Value chain hygiene practices and microbial contamination of street and market vended ready-to-eat grasshopper, Ruspolia differens in Uganda: Implications for food safety and public health.

Food safety is a major public health issue particularly in developing countries. Ready-to-eat street-vended foods contribute significantly to dietary intake in urban and peri-urban areas, but with elevated public health risk. In this study, hygiene and food safety practices as well as the microbial contamination in Uganda's edible grasshopper value chain were evaluated."A total of 29 grasshopper-processing households participated, and grasshopper samples collected. Indicator pathogens were analyzed using standard microbiological methods. In Kampala 50% and in Masaka 12% households had earth floors. All households in Kampala were one or two-roomed dwellings with no separate room as a kitchen, and shared a toilet. In contrast, 59% of households in Masaka had three or more rooms, 35% had a separate room for a kitchen and 47% did not share a toilet. 83% households in Kampala and 56% in Masaka obtained drinking water from public taps. Handwashing was inadequate and none of the actors was observed to wash their hands after taking a break or handling waste. For vendors, wearing protective clothing was not common, with only 28.5% in Kampala and 30.8% in Masaka wearing an apron. Containers for vending grasshoppers were largely uncovered and the utensils for measuring the grasshoppers were left mainly uncovered. Indicator organisms, Escherichia coli and Salmonella typhimurium, were detected. E. coli was the most common contaminant, but with lower levels in Masaka compared to Kampala. S. typhimurium was mainly a burden in Kampala. Our findings demonstrate that there are enormous contributors to poor hygiene and sanitation along the edible grasshopper value chain. The existence of pathogenic bacteria such as E. coli in ready-to-eat foods imply that their consumption poses a health risk.

Hemoglobin measurement in venous blood compared with pooled and single-drop capillary blood: a method-comparison study in a controlled and survey setting in Uganda among children and women.

BACKGROUND: Standard practice for estimating anemia in population-based surveys is to use a point-of-care device to measure hemoglobin (Hb) in a single drop of capillary blood. Emerging evidence points to larger than expected differences in Hb concentration depending on the blood source. OBJECTIVE: We evaluated use of different blood sources to measure Hb with a HemoCue 201+ analyzer compared with the reference method of venous blood tested with a Sysmex XN-450 hematology analyzer. METHODS: Hb concentration in venous, pooled capillary, and single-drop capillary blood were collected in controlled (laboratory) and survey (Demographic Health Survey-8 pilot) settings in Uganda among children 6-59 mo and nonpregnant women 15-49 y. Venous and capillary blood collected from the same individual was tested using a HemoCue 201+ analyzer and the venous blood was also measured with a Sysmex XN-450 hematology analyzer. Agreement between measures was estimated using Lin's concordance correlation coefficient, Bland-Altman plots, and Deming regression. Means and prevalences were compared using paired t-tests and McNemar's tests, respectively. RESULTS: The limits of agreement between Hb measured using a HemoCue 201+ analyzer and the reference method were lowest for venous (1.1-1.96 g/dL), followed by pooled capillary (1.45-2.27 g/dL), and single-drop capillary blood (2.23-3.41 g/dL). Mean differences were <0.5 g/dL across comparators. There were statistically significant differences in Hb concentration from both types of capillary blood. Anemia prevalence was lower in pooled capillary blood compared with the reference method. CONCLUSIONS: The variability of Hb measured by capillary blood using the HemoCue 201+ analyzer is higher than venous blood but the extent to which this impacts the validity of Hb and anemia estimates requires further exploration. Future research is also needed to evaluate the implications of using venous compared with capillary blood in population-based surveys. This trial was registered at clinicaltrials.gov (NCT05059457).

What Influences Students Choice for Health Professions Education at Makerere University?

BACKGROUND: Motivation to pursue health professions education may stem from external incentives such as wealth, fame, and popularity. For others it is for internal reasons like the desire to serve society. In this study, we aimed to identify what influences students' choice for an undergraduate health professions program at Makerere University College of Health Sciences (MakCHS). METHODS: A cross-sectional qualitative study was conducted among first-year undergraduate students pursuing bachelor degrees in medicine and surgery (MBChB), nursing (BNur), pharmacy (BPharm), medical radiology (BMR), and dental surgery (BDS). A self-administered questionnaire with open-ended questions was distributed to the students during a tutorial session in the second week of the first semester (academic year 2010/2011). Completed questionnaires were entered into a Microsoft Access database. Median (Interquartile range-IQR) and frequencies of respondents were used to describe the study sample. Content analysis with emergent coding was used to analyze the qualitative data. RESULTS: Overall, 145 students (response rate = 72%, N = 201) with a median age of 20 (IQR: 19-20) years responded to the study. The majority of the participants were male (75.2%, n = 109), and were pursuing MBChB (65.5%, n = 91). Two themes identified showed that students appeared to be motivated by internal motivation and external motivation factors. Personal desire, and a calling to serve, were the significant internal motivating factors, while nature of the education system and the need to upgrade were prominent external motivating factor. CONCLUSION: Multiple factors that are both extrinsic and intrinsic influence the choice for medical education among health professions student at this African institution.

An Integrated Infant and Young Child Feeding and Micronutrient Powder Intervention Does Not Affect Anemia, Iron Status, or Vitamin A Status among Children Aged 12-23 Months in Eastern Uganda.

BACKGROUND: Micronutrient powders (MNP) can reduce iron deficiency and anemia in children. OBJECTIVE: We evaluated the impact of an integrated infant and young child feeding (IYCF)-MNP intervention on anemia and micronutrient status among children aged 12-23 mo in Eastern Uganda. The intervention focused on MNP distribution, IYCF education, and caregiver behavior change. METHODS: Population-based cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts were collected in June/July 2015 at baseline (n = 1260) and 12 mo after implementation at endline in 2016 (n = 1490). From pooled capillary blood, we assessed hemoglobin, malaria, ferritin, retinol binding protein (RBP), C-reactive protein, and ɑ1-acid glycoprotein. Ferritin and RBP were regression-adjusted to correct for inflammation. Caregivers reported sociodemographic characteristics and MNP knowledge and practices. Linear regression estimated the difference-in-difference (DiD) effect of MNP on hemoglobin, ferritin, and RBP, and logistic regression estimated DiD effect of MNP on anemia (hemoglobin <11.0 g/dL), iron deficiency (ferritin <12.0 µg/L), iron deficiency anemia (hemoglobin <11.0 g/dL and ferritin <12.0 µg/L), and vitamin A deficiency (VAD; RBP equivalent to <0.70 µmol/L retinol: <0.79 µmol/L at baseline and RBP <0.67 µmol/L at endline). RESULTS: In Amuria, 96% of children had ever consumed MNP versus <1% of children in Soroti. Fifty-four percent of caregivers reported organoleptic changes when MNP were added to foods cooked with soda ash. Adjusting for age, sex, malaria, recent morbidity, and household-level factors, the intervention was associated with -0.83 g/dL lower hemoglobin (95% CI, -1.36, -0.30 g/dL; P = 0.003) but not with anemia, ferritin, iron deficiency, iron deficiency anemia, RBP, or VAD. CONCLUSIONS: Despite high program fidelity, the intervention was associated with reduced hemoglobin concentrations but not with change in anemia or micronutrient status among children aged 12-23 mo in Eastern Uganda. Contextual factors, such as cooking with soda ash, might explain the lack of effectiveness.

Are women in Uganda gaining adequate gestational weight? A prospective study in low income urban Kampala.

BACKGROUND: Pre-pregnancy weight and weight gained during pregnancy significantly influence maternal and infant health. Little information is available regarding optimal gestational weight gain (GWG) in relation to pre-pregnancy body mass index (BMI) in Uganda. The study aimed at determining gestational weight gain (GWG) in women pregnant for the first and second time. METHODS: The study was prospective cohort study which included 221 HIV negative women pregnant for the first or second time. It was conducted in the antenatal clinic of the directorate of gynecology and obstetrics, Mulago hospital and women were recruited at ≤18 weeks of gestation by dates. Follow up measurements were done at 26 and 36 weeks gestation. Measured maternal height and reported pre-pregnancy weight were used to calculate BMI. Depending on BMI category, GWG was categorized as inadequate, adequate and excessive based on the Uganda Ministry of Health guidelines. RESULTS: The participants' mean ± standard deviation (Sd) age was 20.9 ± 2.7 years and mean ± Sd BMI was 21.40 ± 2.73 kg/m2. None of the participants was obese and 68.8% (n = 132) were pregnant for the first time. The mean ± Sd GWG at time of delivery was 10.58 ± 2.44 kg. Inadequate GWG was recorded in 62.5% (n = 120/192) while only 3.1% (n = 6/192) of the participants gained excessive weight during pregnancy. CONCLUSION: About 62% of pregnant women in Kampala did not gain adequate weight during their first/second pregnancy. We recommend that studies be carried out to assess whether the Uganda Ministry of Health recommendations for weight gain during are appropriate for preventing adverse pregnancy outcomes across populations in Uganda.

Influence of community-based education on undergraduate health professions students' decision to work in underserved areas in Uganda.

BACKGROUND: Uganda is beset by a shortage of health workers and the few available are mal-distributed. Providing rural exposure through community-based education could positively influence students' perspectives towards work in rural areas. We aimed to assess the impact of Community-Based Education and Research (COBERS) on health professions students' attitudes towards working in rural areas. This was a before-and-after study among 525 students of 4 medical universities in Uganda. Data was collected using self-administered paper-based questionnaires. Logistic regression and Poisson regression respectively were used to assess intention and intended number of years of work in rural areas. RESULTS: Before COBERS, 228/518 (44.0%) students indicated that they intended to work in rural areas as compared to 245/506 (48.4%) after the COBERS placement. Before the COBERS placement, the factors that were associated with students considering to work in a rural area were: extra allowance (OR = 0.2; 95% CI 0.1-0.6), and availability of social amenities (OR = 0.2; 95% CI 0.1-0.7). After their COBERS placement, the factors were: access to long distance courses (OR = 2.0; 95% CI 1.0-3.7) and being posted to a facility in a rural area (OR = 15.0; 95% CI 6.5-35.5). Before the COBERS placement the factors that influenced how long students thought they would be willing to work in a rural environment were: reliable electricity (IRR = 0.6; 95% CI 0.3-1.0) and Internet (IRR = 1.5; 95% CI 1.0-2.3), high salary (IRR = 0.4; 95% CI 0.3-0.7), and having skills to practice in rural settings (IRR = 2.0; 95% CI 1.3-3.1). Reliable electricity (IRR = 0.5; 95% CI 0.3-0.8) and long distance courses (IRR = 2.1; 95% CI 1.4-3.1) were significant motivators after having undergone the COBERS placement. CONCLUSIONS: The majority of health professions students do not intend to work in rural areas after they graduate. Improving the welfare of health professionals working in rural areas could attract more health professionals to rural areas thus addressing the maldistribution of health workers in Uganda.

Medical Education in Decentralized Settings: How Medical Students Contribute to Health Care in 10 Sub-Saharan African Countries.

PURPOSE: African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities. METHOD: Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences. RESULTS: The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students. CONCLUSIONS: Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments.

Physical Activity, Sleep, and BMI Percentile in Rural and Urban Ugandan Youth.

BACKGROUND: Uganda is experiencing a dual burden of over- and undernutrition, with overweight prevalence increasing while underweight remains common. Potential weight-related factors, particularly physical activity, sleep, and rural/urban status, are not currently well understood or commonly assessed in Ugandan youth. OBJECTIVE: The purpose of this study was to pilot test a survey measuring weight-related factors in rural and urban Ugandan schoolchildren. METHODS: A cross-sectional survey measured sociodemographics, physical activity, sleep patterns, and dietary factors in 148 rural and urban schoolchildren aged 11-16 in central Uganda. Height and weight were objectively measured. Rural and urban youth were compared on these factors using χ2 and t tests. Regression was used to identify correlates of higher body mass index (BMI) percentile in the full sample and nonstunted youth. FINDINGS: Youth were on average 12.1 ± 1.1 years old; underweight (10%) was more common than overweight (1.4%). Self-reported sleep duration and subjective sleep quality did not differ by rural/urban residence. Rural children overall had higher BMI percentile and marginally higher stunting prevalence. In adjusted analyses in both the full and nonstunted samples, higher BMI percentile was related to living in a rural area, higher frequency of physical activity, and higher subjective sleep quality; it was negatively related to being active on weekends. In the full sample, higher BMI percentile was also related to female gender, whereas in nonstunted youth, higher BMI was related to age. BMI percentile was unrelated to sedentary time, performance of active chores and sports, and dietary factors. CONCLUSIONS: This study is one of the first to pilot test a survey assessing weight-related factors, particularly physical activity and sleep, in Ugandan schoolchildren. BMI percentile was related to several sociodemographic, sleep, and physical activity factors among primarily normal-weight school children in Uganda, providing a basis for understanding weight status in the context of the nutrition transition.

Effect of maternal Helicobacter Pylori infection on gestational weight gain in an urban community of Uganda.

INTRODUCTION: Maternal Helicobacter pylori (H. pylori) infection has been associated with undesirable effects during pregnancy such as; hyperemesis gravidarum, anemia, intrauterine fetal growth restriction and miscarriage. Our aim was to document the effect of H. pylori infection on gestational weight gain (GWG) in a low-income urban setting in Uganda. METHODS: This was a prospective cohort study conducted in Kampala between May 2012 and May 2013. The participants were HIV negative, H. pylori positive and H. pylori negative primigravidae and secundigravidae. Recruitment was at gestation age of eighteen or less weeks and follow up assessments were carried out at 26 and 36 weeks gestation age. H. pylori infection was determined using H. pylori stool antigen test. Maternal weight and height were measured, and body mass index (BMI) and rates of GWG were calculated. RESULTS: The participants' mean±standard deviation (sd) age was 20.9±2.7 years. Primigravidae were 68.8% (n = 132) and 57.3% (n = 110) of the participants were positive for H. pylori infection. Low pre-women pregnancy BMI (< 18.5 kg/m2) was recorded in 14.6% (n = 28). The mean±sd rate of GWG during second and third trimesters was 300.5±79.7 grams/week. The mean±sd weight gained by 36 weeks of gestation was 9.6±2.2 kg while gestation age at delivery was 39.4±1.0 weeks. Factors independently associated with the rates of GWG during the second and third trimesters were parity (P=0.023), H. pylori infection (P = 0.006), pre-pregnancy BMI (P = 0.037), height (P = 0.022) and household income (P = 0.003). CONCLUSION: H. pylori infection is associated with low rates of GWG among primigravidae and secundigravidae.

Effect of maternal Helicobacter Pylori infection on birth weight in an urban community in Uganda.

BACKGROUND: Helicobacter pylori, a widespread infection particularly in developing countries has been associated with many adverse effects during pregnancy including hyperemesis gravidarum, neural tube defects in newborns, intrauterine fetal growth restriction and miscarriage. We sought to document the effects of H. pylori infection on birth weight in a low-income setting in Kampala, Uganda. METHODS: This was a prospective cohort study conducted in Kampala between May 2012 and May 2013. The participants were H. pylori positive and H. pylori negative HIV negative primigravidae and secundigravidae. Recruitment was at ≤18 gestation weeks and follow up assessments were carried out at 26 and 36 gestation weeks and soon after delivery. H. pylori infection was determined using H. pylori stool antigen test. Maternal weight and height were measured, and body mass index (BMI) and gestational weight gain were calculated. Only term and live babies were considered. Low birth weight (LBW) was defined as a birth weight of <2500 gram. RESULTS: A total of 221 participants were enrolled with mean ± standard deviation (SD) age of 20.9 ± 2.7 years. The mean ± SD gestation age at delivery was 39.4 ± 1.0 weeks. Primigravidae were 61.5 % (n = 188) and 52.9 % (n = 117) of the participants were positive for H. pylori infection. Low pre-pregnancy BMI (<18.5 kg/m(2)) was recorded in 14.6 % (n = 28) while 38 % (n = 73) had a height <156 cm at recruitment. Of the infants born to the participants, 13.6 % (n = 26) had low birth weight (<2500 gram). Independent predictors for LBW were the mother being positive for H. pylori infection (odds ratio, OR, 3.6, 95 % CI 1.1 - 11.5; P = 0.031) maternal height at recruitment <156 cm (OR 3.4, 95 % CI 1.4-8.2; P = 0.008) and maternal weight gain rates <0.3 kg/week during the 2(nd) and 3(rd) trimesters (OR 3.8, 95 % CI 1.0-14.1; P = 0.044). CONCLUSION: H. pylori infection is associated with LBW among primigravidae and secundigravidae in Kampala, Uganda.

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

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

Developing hospital accreditation standards in Uganda.

BACKGROUND: Whereas accreditation is widely used as a tool to improve quality of healthcare in the developed world, it is a concept not well adapted in most developing countries for a host of reasons, including insufficient incentives, insufficient training and a shortage of human and material resources. The purpose of this paper is to describe refining use and outcomes of a self-assessment hospital accreditation tool developed for a resource-limited context. METHODS: We invited 60 stakeholders to review a set of standards (from which a self-assessment tool was developed), and subsequently refined them to include 485 standards in 7 domains. We then invited 60 hospitals to test them. A study team traveled to each of the 40 hospitals that agreed to participate providing training and debrief the self-assessment. The study was completed in 8 weeks. RESULTS: Hospital self-assessments revealed hospitals were remarkably open to frank rating of their performance and willing to rank all 485 measures. Good performance was measured in outreach programs, availability of some types of equipment and running water, 24-h staff calls systems, clinical guidelines and waste segregation. Poor performance was measured in care for the vulnerable, staff living quarters, physician performance reviews, patient satisfaction surveys and sterilizing equipment. CONCLUSION: We have demonstrated the feasibility of a self-assessment approach to hospital standards in low-income country setting. This low-cost approach may be used as a good precursor to establishing a national accreditation body, as indicated by the Ministry's efforts to take the next steps. Copyright © 2015 John Wiley & Sons, Ltd.

Evaluating community-based medical education programmes in Africa: A workshop report.

BACKGROUND: The Medical Education Partnership Initiative (MEPI) supports medical schools in Africa to increase the capacity and quality of medical education, improve retention of graduates, and promote regionally relevant research. Many MEPI programmes include elements of community-based education (CBE) such as: community placements; clinical rotations in underserved locations, community medicine, or primary health; situational analyses; or student-led research. METHODS: CapacityPlus and the MEPI Coordinating Center conducted a workshop to share good practices for CBE evaluation, identify approaches that can be used for CBE evaluation in the African context, and strengthen a network of CBE collaborators. Expected outcomes of the workshop included draft evaluation plans for each school and plans for continued collaboration among participants. The workshop focused on approaches and resources for evaluation, guiding exploration of programme evaluation including data collection, sampling, analysis, and reporting. Participants developed logic models capturing inputs, activities, outputs, and expected outcomes of their programmes, and used these models to inform development of evaluation plans. This report describes key insights from the workshop, and highlights plans for CBE evaluation among the MEPI institutions. RESULTS: Each school left the workshop with a draft evaluation plan. Participants agreed to maintain communication and identified concrete areas for collaboration moving forward. Since the workshop's conclusion, nine schools have agreed on next steps for the evaluation process and will begin implementation of their plans. CONCLUSION: This workshop clearly demonstrated the widespread interest in improving CBE evaluation efforts and a need to develop, implement, and disseminate rigorous approaches and tools relevant to the African context.

A situation analysis of inter-professional education and practice for ethics and professionalism training at Makerere University College of Health Sciences.

BACKGROUND: Students at Makerere University College of Health Sciences (MakCHS) are introduced to ethics and professionalism using the inter-professional education (IPE) model. Ethics and professionalism should be running themes throughout succeeding years of study during which students are expected to develop qualities and skills for future inter-professional practice (IPP). We performed a situation analysis of IPE and IPP among students and teaching health professionals at MakCHS to guide development of a relevant training curriculum of ethics and professionalism. METHODS: A cross sectional study with quantitative and qualitative methods which included questionnaires, focus group discussions and key informant interviews. RESULTS: We interviewed 236 undergraduate students (148, 63 % male) and 32 teaching health professionals (25, 78 % male). Two hundred fifteen (91 %) students indicated they had joint learning activities with students of other professions and 166 (70 %) stated there was benefit in having an IPE model training curriculum. Most students (140, 59 %) strongly agreed that learning with other students will make them more effective members of the health team. Whereas the respondents reported inter professionalism as being well articulated in their course curricula, more than half said IPE is only implemented in the pre-clinical years of study. They noted that IPE and IPP concepts were not well programmed, health professionals engaged in teaching had poor attitudes towards IPE and IPP, there were limited numbers of skilled health care workers to implement IPP and there was poor communication between students and teaching health professionals. Majority of teaching health professionals noted challenges in implementation of IPE such as poor coordination and large student population and major factors influencing ethics and professionalism in healthcare such as limited government support, low pay for the health care workers, disrespect and lack of appreciation of the health workers by the public. CONCLUSIONS: Our findings demonstrate that IPE, IPP, ethics and professionalism are not emphasized in the clinical years of study at MakCHS. We recommend increased sensitization on the concepts of IPE and IPP plus enhanced mentorship for both students and teaching health professionals. Innovative strategies of implementation of IPE and IPP for training in ethics and professionalism must be introduced.

The aetiology of anaemia during pregnancy: a study to evaluate the contribution of iron deficiency and common infections in pregnant Ugandan women.

OBJECTIVE: To describe the aetiology of anaemia in pregnant Ugandan women and explore Fe deficiency and common infections as contributors to anaemia in this population. DESIGN: Cross-sectional study in which Hb, ferritin, transferrin receptor (sTfR), C-reactive protein, α-1 acid glycoprotein, hepcidin, malaria, hookworm infestation, syphilis and Helicobacter pylori infection were assessed. SETTING: Antenatal care clinic at Kawempe Health Centre, Kampala, Uganda. SUBJECTS: HIV-negative women (n 151) in their first or second pregnancy at 10-16 weeks' gestation. RESULTS: The prevalence of anaemia was 29·1 %. Fe deficiency was 40·4 % and 14·6 % based on ferritin 8·3 µg/ml. The prevalence of Fe-deficiency anaemia was 9·3 % based on ferritin 8·3 µg/ml. Hepcidin concentration was positively correlated with ferritin concentration (n 151, r=0·578, P1 g/l and/or C-reactive protein >5 mg/l. Malaria parasitaemia (OR=6·85; 95 % CI 1·25, 37·41, P=0·026) and Fe deficiency defined using sTfR (OR=5·58; 95 % CI 1·26, 24·80, P=0·024) were independently and positively associated with anaemia. Population-attributable risk factors for anaemia for raised C-reactive protein, Fe deficiency defined by sTfR >8·3 µg/ml and presence of malaria parasites were 41·6 (95 % CI 11·1, 72·2) %, 13·5 (95 % CI 2·0, 25·0) % and 12·0 (95 % CI 1·4, 22·6) %, respectively. CONCLUSIONS: Infections and inflammation are of greater significance than Fe deficiency in the aetiology of anaemia in pregnant Ugandan women during the first trimester.

A consortium approach to competency-based undergraduate medical education in Uganda: process, opportunities and challenges.

BACKGROUND: Uganda, like the rest of Africa, is faced with serious health challenges including human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), other infectious diseases and increasing non-communicable diseases, yet it has a significant shortage of health workers. Even the few health workers available may lack desired competencies required to address current and future health challenges. Reducing Uganda's disease burden and addressing health challenges requires Ugandan medical schools to produce health workers with the necessary competencies. This study describes the process which a consortium of Ugandan medical schools and the Medical Education Partnership for Equitable Services to all Ugandans (MESAU) undertook to define the required competencies of graduating doctors in Uganda and implement competency-based medical education (CBME). METHODS: A retrospective qualitative study was conducted in which document analysis was used to collect data employing pre-defined checklists, in a desktop or secondary review of various documents. These included reports of MESAU meetings and workshops, reports from individual institutions as well as medical undergraduate curricula of the different institutions. Thematic analysis was used to extract patterns from the collected data. RESULTS: MESAU initiated the process of developing competencies for medical graduates in 2011 using a participatory approach of all stakeholders. The process involved consultative deliberations to identify priority health needs of Uganda and develop competencies to address these needs. Nine competence domain areas were collaboratively identified and agreed upon, and competencies developed in these domains. DISCUSSION: Key successes from the process include institutional collaboration, faculty development in CBME and initiating the implementation of CBME. The consortium approach strengthened institutional collaboration that led to the development of common competencies desired of all medical graduates to address priority health challenges in Uganda. It is important that the MESAU consortium continues engaging all stakeholders in medical education to support the implementation and sustainability of CBME in Uganda.

Helicobacter pylori infection in pregnant women in four districts of Uganda: role of geographic location, education and water sources.

BACKGROUND: The prevalence of Helicobacter pylori infection varies in relation to geography, ethnicity and socioeconomic factors. Available data on the prevalence of Helicobacter pylori infection in Uganda are not representative of the general population. We sought to describe the epidemiology of this infection in pregnant women in Uganda to provide background data for a study into the effect of H. pylori infection during pregnancy on the hematological response to iron supplementation. METHODS: Using a cross-sectional design, H. pylori infection was assessed by the stool antigen test among 447 pregnant women attending antenatal care clinics in Apac, Mbale, Mbarara and Rakai Districts which are in different geographical regions in Uganda, and at Kawempe Health Center which serves a low-income densely populated area in Kampala City. Socio-demographic and household data were collected by face-to-face interviews using a questionnaire. Associations between H. pylori infection and socio-demographic and household characteristics were analyzed using logistic regression. RESULTS: The overall prevalence of H. pylori infection was 45.2% but varied by geographical location from 18.2% in Apac District to 60.5% at Kawempe Health Centre. At 18.4%, the Langi ethnic group, who were enrolled exclusively in Apac District, had the lowest prevalence of H. pylori infection while the Gisu had the highest prevalence (58.4%). H. pylori was independently associated with enrollment at clinics not in Apac (adjusted OR = 5.68; 95% CI: 3.02-10.7) and with using water from public wells, boreholes or springs (AOR = 3.20; 95% CI: 1.19-8.61) and from rivers, lakes or streams (AOR = 5.20; 95% CI: 1.58-17.05). Urban residence (AOR = 1.71; 95% CI: 1.13-2.60) and no formal education (AOR = 1.95; 95% CI: 1.03-3.67) were also independently associated with H. pylori infection. CONCLUSIONS: The unexpected variation in the prevalence of H. pylori infection in Uganda calls for population-based studies in the region and offers an opportunity to study the transmission dynamics of H. pylori infection. The association between H. pylori infection and surface water sources for household use suggests waterborne transmission of H. pylori infection highlighting the need for concerted efforts in environmental health in communities and at the household level.

Community-based education programs in Africa: faculty experience within the Medical Education Partnership Initiative (MEPI) network.

PURPOSE: This paper examines the various models, challenges, and evaluative efforts of community-based education (CBE) programs at Medical Education Partnership Initiative (MEPI) schools and makes recommendations to strengthen those programs in the African context. METHODS: Data were gathered from 12 MEPI schools through self-completion of a standardized questionnaire on goals, activities, challenges, and evaluation of CBE programs over the study period, from November to December 2013. Data were analyzed manually through the collation of inputs from the schools included in the survey. RESULTS: CBE programs are a major component of the curricula of the surveyed schools. CBE experiences are used in sensitizing students to community health problems, attracting them to rural primary health care practice, and preparing them to perform effectively within health systems. All schools reported a number of challenges in meeting the demands of increased student enrollment. Planned strategies used to tackle these challenges include motivating faculty, deploying students across expanded centers, and adopting innovations. In most cases, evaluation of CBE was limited to assessment of student performance and program processes. CONCLUSIONS: Although the CBE programs have similar goals, their strategies for achieving these goals vary. To identify approaches that successfully address the challenges, particularly with increasing enrollment, medical schools need to develop structured models and tools for evaluating the processes, outcomes, and impacts of CBE programs. Such efforts should be accompanied by training faculty and embracing technology, improving curricula, and using global/regional networking opportunities.

Medical Education for Equitable Services for All Ugandans (MESAU) consortium: development and achievements.

PURPOSE: In 2011, five medical schools in Uganda formed the Medical Education for Equitable Services for All Ugandans consortium to address the medical education challenges in meeting the nation's health needs. In this paper, the authors document the development and achievements of this unique collaboration to transform medical education in Uganda. METHOD: A longitudinal qualitative study employed anthropological techniques to examine the proposed idea and development of the consortium, the experiences of consortium members, and the successes and challenges encountered during its first three years (2011-2013). RESULTS: The consortium approach to medical education has made important contributions to member institutions despite initial reservations and uncertainties. Acceptance of the consortium emerged because of the added benefits accruing to individual institutions and the network. The consortium has flourished partly because of its organizational structure, the support of its leadership, the ownership and active participation by member institutions, and a strong commitment to its broader goals. However, some challenges in implementation remain, including inadequate capacity, limited grants management experience, and varying degrees of research expertise among the participating institutions. CONCLUSIONS: Despite these challenges, the consortium approach has had a positive impact on medical education by reducing interinstitutional rivalries, promoting strong collaboration, and providing mutual support and the sharing of resources for medical education and research in Uganda.

Investing in community-based education to improve the quality, quantity, and retention of physicians in three African countries.

CONTEXT: The Medical Education Partnership Initiative (MEPI) is a $US 130 million program funded by the United States government supporting 13 African medical schools to increase the quantity, quality, and retention of physicians in underserved areas. This paper examines how community-based education (CBE) is evolving at MEPI schools to achieve these goals. METHODS: We utilized data from the first two years of site visits and surveys to characterize CBE efforts across the MEPI network and provide detailed descriptions of three models of CBE among the MEPI programs. RESULTS: There is widespread investment in CBE, with considerable diversity in the goals and characteristics of training activities among MEPI schools. Three examples described here show how schools are strengthening and evaluating different models of CBE to achieve MEPI goals. In Nigeria, students are being sent for clinical rotations to community hospitals to offload the tertiary hospital. In Uganda, the consistency and quality of teaching in CBE is being strengthened by adopting a competency-based curriculum and developing criteria for community sites. At Stellenbosch University in South Africa, students are now offered an elective year-long comprehensive rural immersion experience. Despite the diversity in CBE models, all schools are investing in e-learning and faculty development. Extensive evaluations are planned to examine the impact of CBE strategies on the health workforce and health services. DISCUSSION: The MEPI program is stimulating an evolution in CBE among African medical schools to improve the quality, quantity, and retention of physicians. Identifying the strategies within CBE that are reproducible, scalable and optimize outcomes will be instructive for health professions training programs across the continent.