Air quality and attributable mortality among city dwellers in Kampala, Uganda: results from 4 years of continuous PM2.5 concentration monitoring using BAM 1022 reference instrument.

BACKGROUND: Air pollution is a known risk factor for non-communicable diseases that causes substantial premature death globally. Rapid urban growth, burning of biomass and solid waste, unpaved sections of the road network, rising numbers of vehicles, some with highly polluting engines, contribute to the poor air quality in Kampala. OBJECTIVE: To provide evidence-based estimates of air pollution attributable mortality in Kampala city, with focus on ambient fine particulate matter (PM2.5). METHODS: We utilized a time series design and prospectively collected data on daily ambient PM2.5 concentration levels in micrograms per cubic meter (µg/m3) using a Beta Attenuation Monitor (BAM-1022) in Kampala city, Uganda. We combined the PM2.5 data with all-cause mortality data obtained from the Uganda Bureau of Statistics and the Ministry of Health in Kampala. We calculated attributable risk estimates for mortality using the WHO AirQ+ tools. RESULTS: Overall, the annual average concentration for PM2.5 for the period of 4 years, 2018-2021, was 39 µg/m3. There was seasonal variation, with the rainy season months (March-June and October-December) having lower values. PM2.5 concentrations tend to be highest in the morning (09.00 h) and in the evening (21.00 h.) likely due to increased vehicular emissions as well as the influence of weather patterns (atmospheric temperature, relative humidity and wind). Saturday has the most pollution (daily average over 4 years of 41.2 µg/m3). Regarding attributable risk, we found that of all the deaths in Kampala, 2777 (19.3%), 2136 (17.9%), 1281 (17.9%) and 1063 (19.8%) were attributable to long-term exposure to air pollution (i.e., exposure to PM2.5 concentrations above the WHO annual guideline of 5 µg/m3) from 2018 to 2021, respectively. For the 4 years and considering the WHO annual guideline as the reference, there were 7257 air pollution-related deaths in Kampala city. IMPACT: Our study is the first to estimate air pollution attributable deaths in Kampala city considering the target as the WHO annual guideline value for PM2.5 of 5 µg/m3. Our monitoring data show that fine particulate matter air pollution in Kampala is above the WHO Air Quality Guideline value, likely resulting in substantial adverse health effects and premature death. While further monitoring is necessary, there is a clear need for control measures to improve air quality in Kampala city.

Factors influencing consistent use of bed nets for the control of malaria among children under 5 years in Soroti District, North Eastern Uganda.

BACKGROUND: The use of insecticide-treated bed nets has been proven to be effective in reducing malaria transmission in highly endemic areas. Use of long-lasting insecticidal nets (LLINs) has been embraced by many malaria endemic countries. LLINs are up to 95% effective in inhibiting blood feeding, when used consistently even after 7 years. The challenge, however, is enhancing their consistent use, especially by the most vulnerable groups (children under 5 years and pregnant women). The study established factors associated with consistent use of bed nets for malaria control among children under 5 years in Soroti district. METHODS: The study employed a cross-sectional design, with multi-stage sampling of households. A total of 400 households (HH) were sampled and the HH head in each household interviewed. Key informant interviews (KIIs) were conducted with 7 key informants who were knowledgeable on the subject matter. Data analysis was done using SPSS 17.0 at Univariate, Bivariate and Multivariable levels; after entry and cleaning. Key informants' data were summarized manually; verbatim quotes and text used to reinforce quantitative data in line with objectives. RESULTS: Only 56.8% of the 690 children under 5 years used bed nets consistently. The factors affecting consistent bed net use were age of the child, their use of bed nets the previous night, occupation of caretaker, respondents' perceived susceptibility, perceived risk of getting malaria, size and shape of the bed nets. Rectangular nets were difficult to hang daily in huts according to most key informants. CONCLUSION: Consistent bed net use among under fives is still below the RBM target of 85% by 2015 and can be enhanced by providing conical bed nets and setting aside a health education programme to emphasize the effectiveness of even one mosquito in spreading malaria at night to the entire household and ability of bed nets to stop transmission better than other methods.

Ambient air pollution is associated with vascular disease in Ugandan HIV-positive adolescents.

OBJECTIVE: In this study, we aim to investigate the relationship between particulate matter, a common proxy indicator for air pollution, and markers of inflammation, monocyte activation, and subclinical vascular disease. DESIGN: A cross-sectional study. METHODS: Adolescents with perinatally acquired HIV (PHIV) and HIV-uninfected adolescents between 10 and 18years living near Kampala, Uganda were included. Daily ambient concentrations of particulate matter (PM2.5) were measured from the Eastern Arica GEOHealth Hub. Outcome variables measured were carotid intima-media thickness (IMT), as well as plasma markers of systemic inflammation, oxidized lipids, and gut integrity. Multivariable quantile regression models were used to explore the relationship between PM2.5 and IMT. RESULTS: One hundred and nineteen participants (69 PHIV, 50 HIV-uninfected) were included. The median (Q1, Q3) age was 12.7 (11.4,14.2) years, 55% were girls. Median daily PM2.5 exposure was 29.08 µg/m3 (23.40, 41.70). There was no significant difference in exposure of PM2.5 between groups (P  = 0.073). PM2.5 significantly correlated with intestinal permeability (zonulin; r = 0.43, P < 0.001), monocyte activation (soluble CD163: r  = 0.25, P = 0.053), and IMT (r  = 0.35, P = 0.004) in PHIV but not in HIV-uninfected (P ≥ 0.05). In multivariable quantile regression, after adjusting for age, sex, poverty level, soluble CD163, and zonulin, daily PM2.5 concentrations remained associated with IMT [ß  = 0.005, 95% CI (0.0003-0.010), P = 0.037] in adolescents with PHIV. CONCLUSION: Adolescents in urban Uganda are exposed to high levels of air pollution. Both PM2.5 and HIV have independently been observed to contribute to atherosclerotic disease, and our findings suggest the combined effects of HIV and air pollution may amplify the development of cardiovascular disease.

Effect and implementation experience of intensive adherence counseling in a public HIV care center in Uganda: a mixed-methods study.

BACKGROUND: Intensive adherence counseling (IAC) is an intervention recommended by the World Health Organization to improve anti-retroviral therapy (ART) adherence among people living with HIV on ART with unsuppressed viral load; and in 2016, the intervention was implemented in Uganda. This study evaluated the effect and experiences of providing IAC in an urban HIV care center in Kampala, Uganda. METHODS: This was a sequential explanatory mixed-method study that compared viral load suppression during IAC implementation (intervention) to the period before IAC at Kisenyi Health centre IV. Data were abstracted from patient files and viral load register. The effect of IAC on viral load suppression and associated factors were analyzed using modified Poisson regression with robust standard errors. Using in-depth interviews and an inductive analysis approach in Atlas-ti 8. We also explored experiences of providing IAC among healthcare workers. RESULTS: A total of 500 records were sampled: 249 (49.8%) in the intervention period and 251 (51.2%) in the pre-intervention period. The mean age was lower during the intervention period 33.1 (± 12.0) than 36.5 (± 13.4) in the pre- intervention period, p = 0.002. More clients were currently on Protease-based regimen in the pre-intervention period 179 (71.3%) than 135 (54.2%) in the intervention period, p ≤ 0.001. In the intervention period, all eligible clients received IAC [249/249 (100.0%)]. Overall, 325 (65.0%) received IAC and of these, 143 (44.1%) achieved viral load suppression compared to 46 (26.3%) who received regular counseling. Receiving IAC significantly increased viral load suppression by 22% (aPR 1.22, 95% CI 1.01-1.47). Clients on Protease-based regimen were less likely to suppress than those on Efavirenz or Nevirapine-based regimens (aPR 0.11, 95% CI 0.08-0.15). All the interviewed healthcare workers lauded IAC for improving ART adherence. However, patient and health care system related factors hindered adherence during IAC. CONCLUSIONS: The full potential of IAC in achieving viral load suppression in this setting has not been reached due to a combination of the patient and health care system related factors. Provision of adequate IAC necessities and use of patient centered approach should be emphasized to obtain the maximum benefit of the intervention.

A positive attitude among primary healthcare providers predicts better hepatitis B prevention practices: evidence from a cross-sectional survey in Wakiso district, Central Uganda.

Background: Hepatitis B Virus (HBV) infection is an important occupational health risk among primary healthcare providers (PHCPs). However, there is limited evidence on whether PHCPs' level of knowledge and attitude can predict better HBV infection prevention practices. This study established the relationship between knowledge, attitude, and HBV infection prevention practices among PHCPs in Wakiso district, Central Uganda. Methods: A cross-sectional study design was used. Data were collected from 306 PHCPs, using a structured questionnaire. PHCPs were randomly selected from 55 healthcare facilities. STATA version 14.0 was used to analyse data. A 'modified Poisson' regression model was used for inferential statistics. Results: About 42.2% of PHCPs exhibited poor knowledge of HBV infection transmission and prevention, 41.8% had a negative attitude, and 41.5% exhibited poor prevention practices. Age (PR 1.82, 95% CI: 1.24-2.66) was positively associated with the level of knowledge. Healthcare facility level (PR 0.53, 95% CI: 0.34-0.84), main department of work (PR 0.69, 95% CI: 0.51-0.95), years in service (PR 0.66, 95% CI: 0.44-0.99), working in private not-for-profit healthcare facilities (PR 0.59, 95% CI: 0.34-0.99), and public healthcare facilities (PR 0.58, 95% CI: 0.42-0.80) were negatively associated with the level of knowledge. There was a negative association between the location of healthcare facility (PR 0.76, 95% CI: 0.62-0.93) and attitude, and a positive association between level of knowledge (PR 1.36, 95% 1.12-1.65) and attitude. Working in a public healthcare facility (PR 0.80, 95% CI: 0.64-0.99) was negatively associated with practices while having a positive attitude (PR 1.60, 95% CI: 1.28-1.99) predicted better HBV infection prevention practices. Conclusion: PHCPs who were more knowledgeable about HBV infection were more likely to have a positive attitude. In turn, having a positive attitude was associated with better HBV infection prevention practices. There is a need to sensitise PHCPs on HBV infection, and provision of screening and vaccination services in order to address the KAP gaps.

Understanding the diagnostic delays and pathways for diabetes in eastern Uganda: A qualitative study.

BACKGROUND: Type 2 diabetes is rapidly becoming a significant challenge in Uganda and other low and middle-income countries. A large proportion of the population remains undiagnosed. To understand diagnostic delay, we explored the diagnostic pathways for diabetes among patients receiving care at a semi-urban district hospital in eastern Uganda. METHODS: Eligible participants were patients aged 35-70 years receiving care at the diabetes clinic of Iganga district hospital between April and May 2019 and their healthcare providers. Patients were interviewed using an interview guide to collect information on patients' symptoms and their diagnostic experience. A separate interview guide was used to understand the organisation of the diabetes services and the diabetes diagnostic process at the hospital. Using maximum variation purposive sampling, we selected 17 diabetes patients aged 35-68 years, diagnosed within the previous three years, and the three health workers managing the diabetes clinic at Iganga hospital. The data was analysed using ATLAS.ti version 8 to code, organise and track the data segments. We conducted template analysis using a priori themes derived from the intervals of Walter's model of Pathways to Treatment to identify the factors influencing diagnostic delay. RESULTS: We identified four typologies: a short diagnostic pathway, protracted appraisal pathway, protracted appraisal and diagnostic interval pathway, and delayed treatment pathway. The pathways of patients with protracted appraisal or diagnostic intervals demonstrated strong socio-cultural influences. There was a firm reliance on traditional healers both before and after diagnosis which deferred enrolment into care. Other health system barriers implicated in delayed diagnosis included stock-out of diagnostic supplies, misdiagnosis, and missed diagnosis. Denial of diagnosis was also found to lead to delayed initiation of care. CONCLUSION: Reducing diagnostic delay requires addressing both negative socio-cultural influences and the adoption of system-wide interventions to address barriers to timely diagnosis.

Hepatitis B screening and vaccination status of healthcare providers in Wakiso district, Uganda.

BACKGROUND: Screening and vaccination against Hepatitis B virus (HBV) infection remains the most effective intervention in curbing the disease. However, there is limited evidence on the factors associated with the uptake of these services in Uganda. This study determined the uptake of HBV screening and vaccination status, and associated factors among Healthcare Providers (HCPs) in Wakiso district, Uganda. MATERIALS AND METHODS: This cross-sectional study was conducted among 306 HCPs, randomly selected from 55 healthcare facilities. Prevalence ratios (PR) were used to determine the factors associated with HBV screening and vaccination status of HCPs. RESULTS: Of the 306 HCPs, 230 (75.2%) had ever screened for HBV infection while 177 (57.8%) were fully vaccinated. Being male was positively associated with 'ever been screened' for HBV infection (Adjusted PR = 1.27, 95%CI 1.13-1.41). Working in a public healthcare facility (Adjusted PR = 0.78, 95%CI 0.68-0.90) was negatively associated with ever been screened. Male sex (Adjusted PR = 1.21, 95%CI 1.01-1.46), the belief that the HBV vaccine was safe (Adjusted PR = 1.72, 95%CI 1.03-2.89) and ever been screened (Adjusted PR = 2.28, 95%CI 1.56-3.34) were positively associated with being fully vaccinated. However, working in a public healthcare facility (Adjusted PR = 0.79, 95%CI 0.64-0.98), self-perceived risk of HBV infection (Adjusted PR = 0.72, 95% CI:0.62-0.84), and working in a healthcare facility with infection control guidelines (Adjusted PR = 0.79, 95%CI 0.66-0.95) were negatively associated with being fully vaccinated. CONCLUSION: Three quarters of HCPs had ever been screened for HBV while slightly more than half were fully vaccinated. HBV screening and vaccination interventions need to consider the HCP sex, risk perception, attitude towards safety and efficacy of the hepatitis B vaccine, and healthcare facility characteristics such as ownership and availability of infection control guidelines, in order to be successful.

Environmental health research challenges in Africa: Insights from symposia organized by the ISEE Africa Chapter at ISES-ISEE 2018.

Supplemental Digital Content is available in the text.

Ebola a reality of modern Public Health; need for Surveillance, Preparedness and Response Training for Health Workers and other multidisciplinary teams: a case for Uganda.

INTRODUCTION: West Africa is experiencing the largest ever reported Ebola outbreak. Over 20,000 people have been infected of which about 9000 have died. It is possible that lack of community understanding of the epidemic and lack of institutional memory and inexperienced health workers could have led to the rapid spread of the disease. In this paper, we share Uganda's experiences on how the capacity of health workers and other multidisciplinary teams can be improved in preparing and responding to Ebola outbreaks. METHODS: Makerere University School of Public Health in collaboration with the Ministry of Health and the African Field Epidemiology Network (AFENET), trained health care workers and other multidisciplinary teams from six border districts of Uganda so as to increase their alertness and response capabilities towards Ebola. We used participatory training methods to impart knowledge and skills and guided participants to develop district epidemic response plans. Communities were sensitized about Ebola through mass media, IEC materials, and infection control and prevention materials were distributed in districts. RESULTS: We trained 210 health workers and 120 other multidisciplinary team members on Ebola surveillance, preparedness and response. Evaluation results demonstrated a gain in knowledge and skills. Communities were sensitized about Ebola and Districts received person protective equipments and items for infection prevention. Epidemic Preparedness and Response plans were also developed. CONCLUSION: Training of multidisciplinary teams improves the country's preparedness, alertness and response capabilities in controlling Ebola. West African countries experiencing Ebola outbreaks could draw lessons from the Uganda experience to contain the outbreak.

Knowledge and practices on malaria prevention in two rural communities in Wakiso District, Uganda.

BACKGROUND: Malaria is the leading cause of morbidity and mortality in Uganda particularly among children under 5 years of age. OBJECTIVES: The study assessed the knowledge and practices on malaria prevention in 2 rural communities in Wakiso District, Uganda with emphasis on the various prevention methods. METHODS: The study was a cross-sectional survey carried out among 376 households using both quantitative and qualitative methods. Log-binomial regression, chi square and Spearman's rank order correlation were used to test for associations. RESULTS: The majority of participants (64.6%) had low knowledge on malaria prevention methods, with untreated mosquito nets (81.7%), mosquito coils (36.9%) and insecticide treated nets (29.6%) being the most known methods. Knowledge on malaria prevention methods was associated with age (χ2 = 32.1; p < 0.01), employment status (χ2 = 18.1; p < 0.01), education (χ2 = 20.3; p = 0.01), income (χ2 = 14.5; p = 0.01) and having heard a malaria message in the previous 12 months (χ2 = 92.3; p < 0.01). Households that had at least one mosquito net were 45.5% and net ownership increased with household income. Only 0.5% of the houses had undergone indoor residual spraying in the previous 12 months, while 2.1% had complete mosquito proofing in windows and ventilators to prevent mosquito entry. CONCLUSION: There is potential to improve practices on malaria prevention by targeting other methods beyond mosquito nets such as installing proofing in windows and ventilators. The integrated approach to malaria prevention which advocates the use of several malaria prevention methods in a holistic manner should be explored for this purpose.

'Change means sacrificing a good life': perceptions about severity of type 2 diabetes and preventive lifestyles among people afflicted or at high risk of type 2 diabetes in Iganga Uganda.

BACKGROUND: Interventions for prevention of type 2 diabetes ought to be acceptable to target communities. We assessed perceptions about type 2 diabetes and lifestyle change among people afflicted or at high risk of this disease in a low income setting in Iganga Uganda. METHODS: Twelve focus group discussions (FGDs) of eight participants each were conducted, balancing rural and peri-urban (near the Municipality) residence and gender. The FGDs involved people with suspected type 2 diabetes (based on fasting plasma glucose (FPG), people with suspected pre-diabetes and obese people with normal FPG. Content analysis was conducted. RESULTS: Diabetes was perceived to be a very severe disease. Its severity was attributed to its incurability and its numerous health effects. Men were also concerned about reduced sexual performance. However, participants' strong concerns about the severity of diabetes were not reflected in their perceptions about the risk factors and lifestyles associated with it. While people with diabetes perceive obesity as 'sickness', those without diabetes perceive it as a sign of 'success'. Although participants are willing to change their diet, they mention numerous barriers including poverty, family size, and access to some foods. Because of their good taste, reduction of high risk foods like sugar and fried food is perceived as 'sacrificing a good life'. Increments in physical activity were said to be feasible, but only in familiar forms like domestic work. An over-arching theme emerged that 'lifestyle changes are viewed as sacrificing a good life'. CONCLUSIONS: Health promotion should target both community norms and individual awareness regarding obesity, physical activity and diet, and should address the notion that obesity and unhealthy foods represent a good life. Health educators should plan with clients on how to overcome barriers and misconceptions to lifestyle change, leveraging the pervasive perception of type 2 diabetes as a severe disease to motivate change.