"If your mother does not teach you, the world will ": a qualitative study of parent-adolescent communication on sexual and reproductive health issues in Border districts of eastern Uganda.

BACKGROUND: Adolescents experience a host of sexual and reproductive health (SRH) challenges, with detrimental SRH and socio-economic consequences. These include early sexual debut, sexually transmitted infections including HIV/AIDS, teenage pregnancy, and early childbearing. Parent-adolescent communication about SRH has significant potential to reduce adolescents' risky sexual behaviors. However, communication between parents and adolescents is limited. This study explored the facilitators and barriers to parent-adolescent communication about sexual and reproductive health. METHODS: We conducted a qualitative study in the border districts of Busia and Tororo in Eastern Uganda. Data collection entailed 8 Focus Group Discussions comprising of parents, adolescents (10-17 years), and 25 key informants. Interviews were audio-recorded, transcribed, and translated into English. Thematic analysis was conducted with the aid of NVIVO 12 software. RESULTS: Participants acknowledged the key role parents play in communicating SRH matters; however, only a few parents engage in such discussions. Facilitators of parent-adolescent communication were: having a good parent-child relationship which makes parents approachable and motivates children to discuss issues openly, a closer bond between mothers and children which is partly attributed to gender roles and expectations eases communication, and having parents with high education making them more knowledgeable and confident when discussing SRH issues with children. However, the discussions are limited by cultural norms that treat parent-child conversations on SRH as a taboo, parents' lack of knowledge, and parents busy work schedules made them unavailable to address pertinent SRH issues. CONCLUSION: Parents' ability to communicate with their children is hindered by cultural barriers, busy work schedules, and a lack of knowledge. Engaging all stakeholders including parents to deconstruct sociocultural norms around adolescent SRH, developing the capacity of parents to confidently initiate and convey accurate SRH information, initiation of SRH discussions at early ages, and integrating parent-adolescent communication into parenting interventions, are potential strategies to improve SRH communication between parents and adolescents in high-risk settings such as borders.

Synergistic Impact of Training Followed by On-Site Support on HIV Clinical Practice: A Mixed-Design Study in Uganda With Pre/Post and Cluster-Randomized Trial Components.

BACKGROUND: Task shifting can expand antiretroviral therapy access, but little is known about effective approaches to improve clinical practice among midlevel practitioners (MLPs) such as clinical officers, nurses, and midwives. The Integrated Infectious Diseases Capacity Building Evaluation compared training alone with training combined with on-site support (OSS). METHODS: Two MLPs each from 36 health facilities attended the 5-week Integrated Management of Infectious Disease training. After training, 18 facilities randomly assigned to arm A received OSS for 9 months, whereas 18 arm B facilities did not. Clinical faculty assessed MLP HIV clinical practice on 6 tasks: history taking, physical examination, laboratory investigations, diagnosis, treatment, and patient education. We analyzed the effect of training alone and training combined with OSS as the pre/post change within each arm. We analyzed the incremental effect of OSS with a difference-in-difference analysis that compared changes between arms. RESULTS: Training alone and training combined with OSS significantly improved clinical practice in patient history taking (13% and 24% increase, respectively), physical examination (54% and 71%), laboratory investigations (32% and 20%), and diagnosis (31% and 51%). Combined training and OSS also improved patient education significantly (72% increase). Effect sizes for training combined with OSS were larger than for training alone except for laboratory investigations, and the effects were robust in sensitivity analyses. The incremental effect of OSS on diagnosis was significant [adjusted relative risk = 1.23; 95% confidence interval = 1.00 to 1.50]. CONCLUSIONS: Combined training and OSS improved MLP HIV clinical practice over training alone and can contribute to continued expansion of access to antiretroviral therapy.

Effect of On-Site Support on Laboratory Practice for Human Immunodeficiency Virus, Tuberculosis, and Malaria Testing.

OBJECTIVES: To evaluate the effect of on-site support in improving human immunodeficiency virus (HIV) rapid testing, tuberculosis (TB) sputum microscopy, and malaria microscopy among laboratory staff in a low-resource setting. METHODS: This cluster randomized trial was conducted at 36 health facilities in Uganda. From April to December 2010, laboratory staff at 18 facilities participated in monthly on-site visits, and 18 served as control facilities. After intervention, 128 laboratory staff were observed performing 587 laboratory tests across three diseases: HIV rapid testing, TB sputum microscopy, and malaria microscopy. Outcomes were the proportion of laboratory procedures correctly completed for the three laboratory tests. RESULTS: Laboratory staff in the intervention arm performed significantly better than the control arm in correctly completing laboratory procedures for all three laboratory tests, with an adjusted relative risk (95% confidence interval) of 1.18 (1.10-1.26) for HIV rapid testing, 1.29 (1.21-1.40) for TB sputum microscopy, and 1.19 (1.11-1.27) for malaria microscopy. CONCLUSIONS: On-site support significantly improved laboratory practices in conducting HIV rapid testing, TB sputum microscopy, and malaria microscopy. It could be an effective method for improving laboratory practice, without taking limited laboratory staff away from health facilities for training.

Effect of Educational Outreach Timing and Duration on Facility Performance for Infectious Disease Care in Uganda: A Trial with Pre-Post and Cluster Randomized Controlled Components.

BACKGROUND: Classroom-based learning is often insufficient to ensure high quality care and application of health care guidelines. Educational outreach is garnering attention as a supplemental method to enhance health care worker capacity, yet there is little information about the timing and duration required to improve facility performance. We sought to evaluate the effects of an infectious disease training program followed by either immediate or delayed on-site support (OSS), an educational outreach approach, on nine facility performance indicators for emergency triage, assessment, and treatment; malaria; and pneumonia. We also compared the effects of nine monthly OSS visits to extended OSS, with three additional visits over six months. METHODS: This study was conducted at 36 health facilities in Uganda, covering 1,275,960 outpatient visits over 23 months. From April 2010 to December 2010, 36 sites received infectious disease training; 18 randomly selected sites in arm A received nine monthly OSS visits (immediate OSS) and 18 sites in arm B did not. From March 2011 to September 2011, arm A sites received three additional visits every two months (extended OSS), while the arm B sites received eight monthly OSS visits (delayed OSS). We compared the combined effect of training and delayed OSS to training followed by immediate OSS to determine the effect of delaying OSS implementation by nine months. We also compared facility performance in arm A during the extended OSS to immediate OSS to examine the effect of additional, less frequent OSS. RESULTS: Delayed OSS, when combined with training, was associated with significant pre/post improvements in four indicators: outpatients triaged (44% vs. 87%, aRR = 1.54, 99% CI = 1.11, 2.15); emergency and priority patients admitted, detained, or referred (16% vs. 31%, aRR = 1.74, 99% CI = 1.10, 2.75); patients with a negative malaria test result prescribed an antimalarial (53% vs. 34%, aRR = 0.67, 99% CI = 0.55, 0.82); and pneumonia suspects assessed for pneumonia (6% vs. 27%, aRR = 2.97, 99% CI = 1.44, 6.17). Differences between the delayed OSS and immediate OSS arms were not statistically significant for any of the nine indicators (all adjusted relative RR (aRRR) between 0.76-1.44, all p>0.06). Extended OSS was associated with significant improvement in two indicators (outpatients triaged: aRR = 1.09, 99% CI = 1.01; emergency and priority patients admitted, detained, or referred: aRR = 1.22, 99% CI = 1.01, 1.38) and decline in one (pneumonia suspects assessed for pneumonia: aRR: 0.93; 99% CI = 0.88, 0.98). CONCLUSIONS: Educational outreach held up to nine months after training had similar effects on facility performance as educational outreach started within one month post-training. Six months of bi-monthly educational outreach maintained facility performance gains, but incremental improvements were heterogeneous.

Effect of integrated infectious disease training and on-site support on the management of childhood illnesses in Uganda: a cluster randomized trial.

BACKGROUND: The Integrated Infectious Disease Capacity-Building Evaluation (IDCAP) was designed to test the effects of two interventions, Integrated Management of Infectious Disease (IMID) training and on-site support (OSS), on clinical practice of mid-level practitioners. This article reports the effects of these interventions on clinical practice in management of common childhood illnesses. METHODS: Two trainees from each of 36 health facilities participated in the IMID training. IMID was a three-week core course, two one-week boost courses, and distance learning over nine months. Eighteen of the 36 health facilities were then randomly assigned to arm A, and participated in OSS, while the other 18 health facilities assigned to arm B did not. Clinical faculty assessed trainee practice on clinical practice of six sets of tasks: patient history, physical examination, laboratory tests, diagnosis, treatment, and patient/caregiver education. The effects of IMID were measured by the post/pre adjusted relative risk (aRR) of appropriate practice in arm B. The incremental effects of OSS were measured by the adjusted ratio of relative risks (aRRR) in arm A compared to arm B. All hypotheses were tested at a 5% level of significance. RESULTS: Patient samples were comparable across arms at baseline and endline. The majority of children were aged under five years; 84% at baseline and 97% at endline. The effects of IMID on patient history (aRR = 1.12; 95% CI = 1.04-1.21) and physical examination (aRR = 1.40; 95% CI = 1.16-1.68) tasks were statistically significant. OSS was associated with incremental improvement in patient history (aRRR = 1.18; 95% CI = 1.06-1.31), and physical examination (aRRR = 1.27; 95% CI = 1.02-1.59) tasks. Improvements in laboratory testing, diagnosis, treatment, and patient/caregiver education were not statistically significant. CONCLUSION: IMID training was associated with improved patient history taking and physical examination, and OSS further improved these clinical practices. On-site training and continuous quality improvement activities support transfer of learning to practice among mid-level practitioners.

In vivo selection of Plasmodium falciparum Pfcrt and Pfmdr1 variants by artemether-lumefantrine and dihydroartemisinin-piperaquine in Burkina Faso.

Plasmodium falciparum Pfcrt-76 and Pfmdr1-86 gene polymorphisms were determined during a clinical trial in Burkina Faso comparing the efficacies of dihydroartemisinin-piperaquine (DHA-PPQ) and artemether-lumefantrine (AL). Significant selection of Pfcrt-K76 was observed after exposure to AL and DHA-PPQ, as well as selection of Pfmdr1-N86 after AL but not DHA-PPQ treatment, suggesting reverse selection on the Pfcrt gene by PPQ. These results support the rational use of DHA-PPQ in settings where chloroquine (CQ) resistance is high.

Improving facility performance in infectious disease care in Uganda: a mixed design study with pre/post and cluster randomized trial components.

BACKGROUND: The effects of two interventions, Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS), were tested on 23 facility performance indicators for emergency triage assessment and treatment (ETAT), malaria, pneumonia, tuberculosis, and HIV. METHODS: The trial was implemented in 36 primary care facilities in Uganda. From April 2010, two mid-level practitioners per facility participated in IMID training. Eighteen of 36 facilities were randomly assigned to Arm A, and received OSS in 2010 (nine monthly two-day sessions); 18 facilities assigned to Arm B did not receive OSS in 2010. Data were collected from Nov 2009 to Dec 2010 using a revised Ministry of Health outpatient medical form and nine registers. We analyzed the effect of IMID training alone by measuring changes before and during IMID training in Arm B, the combined effect of IMID training and OSS by measuring changes in Arm A, and the incremental effect of OSS by comparing changes across Arms A and B. RESULTS: IMID training was associated with statistically significant improvement in three indicators: outpatients triaged (adjusted relative risks (aRR) = 1.29, 99%CI = 1.01,1.64), emergency and priority patients admitted, detained, or referred (aRR = 1.59, 99%CI = 1.04,2.44), and pneumonia suspects assessed (aRR = 2.31, 99%CI = 1.50,3.55). IMID training and OSS combined was associated with improvements in six indicators: three ETAT indicators (outpatients triaged (aRR = 2.03, 99%CI = 1.13,3.64), emergency and priority patients admitted, detained or referred (aRR = 3.03, 99%CI = 1.40,6.56), and emergency patients receiving at least one appropriate treatment (aRR = 1.77, 99%CI = 1.10,2.84)); two malaria indicators (malaria cases receiving appropriate antimalarial (aRR = 1.50, 99%CI = 1.04,2.17), and patients with negative malaria test results prescribed antimalarial (aRR = 0.67, 99%CI = 0.46,0.97)); and enrollment in HIV care (aRR = 1.58, 99%CI = 1.32,1.89). OSS was associated with incremental improvement in emergency patients receiving at least one appropriate treatment (adjusted ratio of RR = 1.84,99%CI = 1.09,3.12). CONCLUSION: The trial showed that the OSS intervention significantly improved performance in one of 23 facility indicators.

Correlates of inappropriate prescribing of antibiotics to patients with malaria in Uganda.

BACKGROUND: In many rural areas of Uganda, febrile patients presenting to health facilities are prescribed both antimalarials and antibiotics, contributing to the overuse of antibiotics. We identified the prevalence and correlates of inappropriate antibiotic management of patients with confirmed malaria. METHODS: We utilized individual outpatient data from 36 health centers from January to September 2011. We identified patients who were prescribed antibiotics without an appropriate clinical indication, as well as patients who were not prescribed antibiotics when treatment was clinically indicated. Multivariate logistic regression models were used to identify clinical and operational factors associated with inappropriate case management. FINDINGS: Of the 45,591 patients with parasitological diagnosis of malaria, 40,870 (90%) did not have a clinical indication for antibiotic treatment. Within this group, 17,152 (42%) were inappropriately prescribed antibiotics. The odds of inappropriate prescribing were higher if the patient was less than five years old (aOR 1.96, 95% CI 1.75-2.19) and if the health provider had the fewest years of training (aOR 1.86, 95% CI 1.05-3.29). The odds of inappropriate prescribing were lower if patients had emergency triage status (aOR 0.75, 95% CI 0.59-0.96) or were HIV positive (aOR 0.31, 95% CI 0.20-0.45). Of the 4,721 (10%) patients with clinical indications for antibiotic treatment, 521 (11%) were inappropriately not prescribed antibiotics. Clinical officers were less likely than medical officers to inappropriately withhold antibiotics (aOR 0.54, 95% CI 0.29-0.98). CONCLUSION: Over 40% of the antibiotic treatment in malaria positive patients is prescribed despite a lack of documented clinical indication. In addition, over 10% of patients with malaria and a clinical indication for antibiotics do not receive them. These findings should inform facility-level trainings and interventions to optimize patient care and slow trends of rising antibiotic resistance.