.

BACKGROUND: Worldwide, two million babies are stillborn and 1.8 million babies die before completing seven days of life. Approximately 4% of pregnant women in Uganda experience perinatal death. The response following a perinatal death tends to be socio-culturally constructed. Investigating the unique personal experiences of parents from a low-income setting with unique cultural beliefs and practices is crucial for the design and implementation of appropriate interventions. OBJECTIVE: To describe the lived experiences of parents following perinatal death in Lira district, Northern Uganda. METHODS: A qualitative study was carried out drawing on the tenets of descriptive phenomenology. We conducted 32 in-depth interviews in Lira district, Northern Uganda between August 2019 and September 2020 with 18 women and 14 men who had experienced a stillbirth or an early neonatal death within the preceding 2 years. Participants were selected from different families and interviewed. A local IRB approved the study. All in-depth interviews were audio-recorded, transcribed, translated, and data were analysed using a content thematic approach. Key findings were discussed based on Worden's Four Tasks of Mourning theory. RESULTS: The themes that emerged from the analyses included reaction to the perinatal loss and suggestions for support. The participants' immediate reactions were pain, confusion, and feelings of guilt which were aggravated by the unsupportive behaviour of health care providers. Men cumulatively lost financial resources in addition to facing multiple stressful roles. Delayed reactions such as pain and worries were triggered by the sight of similar-age-babies, subsequent pregnancy losses, and marital challenges. Participants recommended emotional support and management of postnatal complications for parents faced with perinatal loss. CONCLUSION: Losing a baby during the perinatal period in a resource-constrained setting negatively affected both gender. In addition, men suffered the loss of financial resources and the burden of multiple stressful roles. Acknowledging the pain and offering support to the grieving parents reinforce their coping with a perinatal loss. In addition to family and community members, health care providers need to provide emotional support and postnatal care to parents who experience perinatal death.

Newborn weight change and predictors of underweight in the neonatal period in Guinea-Bissau, Nepal, Pakistan and Uganda.

In low- and middle-income countries (LMIC), growth impairment is common; however, the trajectory of growth over the course of the first month has not been well characterised. To describe newborn growth trajectory and predictors of growth impairment, we assessed growth frequently over the first 30 days among infants born ≥2000 g in Guinea-Bissau, Nepal, Pakistan and Uganda. In this cohort of 741 infants, the mean birth weight was 3036 ± 424 g. For 721 (98%) infants, weight loss occurred for a median of 2 days (interquartile range, 1-4) following birth until weight nadir was reached 5.9 ± 4.3% below birth weight. At 30 days of age, the mean weight was 3934 ± 592 g. The prevalence of being underweight at 30 days ranged from 5% in Uganda to 31% in Pakistan. Of those underweight at 30 days of age, 56 (59%) had not been low birth weight (LBW), and 48 (50%) had reached weight nadir subsequent to 4 days of age. Male sex (relative risk [RR] 2.73 [1.58, 3.57]), LBW (RR 6.41 [4.67, 8.81]), maternal primiparity (1.74 [1.20, 2.51]) and reaching weight nadir subsequent to 4 days of age (RR 5.03 [3.46, 7.31]) were highly predictive of being underweight at 30 days of age. In this LMIC cohort, country of birth, male sex, LBW and maternal primiparity increased the risk of impaired growth, as did the modifiable factor of delayed initiation of growth. Interventions tailored to infants with modifiable risk factors could reduce the burden of growth impairment in LMIC.

Vaginal colonisation of women in labour with potentially pathogenic bacteria: a cross sectional study at three primary health care facilities in Central Uganda.

BACKGROUND: Potentially pathogenic bacteria that colonise the lower genital tract of women in labour can be passed to the baby during birth. While many babies become colonised with these bacteria after delivery, a few develop neonatal infections. The lower genital tract is a reservoir for potential pathogens and a source of infection for neonates. We determined the prevalence of vaginal colonisation of potentially pathogenic bacteria among women in labour in Central Uganda and identified potential risk factors associated with this colonisation. METHODS: We conducted a cross sectional study at three primary health care facilities and collected vaginal swabs from HIV-1 negative women in labour. Specimens were cultured on different selective microbiological media, and biochemical tests were used to classify bacterial isolates on the species level. Multivariable logistic regression analyses were used to estimate the association between relevant exposures and colonisation with potentially pathogenic bacteria. RESULTS: We recruited 1472 women in labour whose mean age was 24.6 years (standard deviation [SD] 4.9). Of these, 955 (64.9%; 95% Confidence Interval [CI] 62.4, 67%) were vaginally colonised with at least one potentially pathogenic bacterial species. The most commonly isolated species were Escherichia coli (n = 508; 34.5%), Klebsiella pneumoniae (n = 144; 9.8%) and Staphylococcus aureus (n = 121; 8.2%). Results from exploratory multivariable regression analyses indicated that having had ≥5 previous pregnancies (adjusted odds ratio [aOR] 0.59; 95% CI 0.35, 0.97) or being ≥30 years old (aOR 1.52; 95% CI 1.03, 2.23) could be associated with vaginal colonisation with any potentially pathogenic bacteria, as well as with vaginal colonisation with S. aureus (aOR 0.33; 95% CI 0.12, 0.88, and aOR 2.17; 95% CI 1.17, 4.00, respectively). Possession of domestic animals in a household (aOR 0.57; 95% CI 0.35, 0.92) could be associated with vaginal colonisation with E. coli. CONCLUSIONS: Two-thirds of HIV-1 negative women in labour were vaginally colonised by potentially pathogenic bacteria, mainly E. coli, K. pneumoniae, and S. aureus.

"The cord is the child": meanings and practices related to umbilical cord care in Central Uganda.

BACKGROUND: Infections account for a quarter of all newborn deaths and the umbilical cord has been identified as a major route of newborn infections. OBJECTIVE: To explore the meanings and practices related to the umbilical cord among caretakers of newborns in central Uganda. METHODS: This was a qualitative study, designed to inform the design, and interpretation of a randomized controlled trial assessing the effectiveness of chlorhexidine use for the umbilical cord. We conducted 22 in-depth interviews exploring umbilical cord care practices among ten mothers, four health workers, five traditional birth attendants, and three men. We also conducted three focus group discussions with young mothers and elderly women. We used qualitative content analysis to analyze our findings and we borrow upon Mary Douglas' concepts of dirt to present our findings. RESULTS: The umbilical cord had a symbolic position in newborn care. The way it was perceived and handled had far reaching consequences for the survival and wellbeing of the baby. The umbilical cord was a centre of anxiety, a possible gate to illness, a test of fatherhood and a signifier of parental responsibility. Hence, the umbilical cord and the way it was cared for played a part in the present and future survival of the baby, as well as the survival and wellbeing of the household. Persons other than the mother such as older female relatives were very influential in the care of the umbilical cord. CONCLUSIONS: The umbilical cord carried symbolic meanings, which extended beyond the newborn and the newborn period, and in turn influenced the various practices of umbilical cord care. The important position of the cord in local newborn care practices should be recognized and taken into consideration when scaling up newborn care interventions in the country.

Prenatal hepatitis B screening and associated factors in a high prevalence district of Lira, northern Uganda: a community based cross sectional study.

BACKGROUND: Chronic hepatitis B Virus (HBV) infection affects 80-100 million people in sub-Saharan Africa and accounts for an estimated 650,000 deaths annually. The prevalence of active hepatitis B virus infection among women aged 15-64 in mid-Northern Uganda is about 5%. Lira district is among the high prevalence areas where government embarked on mass HBV screening since 2015 as a gateway for access to prevention, treatment services, and an effective response to the hepatitis B epidemic. The current proportion of pregnant women screened and the factors associated with prenatal HBVscreening in Lira are not known despite the fact that women contribute largely to both vertical and horizontal transmission of HBV. This study aimed at determining the proportion of pregnant women screened for HBV and factors associated with prenatal HBV screening in Lira district. METHODS: This was a community based cross sectional study conducted among 423 pregnant women in the sub counties of Aromo and Agweng in Lira district. Data were collected using open data kit and analysed using STATA version 14. The outcome variable was prenatal HBV screening while predictor variables were community, individual and health facility factors associated with HBV screening. Multivariable logistic regression was used to determine factors associated with prenatal HBV screening. RESULTS: Thirty five women (8.3%) had been screened for HBV during the current pregnancy. Factors associated with prenatal HBV screening in Lira included perceived risk (Adjusted Odds Ratio (AOR) 3.78, 95% CI 1.01-6.14), respondent's age (AOR = 3.98, 95% CI 1.39-5.09), husband/partner's education (AOR = 3.34, 95% CI 1.10-5.12) and past failure to access to HBV screening services at government health facilities (AOR = 6.44, 95% CI 2.10-8.02). CONCLUSION: The level of HBV screening among pregnant women in Lira was low and is mainly associated with perceived risk, age, access to HBV screening services and spousal education level. More effort is needed in creating mass awareness on the need and importance of HBV screening most especially among pregnant women.

A usability design checklist for Mobile electronic data capturing forms: the validation process.

BACKGROUND: New Specific Application Domain (SAD) heuristics or design principles are being developed to guide the design and evaluation of mobile applications in a bid to improve on the usability of these applications. This is because the existing heuristics are rather generic and are often unable to reveal a large number of mobile usability issues related to mobile specific interfaces and characteristics. Mobile Electronic Data Capturing Forms (MEDCFs) are one of such applications that are being used to collect health data particularly in hard to reach areas, but with a number of usability challenges especially when used in rural areas by semi literate users. Existing SAD design principles are often not used to evaluate mobile forms because their focus on features specific to data capture is minimal. In addition, some of these lists are extremely long rendering them difficult to use during the design and development of the mobile forms. The main aim of this study therefore was to generate a usability evaluation checklist that can be used to design and evaluate Mobile Electronic Data Capturing Forms in a bid to improve their usability. We also sought to compare the novice and expert developers' views regarding usability criteria. METHODS: We conducted a literature review in August 2016 using key words on articles and gray literature, and those with a focus on heuristics for mobile applications, user interface designs of mobile devices and web forms were eligible for review. The data bases included the ACM digital library, IEEE-Xplore and Google scholar. We had a total of 242 papers after removing duplicates and a total of 10 articles which met the criteria were finally reviewed. This review resulted in an initial usability evaluation checklist consisting of 125 questions that could be adopted for designing MEDCFs. The questions that handled the five main categories in data capture namely; form content, form layout, input type, error handling and form submission were considered. A validation study was conducted with both novice and expert developers using a validation tool in a bid to refine the checklist which was based on 5 criteria. The criteria for the validation included utility, clarity, question naming, categorization and measurability, with utility and measurability having a higher weight respectively. We then determined the proportion of participants who agreed (scored 4 or 5), disagreed (scored 1 or 2) and were neutral (scored 3) to a given criteria regarding a particular question for each of the experts and novice developers. Finally, we selected questions that had an average of 85% agreement (scored 4 or 5) across all the 5 criteria by both novice and expert developers. 'Agreement' stands for capturing the same views or sentiments about the perceived likeness of an evaluation question. RESULTS: The validation study reduced the initial 125 usability evaluation questions to 30 evaluation questions with the form layout category having the majority questions. Results from the validation showed higher levels of affirmativeness from the expert developers compared to those of the novice developers across the different criteria; however the general trend of agreement on relevance of usability questions was similar across all the criteria for the developers. The evaluation questions that were being validated were found to be useful, clear, properly named and categorized, however the measurability of the questions was found not to be satisfactory by both sets of developers. The developers attached great importance to the use of appropriate language and to the visibility of the help function, but in addition expert developers felt that indication of mandatory and optional fields coupled with the use of device information like the Global Positioning System (GPS) was equally important. And for both sets of developers, utility had the highest scores while measurability scored least. CONCLUSION: The generated checklist indicated the design features the software developers found necessary to improve the usability of mobile electronic data collection tools. In the future, we thus propose to test the effectiveness of the measure for suitability and performance based on this generated checklist, and test it on the end users (data collectors) with a purpose of picking their design requirements. Continuous testing with the end users will help refine the checklist to include only that which is most important in improving the data collectors' experience.

"We shall count it as a part of kyogero": acceptability and considerations for scale up of single dose chlorhexidine for umbilical cord care in Central Uganda.

BACKGROUND: Cleansing the umbilical cord with chlorhexidine reduces neonatal morbidity and mortality, particularly in communities where newborn deaths and home births are common. As a result, the World Health Organization and national authorities are advocating the scale up of this intervention. In order for such a scale up to be effective, it has to be acceptable to the targeted population. With the overall aim to clarify conditions for scale-up, this study explored the acceptability of single dose chlorhexidine solution for umbilical cord care among health workers and infant care providers in the districts of Kampala and Mukono in Central Uganda. METHODS: This was a qualitative study that involved mothers of neonates enrolled in a chlorhexidine trial, nurses implementing the trial, key community members and opinion leaders in childcare. We conducted 30 in depth interviews (IDIs) with mothers (18), health workers (8), traditional birth attendants (2), a father (1) and a grandmother (1) and 4 focus group discussions (FGDs), 3 with mothers and 1 with health workers. We used qualitative content analysis to analyze our findings and borrow upon Sekhon's model when presenting our findings. RESULTS: Cognitive and emotional responses to chlorhexidine use included ease of use, and a perception that chlorhexidine reduced smell and abdominal colic. We also found that wider social and cultural factors were important to chlorhexidine use. These included cultural value put on quick separation of the umbilical cord as well as the practice of bathing the baby in a herbal mixture called kyogero. We also found that older relatives were key decision makers in umbilical cord care for newborns, but were seldom present during health workers' counseling of mothers about hygienic care of the cord. CONCLUSIONS: The application of chlorhexidine on the umbilical cord stump at birth was acceptable as an addition rather than a total replacement of traditional substances. The scale up of chlorhexidine should consider how to accommodate local beliefs and practices in a way that does not compromise the effect of the intervention; encouraging mothers to delay the bathing of babies in kyogero could be one way of doing this.

Rapid reduction of malaria following introduction of vector control interventions in Tororo District, Uganda: a descriptive study.

BACKGROUND: In 2012, Tororo District had the highest malaria burden in Uganda with community Plasmodium prevalence of 48%. To control malaria in the district, the Ministry of Health introduced universal distribution of long lasting insecticide-treated nets (LLINs) in 2013 and added indoor residual spraying (IRS) in 2014. This study assessed malaria incidence, test positivity rates and outpatient (OPD) attendance due to malaria before and after vector control interventions. METHODS: This study was based on analysis of Health Management Information System (HMIS) secondary malaria surveillance data of 2,727,850 patient records in OPD registers of 61 health facilities from 2012 to 2015. The analysis estimated monthly malaria incidence for the entire population and also separately for <5- and ≥5-year-olds before and after introduction of vector control interventions; determined laboratory test positivity rates and annual percentage of malaria cases in OPD. Chi square for trends was used to analyse annual change in malaria incidence and logistic regression for monthly reduction. RESULTS: Following universal LLINs coverage, the annual mean monthly malaria incidence fell from 95 cases in 2013 to 76 cases per 1000 in 2014 with no significant monthly reduction (OR = 0.99, 95% CI 0.96-1.01, P = 0.37). Among children <5 years, the malaria incidence reduced from 130 to 100 cases per 1000 (OR = 0.98, 95% CI 0.97-1.00, P = 0.08) when LLINs were used alone in 2014, but declined to 45 per 1000 in 2015 when IRS was combined with LLINs (OR = 0.94, 95% CI 0.91-0.996, P < 0.0001). Among individuals aged ≥5 years, mean monthly malaria incidence reduced from 59 to 52 cases per 1000 (OR = 0.99, 95% CI 0.97-1.02, P = 0.8) when LLINs were used alone in 2014, but reduced significantly to 25 per 1000 in 2015 (OR = 0.91, 95% CI 0.88-0.94, P < 0.0001). Malaria test positivity rate reduced from 57% in 2013 to 30% (Chi = 15, P < 0.0001) in 2015. Slide positivity rate reduced from 45% in 2013 to 21% in 2015 (P = 0.004) while RDT positivity declined from 69 to 40%. CONCLUSIONS: A rapid reduction in malaria incidence was observed in Tororo District following the introduction of IRS in addition to LLINs. There was no significant reduction in malaria incidence following universal distribution of LLINs to communities before introduction of IRS.

Modifiable risk factors for typhoid intestinal perforations during a large outbreak of typhoid fever, Kampala Uganda, 2015.

BACKGROUND: Between January and June, 2015, a large typhoid fever outbreak occurred in Kampala, Uganda, with 10,230 suspected cases. During the outbreak, area surgeons reported a surge in cases of typhoid intestinal perforation (TIP), a complication of typhoid fever. We conducted an investigation to characterize TIP cases and identify modifiable risk factors for TIP. METHODS: We defined a TIP case as a physician-diagnosed typhoid patient with non-traumatic terminal ileum perforation. We identified cases by reviewing medical records at all five major hospitals in Kampala from 2013 to 2015. In a matched case-control study, we compared potential risk factors among TIP cases and controls; controls were typhoid patients diagnosed by TUBEX TF, culture, or physician but without TIP, identified from the outbreak line-list and matched to cases by age, sex and residence. Cases and controls were interviewed using a standard questionnaire from 1st -23rd December 2015. We used conditional logistic regression to assess risk factors for TIP and control for confounding. RESULTS: Of the 88 TIP cases identified during 2013-2015, 77% (68/88) occurred between January and June, 2015; TIPs sharply increased in January and peaked in March, coincident with the typhoid outbreak. The estimated risk of TIP was 6.6 per 1000 suspected typhoid infections (68/10,230). The case-fatality rate was 10% (7/68). Cases sought care later than controls; Compared with 29% (13/45) of TIP cases and 63% (86/137) of controls who sought treatment within 3 days of onset, 42% (19/45) of cases and 32% (44/137) of controls sought treatment 4-9 days after illness onset (ORadj = 2.2, 95%CI = 0.83-5.8), while 29% (13/45) of cases and 5.1% (7/137) of controls sought treatment ≥10 days after onset (ORadj = 11, 95%CI = 1.9-61). 68% (96/141) of cases and 23% (23/100) of controls had got treatment before being treated at the treatment centre (ORadj = 9.0, 95%CI = 1.1-78). CONCLUSION: Delay in seeking treatment increased the risk of TIPs. For future outbreaks, we recommended aggressive community case-finding, and informational campaigns in affected communities and among local healthcare providers to increase awareness of the need for early and appropriate treatment.

Factors Associated with Virological Non-suppression among HIV-Positive Patients on Antiretroviral Therapy in Uganda, August 2014-July 2015.

BACKGROUND: Despite the growing number of people on antiretroviral therapy (ART), there is limited information about virological non-suppression and its determinants among HIV-positive (HIV+) individuals enrolled in HIV care in many resource-limited settings. We estimated the proportion of virologically non-suppressed patients, and identified the factors associated with virological non-suppression. METHODS: We conducted a descriptive cross-sectional study using routinely collected program data from viral load (VL) samples collected across the country for testing at the Central Public Health Laboratories (CPHL) in Uganda. Data were generated between August 2014 and July 2015. We extracted data on socio-demographic, clinical and VL testing results. We defined virological non-suppression as having ≥1000 copies of viral RNA/ml of blood for plasma or ≥5000 copies of viral RNA/ml of blood for dry blood spots. We used logistic regression to identify factors associated with virological non-suppression. RESULTS: The study was composed of 100,678 patients; of these, 94,766(94%) were for routine monitoring, 3492(4%) were suspected treatment failures while 1436(1%) were repeat testers after suspected failure. The overall proportion of non-suppression was 11%. Patients on routine monitoring registered the lowest (10%) proportion of non-suppressed patients. Virological non-suppression was higher among suspected treatment failures (29%) and repeat testers after suspected failure (50%). Repeat testers after suspected failure were six times more likely to have virological non-suppression (ORadj = 6.3, 95%CI = 5.5-7.2) when compared with suspected treatment failures (ORadj = 3.3, 95%CI = 3.0-3.6). The odds of virological non-suppression decreased with increasing age, with children aged 0-4 years (ORadj = 5.3, 95%CI = 4.6-6.1) and young adolescents (ORadj = 4.1, 95%CI = 3.7-4.6) registering the highest odds. Poor adherence (ORadj = 3.4, 95%CI = 2.9-3.9) and having active TB (ORadj = 1.9, 95%CI = 1.6-2.4) increased the odds of virological non-suppression. However, being on second/third line regimens (ORadj = 0.86, 95%CI = 0.78-0.95) protected patients against virological non-suppression. CONCLUSION: Young age, poor adherence and having active TB increased the odds of virological non-suppression while second/third line ART regimens were protective against non-suppression. We recommend close follow up and intensified targeted adherence support for repeat testers after suspected failure, children and adolescents.

eRegistries: indicators for the WHO Essential Interventions for reproductive, maternal, newborn and child health.

BACKGROUND: Electronic health registries - eRegistries - can systematically collect relevant information at the point of care for reproductive, maternal, newborn and child health (RMNCH). However, a suite of process and outcome indicators is needed for RMNCH to monitor care and to ensure comparability between settings. Here we report on the assessment of current global indicators and the development of a suite of indicators for the WHO Essential Interventions for use at various levels of health care systems nationally and globally. METHODS: Currently available indicators from both household and facility surveys were collated through publicly available global databases and respective survey instruments. We then developed a suite of potential indicators and associated data points for the 45 WHO Essential Interventions spanning preconception to newborn care. Four types of performance indicators were identified (where applicable): process (i.e. coverage) and outcome (i.e. impact) indicators for both screening and treatment/prevention. Indicators were evaluated by an international expert panel against the eRegistries indicator evaluation criteria and further refined based on feedback by the eRegistries technical team. RESULTS: Of the 45 WHO Essential Interventions, only 16 were addressed in any of the household survey data available. A set of 216 potential indicators was developed. These indicators were generally evaluated favourably by the panel, but difficulties in data ascertainment, including for outcome measures of cause-specific morbidity and mortality, were frequently reported as barriers to the feasibility of indicators. Indicators were refined based on feedback, culminating in the final list of 193 total unique indicators: 93 for preconception and antenatal care; 53 for childbirth and postpartum care; and 47 for newborn and small and ill baby care. CONCLUSIONS: Large gaps exist in the availability of information currently collected to support the implementation of the WHO Essential Interventions. The development of this suite of indicators can be used to support the implementation of eRegistries and other data platforms, to ensure that data are utilised to support evidence-based practice, facilitate measurement and accountability, and improve maternal and child health outcomes.

eRegistries: Electronic registries for maternal and child health.

BACKGROUND: The Global Roadmap for Health Measurement and Accountability sees integrated systems for health information as key to obtaining seamless, sustainable, and secure information exchanges at all levels of health systems. The Global Strategy for Women's, Children's and Adolescent's Health aims to achieve a continuum of quality of care with effective coverage of interventions. The WHO and World Bank recommend that countries focus on intervention coverage to monitor programs and progress for universal health coverage. Electronic health registries - eRegistries - represent integrated systems that secure a triple return on investments: First, effective single data collection for health workers to seamlessly follow individuals along the continuum of care and across disconnected cadres of care providers. Second, real-time public health surveillance and monitoring of intervention coverage, and third, feedback of information to individuals, care providers and the public for transparent accountability. This series on eRegistries presents frameworks and tools to facilitate the development and secure operation of eRegistries for maternal and child health. METHODS: In this first paper of the eRegistries Series we have used WHO frameworks and taxonomy to map how eRegistries can support commonly used electronic and mobile applications to alleviate health systems constraints in maternal and child health. A web-based survey of public health officials in 64 low- and middle-income countries, and a systematic search of literature from 2005-2015, aimed to assess country capacities by the current status, quality and use of data in reproductive health registries. RESULTS: eRegistries can offer support for the 12 most commonly used electronic and mobile applications for health. Countries are implementing health registries in various forms, the majority in transition from paper-based data collection to electronic systems, but very few have eRegistries that can act as an integrating backbone for health information. More mature country capacity reflected by published health registry based research is emerging in settings reaching regional or national scale, increasingly with electronic solutions. 66 scientific publications were identified based on 32 registry systems in 23 countries over a period of 10 years; this reflects a challenging experience and capacity gap for delivering sustainable high quality registries. CONCLUSIONS: Registries are being developed and used in many high burden countries, but their potential benefits are far from realized as few countries have fully transitioned from paper-based health information to integrated electronic backbone systems. Free tools and frameworks exist to facilitate progress in health information for women and children.

Effects of an exclusive breastfeeding intervention for six months on growth patterns of 4-5 year old children in Uganda: the cluster-randomised PROMISE EBF trial.

BACKGROUND: Breastfeeding promotion is regarded as one of the most effective interventions to improve child health, and could reduce under-5-mortality by 8 % globally. Few studies have assessed the health outcomes beyond infancy of interventions promoting exclusive breastfeeding. METHODS: This study assessed growth in under-five children who participated in a cluster-randomised trial in Eastern Uganda (ClinicalTrials.gov.no.NCT00397150). In the intervention arm, peer counsellors promoted exclusive breastfeeding during the first 6 months of infancy. There were no interventions after 6 months of age. Mother-infant pairs were interviewed at visits scheduled at 3, 6, 12 and 24 weeks after birth and follow-up visits at 2 and 5 years, with 765 included in the analyses. RESULTS: The mean length/height-for-age and weight-for-age-z-score (HAZ, WAZ) decreased with increasing age in both the intervention and control arms. At the three weeks visit, HAZ in the intervention was -0.45 (-0.68;-0.21) and -0.32 (-0.56;-0.07) in the control arm. At the 2 year follow-up, the mean HAZ in the intervention was -1.85 (95 % CI -1.97;-1.73) compared to -1.61 (-1.87;-1.34) in the control. Similarly, at the 5 year follow-up, the mean HAZ in the intervention was -1.78 (-2.08;-1.47) compared to -1.53 (-1.79;-1.28) in the control arm. At the 2 year follow-up visit, 139 (45 %) were stunted (HAZ<-2) in the intervention compared to 109 (37 %) in the control arm, odds ratio (OR) 1.7 (1.1;2.4). Underweight (WAZ<-2) was also more common in the intervention arm than in the control at the five years follow-up (OR 1.7 (1.0;2.8)), with a mean WAZ of -1.28 (-1.47;-1.08) and -1.06 (-1.19;-0.92) in the intervention and control arm, respectively. CONCLUSION: While stunting was widespread at 2 and 5 years of age in both arms, it was more common in the intervention arm. It is questionable whether community-based support from lay people with short training and focussing only on exclusive breastfeeding, is an appropriate strategy to improve child health and development. TRIAL REGISTRATION: ClinicalTrials.gov.no. NCT00397150 . Registered 7th of November 2006.

Caretaker's caries experience and its association with early childhood caries and children's oral health-related quality of life: A prospective two-generation study.

OBJECTIVES: The first objective of this study is to examine the association between caretakers' caries experience and caries experience of their children. Second, to investigate whether children's and caretaker's caries experience is associated with oral health-related quality of life (OHRQoL) of children and their families. METHODS: This study is based on the prenatal recruitment interviews and the 5-year follow-up of 417 caretaker-children pairs from the Ugandan site of the PROMISE-EBF trial conducted in Mbale, Eastern Uganda. Face-to-face interviews were conducted with caretakers at the household level. Caries experience of caretakers (DMFT >0) and children (dmft >0) were assessed in accordance with the criteria of the World Health Organization. OHRQoL was assessed using an abbreviated version of the Early Childhood Oral Health Impact Scale (ECOHIS). RESULTS: Adjusted negative binomial regression analysis revealed that caretaker's caries experience was positively associated with early childhood caries of their offspring (IRR 2.0, 95% confidence interval (CI) 1.3-3.0). Children's caries experience (IRR 1.8, 95% CI 1.2-3.0), but not caries experience of caretakers, was associated with worse OHRQoL of children and their families. Caretakers who perceived good child oral health were less likely to report OHRQoL impacts (IRR 0.20, 95% CI 0.12-0.35). CONCLUSION: Improving caretaker's caries experience and her perception of child's oral health status could improve children's caries experience and the OHRQoL of children and family. Such knowledge is important and should inform public oral health programs for young children.

Child survival and BCG vaccination: a community based prospective cohort study in Uganda.

BACKGROUND: Data on non-specific effects of BCG vaccination in well described, general population African cohorts is scanty. We report the effects of BCG vaccination on post-neonatal infant and post-infancy mortality in a cohort of children in Mbale, Eastern Uganda. METHODS: A community-based prospective cohort study was conducted between January 2006 and February 2014. A total of 819 eligible pregnant women were followed up for pregnancy outcomes and survival of their children up to 5 years of age. Data on the children's BCG vaccination status was collected from child health cards at multiple visits between 3 weeks and 7 years of age. Data was also collected on mothers' residence, age, parity, household income, self-reported HIV status as well as place of birth. Multivariable Cox proportional hazards regression models taking into account potential confounders were used to estimate the association between BCG vaccination and child survival. RESULTS: The neonatal mortality risk was 22 (95% CI: 13, 35), post-neonatal infant mortality 21 (12, 34) per 1,000 live births and the mortality risk among children between 1 and 5 years of age (post-infancy) was 63 (47, 82) per 1,000 live births. The median age at BCG vaccination was 4 days. Out of 819 children, 647 (79%) had received the BCG vaccine by 24 weeks of age. In the adjusted analysis, the rate of post-neonatal death among infants vaccinated with BCG tended to be nearly half of that among those who had not received the vaccine (adjusted HR: 0.47; 95% CI: 0.14, 1.53). BCG vaccination was associated with a lower rate of death among children between 1 and 5 years of age (adjusted HR: 0.26; 95% CI: 0.14, 0.48). CONCLUSION: The risk of early childhood death in Mbale, Uganda is unacceptably high. BCG vaccination was associated with an increased likelihood of child survival.

Growth effects of exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa: the cluster-randomised PROMISE EBF trial.

BACKGROUND: In this multi-country cluster-randomized behavioural intervention trial promoting exclusive breastfeeding (EBF) in Africa, we compared growth of infants up to 6 months of age living in communities where peer counsellors promoted EBF with growth in those infants living in control communities. METHODS: A total of 82 clusters in Burkina Faso, Uganda and South Africa were randomised to either the intervention or the control arm. Feeding data and anthropometric measurements were collected at visits scheduled 3, 6, 12 and 24 weeks post-partum. We calculated weight-for-length (WLZ), length-for-age (LAZ) and weight-for-age (WAZ) z-scores. Country specific adjusted Least Squares Means with 95% confidence intervals (CI) based on a longitudinal analysis are reported. Prevalence ratios (PR) for the association between peer counselling for EBF and wasting (WLZ < -2), stunting (LAZ < -2) and underweight (WAZ < -2) were calculated at each data collection point. RESULTS: The study included a total of 2,579 children. Adjusting for socio-economic status, the mean WLZ at 24 weeks were in Burkina Faso -0.20 (95% CI -0.39 to -0.01) and in Uganda -0.23 (95% CI -0.43 to -0.03) lower in the intervention than in the control arm. In South Africa the mean WLZ at 24 weeks was 0.23 (95% CI 0.03 to 0.43) greater in the intervention than in the control arm. Differences in LAZ between the study arms were small and not statistically significant. In Uganda, infants in the intervention arm were more likely to be wasted compared to those in the control arm at 24 weeks (PR 2.36; 95% CI 1.11 to 5.00). Differences in wasting in South Africa and Burkina Faso and stunting and underweight in all three countries were small and not significantly different. CONCLUSIONS: There were small differences in mean anthropometric indicators between the intervention and control arms in the study, but in Uganda and Burkina Faso, a tendency to slightly lower ponderal growth (weight-for-length z-scores) was found in the intervention arms. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT00397150.

Driver yield and safe child pedestrian crossing behavior promotion by a school traffic warden program at primary school crossings: A cluster-randomized trial.

OBJECTIVE: To determine the effect of a school traffic warden program on increasing driver yield and safe child pedestrian crossing behavior in Kampala, Uganda. METHODS: We designed and implemented a school traffic warden program in specific school zones in Kampala, Uganda. We randomly assigned 34 primary schools in Kampala, in a 1:1 ratio, using a computer-generated randomization sequence, to control or intervention arms in a cluster randomized trial. Each school in the intervention group received one trained adult traffic warden stationed at roads adjacent to schools to help young children safely cross. The control schools continued with the standard of care. We extracted and coded outcome data from video recordings on driver yield and child crossing behavior (defined as waiting at the curb, looking both ways for oncoming vehicles, not running while crossing, and avoiding illegal crossing between vehicles) at baseline and after 6 months. Using a mixed effect modified Poisson regression model, we estimated the prevalence ratio to assess whether being in a school traffic warden program was associated with increased driver yield and safe crossing behavior. RESULTS: A higher proportion of drivers yielded to child pedestrians at crossings with a school traffic warden (aPR 7.2; 95% CI 4.42-11.82). Children were 70% more likely to demonstrate safe crossing behavior in the intervention clusters than in control clusters (aPR 1.7; 95% CI 1.04-2.85). A higher prevalence was recorded for walking while crossing (aPR 1.2; 95% CI 1.08-1.25) in the intervention clusters. CONCLUSION: The school traffic warden program is associated with increased driver yield and safe child pedestrian crossing behavior, i.e., stopping at the curb, walking while crossing, and not crossing between vehicles. Therefore, the school traffic warden program could be promoted to supplement other road safety measures, such as pedestrian safety road infrastructure, legislation, and enforcement that specifically protects children in school zones.

Weight change in the first 30 days among infants born less than 2000 grams in Guinea-Bissau and Uganda.

Despite the high prevalence of low birth weight infants in sub-Saharan Africa and the associated poor outcomes, weight change during the newborn period has not been well characterized for this population. We prospectively assessed growth over the first 30 days among 120 infants born < 2000 g (g) in Guinea-Bissau and Uganda, and compared it to a similar cohort of 420 infants born ≥ 2000 g. Among those born < 2000 g, mean birth weight was 1747 ± 164 g, and initial weight loss was 8.25 ± 4.40% of birth weight prior to the initiation of weight gain at a median of 3 (interquartile range 2, 4) days of age. This initial weight loss was more pronounced (8.25 vs 6.06%; p < 0.001) and lasted longer (median 3 vs 2 days; p < 0.001) than for infants born ≥ 2000 g. The initial period of weight loss was an important predictor of growth at 30 days in both cohorts. Infants born < 2000 g on average grew proportionately to their size at birth but did not experience catch-up growth; their weights at 30 days remained much lower than that of infants born ≥ 2000 g and most remained severely underweight. Targeted interventions to optimize early growth should be investigated.