Proposed guidelines for the management of nodding syndrome.

Nodding Syndrome is a poorly understood neurologic disorder of unknown aetiology that affects children and adolescents in Africa. Recent studies have suggested that the head nods are due to atonic seizures and Nodding Syndrome may be classified as probably symptomatic generalised epilepsy. As part of the Ugandan Ministry of Health clinical management response, a multidisciplinary team developed a manual to guide the training of health workers with knowledge and skills to manage the patients. In the absence of a known cause, it was decided to offer symptomatic care. The objective is to relieve symptoms, offer primary and secondary prevention for disability and rehabilitation to improve function. Initial management focuses on the most urgent needs of the patient and the immediate family until 'stability' is achieved. The most important needs were considered as seizure control, management of behavioural and psychiatric difficulties, nursing care, nutritional and subsequently, physical and cognitive rehabilitation. This paper summarises the processes by which the proposed guidelines were developed and provides an outline of the specific treatments currently being provided for the patients.

Barriers to contraception among HIV-positive women in a periurban district of Uganda.

This study explored perceptions and care-seeking practices for HIV testing and contraception in order to obtain data for designing effective interventions to increase contraception among HIV-positive women. A triangulation of methods (household survey, focus group discussions and key informant interviews) were conducted in Wakiso district, central Uganda from January to April 2009. Results show that a majority of women, 2062/2896 (71.2%) would like to have an HIV test, while access to antiretroviral therapy (ART) was low at 237/879 (27%). Of the women who were on ART, 133/266 (50.0%) could not use contraception due to negative perceptions that a combination of ART and contraceptives would weaken them, as these drugs were perceived to be 'strong'. Fear of side-effects for contraceptives and resistance from spouses were other main reasons. Constraints to HIV testing included fear of clients knowing their own HIV status and fear of their spouses' reactions to the test results. Private midwives were identified as a potential outlet for delivering contraception to HIV-positive women.

Barriers to prevention of mother-to-child transmission of HIV services in Uganda.

Understanding care-seeking practices and barriers to prevention of mother-to-child transmission (PMTCT) of HIV is necessary in designing effective programmes to address the high disease burden due to HIV/AIDS in Uganda. This study explored perceptions, care-seeking practices and barriers to PMTCT among young and HIV-positive women. A household survey (10,706 women aged 14-49 years), twelve focus group discussions and 66 key informant interviews were carried out between January and April 2009 in Wakiso district, central Uganda. Results show that access to PMTCT services (family planning, HIV counselling and testing and delivery at health units) was poor. Decision making was an important factor in accessing PMTCT services. Socioeconomic factors (wealth quintile, age, education level) and institutional practices also influenced access to PMTCT. Overall, having had an HIV test was highest when both men and women made decisions together or when women were empowered to make their own decisions. This was significant across wealth quintiles (p=0.0001), age groups (p=0.0001) and education levels (p=0.0001). The least level of HIV testing was when men made decisions for their spouses; and this was the case with family planning and deliveries at health units. Other barriers to PMTCT were fear of women and male spouses to have an HIV test and the perception that HIV testing is compulsory in antenatal clinics. In conclusion, to increase access to PMTCT among women, especially the young, poor and least educated, there is a need to empower them to make decisions on health seeking, and also to empower men to support their spouses to make good decisions. Other barriers like fear of having an HIV test should be addressed through appropriate counselling of clients.

Integration of malaria and HIV/AIDS prevention services through the private sector in Uganda.

This study explored whether private midwives can provide prevention of mother-to-child transmission of human immune deficiency virus (HIV) integrated with malaria prevention services in pregnancy, and assess how this affects access and equity to services. A household survey supplemented by key informant interviews was conducted in Wakiso district, central Uganda from January to April 2009. Results show that private midwives are already providing essential maternity services to women (antenatal care, 22.0% and delivery care, 19.5%); and they are trusted by their communities. Despite this, access to HIV and malaria preventive services was low among women in the lowest wealth quintile, the young and the less educated. Although private midwives understood the concept of integration, their clinics were offering limited integrated services, at 30%. The constraints experienced were inadequate skills, high costs of drugs and supplies limiting the capacity to have enough stocks, lack of support supervision, low community awareness on the importance of seeking antenatal and delivery care from trained providers and inadequate support of women by their spouses. In order to improve integration, it was recommended that private midwives be given refresher courses; improve their capacity to stock essential drugs and supplies; and receive supervision and support from the district health authorities.

Increasing access to prevention of mother-to-child transmission of HIV services through the private sector in Uganda.

OBJECTIVES: To explore whether private midwives can perform HIV counselling and testing, provide antiretroviral treatment and contraceptives, and how this affects access to services especially among young and HIV-positive women. METHODS: A formative study was conducted between January and April 2009 to assess care-seeking practices and perceptions on the prevention of mother-to-child transmission (PMTCT) and family planning services in Wakiso district, central Uganda. A household survey supplemented by 12 focus group discussions and 66 key informant interviews was carried out between January and April 2009. RESULTS: 10,706 women, mean age 25.8 years (14-49 years) were interviewed. The majority of women, 4786 (57%) were in the lowest wealth quintile; 62.0% were not using family planning (p<0.000); 56.2% did not access HIV counselling and testing because they feared knowing their HIV status (p<0.013), while 66.5% feared spouses knowing their HIV status (p<0.013). Access to these services among the young women and those with no education was also poor. Private midwives provide HIV testing to 7.8% of their clients; 5.9% received antiretroviral drugs and 8.6% received contraceptives. Client satisfaction with services at private midwifery practices was high. Private midwives are trusted and many clients confide in them. An intervention through private midwives was perceived to improve access because of short distances and no transport costs. Adolescents prioritized confidentiality, while subsidizing costs, community sensitisation and focusing on male spouses were overwhelmingly recommended. CONCLUSIONS: Private midwives clinics are potential delivery outlets for PMTCT in Uganda. A well-designed intervention linking them to the public sector and the community could increase access to services.

Intermittent preventive treatment of malaria in pregnancy: the incremental cost-effectiveness of a new delivery system in Uganda.

The main objective of this study was to assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilisers could administer intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) to pregnant women. The study was implemented in 21 community clusters (intervention) and four clusters where health centres provided routine IPTp (control). The primary outcome measures were the proportion of women who completed two doses of SP; the effect on anaemia, parasitaemia and low birth weight; and the incremental cost-effectiveness of the intervention. The study enrolled 2785 pregnant women. The majority, 1404/2081 (67.5%) receiving community-based care, received SP early and adhered to the two recommended doses compared with 281/704 (39.9%) at health centres (P<0.001). In addition, women receiving community-based care had fewer episodes of anaemia or severe anaemia and fewer low birth weight babies. The cost per woman receiving the full course of IPTp was, however, higher when delivered via community care at US$2.60 compared with US$2.30 at health centres, due to the additional training costs. The incremental cost-effectiveness ratio of the community delivery system was Uganda shillings 1869 (US$1.10) per lost disability-adjusted life-year (DALY) averted. In conclusion, community-based delivery increased access and adherence to IPTp and was cost-effective.

Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda.

BACKGROUND: The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention. OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer IPTp with sulphadoxine-pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp. STUDY DESIGN: An intervention study compared the delivery of IPTp in the community with routine delivery of IPTp at health units. The primary outcome measures were the proportion of adolescents and primigravidae accessed, and the proportion of women who received two doses of SP. The study also assessed the effect of the intervention on access to malaria treatment, antenatal care, other services and related costs. RESULTS: More women (67.5%) received two doses of SP through the community approach compared with health units (39.9%; P<0.0001). Women who accessed IPTp in the community were at an earlier stage of pregnancy (21.0 weeks of gestation) than women who accessed IPTp at health units (23.1 weeks of gestation; P<0.0001). However, health units were visited by a higher proportion of primigravidae (23.6% vs 20.0%; P<0.04) and adolescents (28.4% vs 25.0%; P<0.03). Generally, women who accessed IPTp at health units made more visits for malaria treatment (2.6 (1.0-4.7) vs 1.8 (1.4-2.2); P<0.03). At recruitment, more women who accessed IPTp at health units sought malaria treatment compared with those who accessed IPTp in the community (56.9% vs 49.2%). However, at delivery, a high proportion of women who accessed IPTp in the community had sought malaria treatment (70.3%), suggesting the possibility that the novel approach had a positive impact on care seeking for malaria. Similarly, utilization of antenatal care, insecticide-treated nets and delivery care by women in the community was high. The total costs per woman receiving two doses of SP for IPTp were 4093 Uganda shillings (US$ 2.3) for women who accessed IPTp at health units, and 4491 Uganda shillings (US$ 2.6) for women who accessed IPTp in the community. CONCLUSION: The community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor in mitigating the burden of malaria in Uganda.

Intermittent preventive treatment of malaria in pregnancy: a new delivery system and its effect on maternal health and pregnancy outcomes in Uganda.

OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive-health workers, or adolescent peer mobilizers could administer intermittent preventive treatment (IPTp) for malaria with sulfadoxine-pyrimethamine to pregnant women. METHODS: A non-randomized community trial was implemented in 21 community clusters (intervention) and four clusters where health units provided routine IPTp (control). The primary outcome measures were access and adherence to IPTp, number of malaria episodes, prevalence of anaemia, and birth weight. Numbers of live births, abortions, still births, and maternal and child deaths were secondary endpoints. FINDINGS: 1404 (67.5%) of 2081 with the new delivery system received two doses of sulfadoxine-pyrimethamine versus 281 (39.9%) of 704 with health units (P < 0.0001). The prevalence of malaria episodes decreased from 906 (49.5%) of 1830 to 160 (17.6%) of 909 (P < 0.001) with the new delivery system and from 161 (39.1%) of 412 to 13 (13.1%) of 99 (P < 0.001) with health units. Anaemia was significantly less prevalent in both arms. There was a lower proportion of low birth weight 6.0% with the new delivery system versus 8.3% with health units (P < 0.03). Few abortions and stillbirths were recorded in either arm. Fewer children and women who accessed IPTp with health units died than in the intervention group. CONCLUSION: The new approaches were associated with early access and increased adherence to IPTp. Health units were, however, more effective in reducing parasitaemia and malaria episodes. We recommend further studies to assess programming modalities linking the new approaches and health units.

Prevention and treatment practices and implications for malaria control in Mukono District Uganda.

Available data in Uganda indicate a resurgence of malaria morbidity and mortality countrywide. This study assessed the burden of malaria, treatment and prevention practices in order initiate a policy debate on the scaling-up of current interventions. A triangulation of methods using a cross-sectional survey and key informant interviews was used to assess self-reported malaria at a household level in Mukono District, Uganda. A total of 5583 households were surveyed, and a high proportion (2897, 51.9%) reported a person with malaria two weeks prior to the survey. Only 546 households (9.8%) owned and used insecticide-treated nets (ITNs) for malaria prevention. Similarly, only a few households (86, 1.5%) used indoor residual spraying. Self-treatment with home-stocked drugs was high, yet there was low awareness of the effectiveness of expired drugs on malaria treatment. Self-reported malaria was associated with socioeconomic, behavioural and environmental factors, but more especially with household ownership of ITNs. These results will contribute to the current debate on identifying new approaches for scaling-up prevention interventions and effective case management, as well as selection of priority interventions for malaria control in Uganda.

Declining maternal mortality ratio in Uganda: priority interventions to achieve the Millennium Development Goal.

PURPOSE: We conducted a survey to determine availability of emergency obstetric care (EmOC) and to provide data for advocating for improved maternal and newborn health in Uganda. METHODS: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions, documented maternal deaths and the related causes. Three levels of health facilities were covered. FINDINGS: Few health units had running water; electricity or a functional operating theater. Yet having these items had a protective effect on maternal deaths as follows: theater (OR 0.56, P<0.0001); electricity (OR 0.39, P<0.0001); laboratory (OR 0.71, P<0.0001) and staffing levels (midwives) OR 0.20, P<0.0001. The availability of midwives had the highest protective effect on maternal deaths, reducing the case fatality rate by 80%. Further, most (97.2%) health facilities expected to offer basic EmOC, were not doing so. This is the likely explanation for the high health facility-based maternal death rate of 671/100,000 live births in Uganda. CONCLUSION: Addressing health system issues, especially human resources, and increasingaccess to EmOC could reduce maternal mortality in Uganda and enable the country to achieve the Millennium Development Goal (MDG).

Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda.

PURPOSE: We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda. METHODS: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services. FINDINGS: A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P<0.002), assisted vaginal delivery (OR 3.3, P<0.001) and blood transfusion (OR 13.7, P<0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly. CONCLUSION: An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda.

A sector-wide approach to emergency obstetric care in Uganda.

PURPOSE: To establish a baseline for the availability, utilization, and quality of EmOC, and to help develop an operational strategy based on the findings. METHODS: A needs assessment of emergency obstetric care (EmOC) was carried out in 197 health facilities in 19 out of 56 districts in Uganda, covering 38% of the total population. FINDINGS: There were a large number of missing signal functions at health facilities and an urgent need to improve the availability of EmOC. CONCLUSION: By using the data from the assessment, it was possible to influence national policy through the health sector-wide approach (SWAp) and place EmOC high on the national agenda. A national strategy and roll out plan to strengthen EmOC is now in place.

Risk factors associated with maternal deaths in health units in Uganda.

This study was conducted to assess the magnitude of maternal deaths in health units in Uganda, and the risk factors associated with such deaths. A retrospective study of maternal deaths in 20 hospitals and 54 randomly selected health centres was conducted in 12 randomly selected districts of Uganda. The reference period for documenting maternal deaths was September 1992 to September 1993. The International Classification of Diseases 10 was used to define a maternal death. Data on maternal deaths and associated risk factors was obtained from admission and patient case notes. SPSS/PC statistical package was used to carry out advanced statistical analysis. Log linear analysis was used to rank risk factors for maternal deaths. A total of 418 maternal deaths and 75,000 live births were recorded, giving a maternal mortality ratio of 557 per 100,000 live births. Three hundred and sixty (86.1%) mothers died within one hour of admission. The risk factors identified were inadequate antibiotic supply, intravenous drug fluids and blood for transfusion in health units; non-use of family planning, use of traditional medicine; mothers aged 15-19 and 30-50 years. Others included those who had a history of two or more abortions and stillbirths; parity of five and above; and living within a distance of more than 10 km to the nearest health unit. We conclude that the focus on risk factors for maternal deaths have policy implications.

An acceptability study of female-controlled methods of protection against HIV and STDs in south-western Uganda.

We aimed to assess the acceptability of a variety of formulations of female-controlled methods of protection against HIV and STDs among men and women in south-western Uganda. Pilot interviews were carried out with 50 men and 55 women and 25 focus group discussions (FGDs) were held with 138 women and 42 men. The female condom, foaming tablets, sponge, foam, gel and film were demonstrated to 146 women and 35 of their male partners, who then tried out 2 of the products. They were interviewed 7 times during the course of 5 months. At the end experiences were evaluated during a second series of FGDs. Sixty-five (45%) women completed the trial. The main reasons for non-completion were related to geographical mobility. Product preference after the initial demonstration was similar to that at the end of the trial. The most popular formulations were the sponge (25% of the women), foaming tablets (23%), and the female condom (19%). The foam was of medium popularity (16%). The gel (9%) and film (7%) were least popular. Ten per cent of the women and 14% of the men reported products interfering with sexual enjoyment; 24% of the women and 67% of the men said products increased enjoyment. 'Dry sex' is not popular in this area and increased lubrication was an important determinant of acceptability. Age, level of education and location did have some effect on preference. Although secrecy was a dominant theme in the FGDs, 87% of the women had informed their partners by the end of the trial. The products were generally well received. Female control was an important issue for both sexes. Male attitudes were ambivalent because female ownership of products increased women's control. Although they have clear preferences, women appear to accept the products generally and might use a single available product just as readily if choice was limited, as long as it conforms to general cultural preferences, such as those relating to wet/dry sex.