Cholera epidemic amidst the COVID-19 pandemic in Moroto district, Uganda: Hurdles and opportunities for control.

INTRODUCTION: On 21st March 2020, the first COVID-19 case was detected in Uganda and a COVID-19 pandemic declared. On the same date, a nationwide lockdown was instituted in response to the pandemic. Subsequently, more cases were detected amongst the returning international travelers as the disease continued to spread across the country. On May 14th, 2020, a cholera epidemic was confirmed in Moroto district at a time when the district had registered several COVID-19 cases and was in lockdown. This study aimed to describe the cholera epidemic and response activities during the COVID-19 pandemic as well as the hurdles and opportunities for cholera control encountered during the response. MATERIALS AND METHODS: In a cross-sectional study design, we reviewed Moroto district's weekly epidemiological records on cholera and COVID-19 from April to July 2020. We obtained additional information through a review of the outbreak investigation and control reports. Data were analyzed and presented in frequencies, proportions, attack rates, case fatality rates, graphs, and maps. RESULTS: As of June 28th, 2020, 458 cases presenting with severe diarrhea and/or vomiting were line listed in Moroto district. The most affected age group was 15-30 years, 30.1% (138/458). The females, 59.0% [270/458], were the majority. The Case Fatality Rate (CFR) was 0.4% (2/458). Whereas home use of contaminated water following the vandalization of the only clean water source in Natapar Kocuc village, Moroto district, could have elicited the epidemic, implementing COVID-19 preventive and control measures presented some hurdles and opportunities for cholera control. The significant hurdles were observing the COVID-19 control measures such as social distancing, wearing of masks, and limited time in the community due to the need to observe curfew rules starting at 6.00 pm. The opportunities from COVID-19 measures complementary to cholera control measures included frequent hand washing, travel restrictions within the district & surrounding areas, and closure of markets. CONCLUSION: COVID-19 preventive and control measures such as social distancing, wearing of masks, and curfew rules may be a hurdle to cholera control whereas frequent hand washing, travel restrictions within the district & surrounding areas, and closure of markets may present opportunities for cholera control. Other settings experiencing concurrent cholera and COVID-19 outbreaks can borrow lessons from this study.

Training, supervision and performance of Community Health Workers in the delivery of ear and hearing care to 321 community members in rural Uganda.

OBJECTIVES: Community Health Workers are one way to address the shortage of ear and hearing care specialists in low-resource settings. However, there are few reports evaluating training and service delivery by Community Health Workers. DESIGN, SETTING AND PARTICIPANTS: We trained 13 Community Health Workers in primary ear and hearing care in Mukono District, Uganda. Community Health Workers attended a two-day training workshop and received remote supervision thereafter during service delivery in the community. An ear camp was held at the local health centre every two months, where a local ENT specialist could assess referred cases. MAIN OUTCOME MEASURES: Clinical and diagnostic skills and decision-making were assessed using an Objective Structured Clinical Examination, with scores recorded at baseline and six months. Service delivery was evaluated by analysing the following: (i) number of individuals evaluated; (ii) treatments delivered; (iii) cases referred for specialist opinion; (iv) proportion of appropriately referred cases; and (v) agreement between Community Health Worker and specialist diagnosis. RESULTS: Observed Structured Clinical Examination scores were high and stable for six months. 312 individuals were screened in the community by the Community Health Workers, with 298 classified as having an abnormality. Care was delivered in the community to 167 of these, and the remaining 131 referred to the ear camp. Diagnostic agreement was 39%, but 98% of referrals were deemed "appropriate" by the ENT specialist. 27 individuals self-presented to the ear camp without prior assessment by a Community Health Worker, and 97% of these were deemed appropriate. CONCLUSION: Trained Community Health Workers can play an important role in delivering ear and hearing services. Future work should look to explore this model in other contexts and/or compare it to other models of service delivery.

The use of low-cost ruggedized Android tablets to augment in-service training of community health workers in Mukono, Uganda: perspectives and lessons learned from the field.

BACKGROUND: Despite potential for community health workers (CHWs) to effectively reduce morbidity and mortality in sub-Saharan Africa, they still face multiple barriers including access to on-going and refresher training. Digital technology offers a potential solution to improve the provision of ongoing training for CHWs. OBJECTIVES: This report shares participant insights and experiences following the implementation of a mobile health (mHealth) assisted Integrated Community Case Management (iCCM) refresher training programme for CHWs in Mukono, Uganda. We seek to document benefits and challenges of such an approach. METHODS: CHWs were trained to recognize, treat and prevent childhood pneumonia via locally made videos preloaded onto low cost, ruggedized Android tablets. Subsequent interviews were compiled with key stakeholders including CHWs, CHW leaders and programme supervisors to better understand the strengths, barriers and lessons learned following the intervention. RESULTS: Success factors included the establishment of CHW leadership structures, the ability to use the tablets to learn on an "any pace, any place" basis and using the tablets to conduct community teaching and outreach. Barriers included appropriate consideration of the implementation timeline and avoiding a "one size fits all" approach to digital literacy training. CONCLUSIONS: The strength of the program stemmed from a grassroots approach that prioritized stakeholder input at all stages. Leadership at a local level, a history of local engagement and trust built up over a period time were also integral. As organizations aim to scale up digitally enhanced training initiatives, it is paramount that attention is paid to these human factors which are key for program success.

The use of low-cost Android tablets to train community health workers in Mukono, Uganda, in the recognition, treatment and prevention of pneumonia in children under five: a pilot randomised controlled trial.

BACKGROUND: Since 2012, The World Health Organization and UNICEF have advocated for community health workers (CHWs) to be trained in Integrated Community Case Management (iCCM) of common childhood illnesses, such as pneumonia. Despite the effectiveness of iCCM, CHWs face many barriers to accessing training. This pilot study compares traditional training with using locally made videos loaded onto low-cost Android tablets to train CHWs on the pneumonia component of iCCM. METHODS: We conducted a pilot randomised controlled trial with CHWs in the Mukono District of Uganda. The unit of randomisation was the sub-county level, and the unit of analysis was at the level of the individual CHW. Eligible CHWs had completed basic iCCM training but had not received any refresher training on the pneumonia component of iCCM in the preceding 2 years. CHWs in the control group received training in the recognition, treatment, and prevention of pneumonia as it is currently delivered, through a 1-day, in-person workshop. CHWs allocated to the intervention group received training via locally made educational videos hosted on low-cost Android tablets. The primary outcome was change in knowledge acquisition, assessed through a multiple choice questionnaire before and after training, and a post-training clinical assessment. The secondary outcome was a qualitative evaluation of CHW experiences of using the tablet platform. RESULTS: In the study, 129 CHWs were enrolled, 66 and 63 in the control and intervention groups respectively. CHWs in both groups demonstrated an improvement in multiple choice question test scores before and after training; however, there was no statistically significant difference in the improvement between groups (t = 1.15, p = 0.254). There was a statistically significant positive correlation (Pearson's r = 0.26, p = 0.03) linking years of education to improvement in test scores in the control group, which was not present in the intervention group. The majority of CHWs expressed satisfaction with the use of tablets as a training tool; however, some reported technical issues (n = 9). CONCLUSION: Tablet-based training is comparable to traditional training in terms of knowledge acquisition. It also proved to be feasible and a satisfactory means of delivering training to CHWs. Further research is required to understand the impacts of scaling such an intervention. TRIAL REGISTRATION: Registered on 23/11/2016 at clinicaltrials.gov ( NCT02971449 ).

Client satisfaction in a faith-based health network: findings from a survey in Uganda.

BACKGROUND: Client satisfaction surveys are important in evaluating quality of the healthcare processes and contribute to health service improvements by assisting health program managers to develop appropriate strategies. The goal of this study was to assess clients' level of satisfaction with services provided by private-not-for-profit member health facilities affiliated to Uganda Protestant Medical Bureau. METHODS: This was a cross-sectional descriptive study using an interviewer-administered questionnaire conducted in 254/278 (91%) of UPMB member health facilities between 27th April and 14th July 2014 among 927 clients. The tool measured ten dimensions of the care-seeking experience namely; health facility access; waiting time; health providers; support staff; rights; payments; facilities and environment; consent; confidentiality; and the overall care seeking experience. Logistic regression was utilised for multivariate analysis. RESULTS: Overall client satisfaction was found to be high within the UPMB network (84.2%). Most of the client satisfaction dimensions were rated above 70% except payments and rights. There was evidence of association with marital status; single/never married were 3.05 times more likely to be dissatisfied compared to widowed. Clients attending HCIII were less likely to be dissatisfied compared to those attending HCII (OR=0.51, 95% CI: 0.25-1.05). Post-secondary education (OR=1.79; 95% CI 1.01-3.17), being formally employed (OR=2.78, 95% CI: 0.91-8.48) or unemployed (OR=3.34, 95% CI: 1.00-11.17), attendance at a hospital (OR=2.15, 95% CI: 1.36- 3.41) were also associated with high dissatisfaction levels with payments. CONCLUSION: This study found a high level of satisfaction with services in the UPMB network but recorded low client satisfaction with the dimensions of rights and payments. Health workers should take time to explain rights and entitlement as well as charges levied to clients.

Introduction of male circumcision for HIV prevention in Uganda: analysis of the policy process.

BACKGROUND: Health policy analysis is important for all health policies especially in fields with ever changing evidence-based interventions such as HIV prevention. However, there are few published reports of health policy analysis in sub-Saharan Africa in this field. This study explored the policy process of the introduction of male circumcision (MC) for HIV prevention in Uganda in order to inform the development processes of similar health policies. METHODOLOGY: Desk review of relevant documents was conducted between March and May 2012. Thematic analysis was used to analyse the data. Conceptual frameworks that demonstrate the interrelationship within the policy development processes and influence of actors in the policy development processes guided the analysis. RESULTS: Following the introduction of MC on the national policy agenda in 2007, negotiation and policy formulation preceded its communication and implementation. Policy proponents included academic researchers in the early 2000s and development partners around 2007. Favourable contextual factors that supported the development of the policy included the rising HIV prevalence, adoption of MC for HIV prevention in other sub-Saharan African countries, and expertise on MC. Additionally, the networking capability of proponents facilitated the change in position of non-supportive or neutral actors. Non-supportive and neutral actors in the initial stages of the policy development process included the Ministry of Health, traditional and Muslim leaders, and the Republican President. Using political authority, legitimacy, and charisma, actors who opposed the policy tried to block the policy development process. Researchers' initial disregard of the Ministry of Health in the research process of MC and the missing civil society advocacy arm contributed to delays in the policy development process. CONCLUSIONS: This study underscores the importance of securing top political leadership as well as key implementing partners' support in policy development processes. Equally important is the appreciation of the various forms of actors' power and how such power shapes the policy agenda, development process, and content.