Factors associated with retention of health workers in remote public health centers in Northern Uganda: a cross-sectional study.

BACKGROUND: Health worker retention in remote and hard-to-reach areas remains a threat in most low- and middle-income countries, and this negatively impacts health service delivery. The health workforce inequity is catastrophic for countries like Uganda that still has a low health worker to patient ratio, and remote areas like Lira District that is still recovering from a long-term civil war. This study explores factors associated with retention of health workers in remote public health centers in Lira district in Northern Uganda. METHODS: A descriptive cross-sectional study with quantitative methods of data collection was used among health workers namely; doctors, clinical officers, nurses, midwives, pharmacists and, laboratory technicians. The study utilized a structured questionnaire with closed ended questions to obtain quantitative information. RESULTS: Most of the respondents were females (62.90%), married (84.62%), with certificate level (55.74%), and nurses as qualification (36.60%) as well as attached to Health Center 3 level (61.28%). Significant individual factors associated with retention included having a certificate as highest level of education, staying with family, and working at facility for 6 or more years. The health system factors were good physical state of facility, equipment availability, availability of sundries, feeling comfortable with rotations, receiving adequate support from staff, feeling valued and respected by colleagues at workplace and access to incentives while career factors were job satisfaction, job motivation, promotion, and further training on scholarship. CONCLUSION: The study established that indeed several individual and social demographics, health system and career-related factors are significantly associated with retention of Health workers in the rural public health facilities and these are critical policy recommendations for establishing retention guidelines in a national human resources for health manual.

Missed opportunity: low uptake of VMMC among men attending the OPD of a public health facility offering free VMMC services in Uganda.

BACKGROUND: Studies in various countries including Uganda and Kenya have shown a much lower incidence of the human immunodeficiency virus (HIV) among men that underwent voluntary medical male circumcision (VMMC) compared to uncircumcised men. Wakiso district, the district with the highest prevalence of HIV in Uganda (7%), has a very low estimated proportion of men who have undergone VMMC (30.5%). Within the district, various public health facilities provide free VMMC services. This study examined the prevalence and factors associated with the uptake of VMMC among men attending the outpatient department (OPD) of a public facility offering VMMC services. METHODS: We conducted a cross-sectional study between July to August 2021 using a sample of men attending the OPD at Kira Health Centre IV. We defined VMMC uptake as the removal of all or part of the foreskin of the penis by a trained healthcare professional. We determined factors independently associated with VMMC uptake using a modified Poisson regression analysis with robust standard errors at a 5% statistical significance level. Adjusted prevalence risk ratios (APRR) were reported as the measure of outcome. RESULTS: Overall, 389 participants were enrolled in the study. The mean age of the participants was 27.2 (standard deviation ± 9.02) years. The prevalence of VMMC uptake was 31.4% (95% Confidence Interval [CI] 26.8-36.2). In the adjusted analysis, the uptake of VMMC among men attending the OPD of Kira HC IV was less likely among married participants compared to unmarried participants (APRR 0.64, 95% CI 0.48-0.88), among participants from Western tribes (APRR 0.50, 95% CI 0.41-0.86) or Eastern tribes (APPR 0.31, 95% CI 0.13-0.72) compared to participants from the Central tribes and among participants who didn't disclose their sexual partner number compared to those that had one or no sexual partner (APRR 0.62, 95% CI 0.40-0.97). On the other hand, the prevalence of uptake of VMMC was 7 times among participants who were aware of VMMC compared to those who were not aware of VMMC (APRR 7.85 95% CI 1.07-9.80) and 2.7 times among participants who knew their HIV status compared to those that didn't know (APRR 2.75, 95% CI 1.85-4.0). Also, the uptake of VMMC was 85% more among participants who knew that Kira HC IV provided free VMMC services compared to those that didn't (APRR 1.85, 95% CI 1.85-4.08). CONCLUSION: VMMC among men attending the OPD at the largest public healthcare facility proving free VMMC services in Kira Municipality was low. The OPD may provide a quick win for improving VMMC uptake. Collaborative efforts among the administration of Kira HC IV, the Ministry of Health and VMMC implementation partners could work towards developing health-facility-based strategies that can improve VMMC awareness and uptake with emphasis on the OPD.

Feasibility and acceptability of integrating hepatitis B care into routine HIV services: a qualitative study among health care providers and patients in West Nile region, Uganda.

BACKGROUND: Despite facing a dual burden of HBV and HIV, Africa lacks experience in offering integrated care for HIV and HBV. To contextualize individual and group-level feasibility and acceptability of an integrated HIV/HBV care model, we explored perspectives of health care providers and care recipients on feasibility and acceptability of integration. METHODS: In two regional hospitals of West Nile region, we performed a demonstration project to assess feasibility and acceptability of merging the care of HBV-monoinfected patients with existing HIV care system. Using interviews with health care providers as key informants, and 6 focus groups discussions with 3 groups of patients, we explored feasibility [(i)whether integration is perceived to fit within the existing healthcare infrastructure, (ii) perceived ease of implementation of HIV/HBV integrated care, and (iii) perceived sustainability of integration] and acceptability [whether the HIV/HBV care model is perceived as (i) suitable, (ii) satisfying and attractive (iii) there is perceived demand, need and intention to recommend its use]. We audio-recorded the interviews and data was analysed using framework analysis. RESULTS: The following themes emerged from the data (i) integrating HBV into HIV care is perceived to be feasible, fit and beneficial, after making requisite adjustments (ii) integration is acceptable due to the need for both free treatment and anticipated collaboration between HIV and HBV clients in terms of peer-support (iii) there are concerns about the likely rise in stigma and the lack of community awareness about integrated care. CONCLUSION: The integrated HIV/HBV care model is feasible and acceptable among both providers and recipients. Necessary adjustments to the existing care system, including training, for community sensitization on the reasons and significance of integration are required.

A training for health care workers to integrate hepatitis B care and treatment into routine HIV care in a high HBV burden, poorly resourced region of Uganda: the '2for1' project.

INTRODUCTION: The "2for1" project is a demonstration project to examine the feasibility and effectiveness of HBV care integrated into an HIV clinic and service. An initial phase in implementation of this project was the development of a specific training program. Our objective was to describe key features of this integrated training curriculum and evaluation of its impact in the initial cohort of health care workers (HCWs). METHODS: A training curriculum was designed by experts through literature review and expert opinion. Key distinctive features of this training program (compared to standard HBV training provided in the Government program) were; (i) Comparison of commonalities between HIV and HBV (ii) Available clinic- and community-level infrastructure, and the need to strengthen HBV care through integration (iii) Planning and coordination of sustained service integration. The training was aided by a power-point guided presentation, question and answer session and discussion, facilitated by physicians and hepatologists with expertise in viral hepatitis. Assessment approach used a self-administered questionnaire among a cohort of HCWs from 2 health facilities to answer questions on demographic information, knowledge and attitudes related to HBV and its prevention, before and after the training. Knowledge scores were generated and compared using paired t- tests. RESULTS: A training curriculum was developed and delivered to a cohort of 44 HCWs including medical and nursing staff from the two project sites. Of the 44 participants, 20 (45.5%) were male, average age (SD) was 34.3 (8.3) with an age range of 22-58 years. More than half (24, 54.5%) had been in service for fewer than 5 years. Mean correct knowledge scores increased across three knowledge domains (HBV epidemiology and transmission, natural history and treatment) post-intervention. However, knowledge related to diagnosis and prevention of HBV did not change. CONCLUSION: A structured HBV education intervention conducted as part of an HIV/HBV care integration training for health care workers yielded improved knowledge on HBV and identified aspects that require further training. This approach may be replicated in other settings, as a public health strategy to heighten HBV elimination efforts.

Antiviral use among hepatitis B infected patients in a low resource setting in Africa: a case study of West Nile, Uganda.

Failure to access antiviral medications is a leading cause of hepatitis B (HBV)-associated morbidity and mortality in sub-Saharan Africa (SSA). Despite guideline availability, SSA is not on course to meet its elimination targets. We characterized factors associated with antiviral medication use and challenges to offering chronic care in a large Ugandan institution. We abstracted HBV care data. 2,175/2,209 (98.5%) had HBV-infection. Most participants were men [1,197 (55%)]; median (IQR) age 27 years (19-35); 388/1689 (23.0%) had cirrhosis by sonography and 141/2175 (6.5%) by the aspartate aminotransferase to platelet ratio index (APRI) score ≥2. Of the eligible, 20/141 (14.2%) with APRI score ≥2 and 24/388 (6.2%) with sonographic evidence of liver cirrhosis were not on antiviral medications. Overall, 1,106 (51%) were on medications though 65.8% had not been fully investigated. In multivariate analysis, age ≥35 years [OR (95% CI) = 1.52 (1.01-2.28), p=0.043], APRI ≥2 [OR (95% CI) =1.79 (1.482.16), p<0.001], hepatitis B viral load >2,000IU/mL [OR (95% CI) = 6.22 (5.08-7.62), p<0.001] were associated with antiviral medications use. Over half of participants in care had not been fully evaluated although on treatment and many eligible patients did not access medications. There is need to bridge these gaps for SSA to realise its HBV elimination goals.

Optimal complementary feeding practices among caregivers and their children aged 6-23 months in Kisoro district, Uganda.

BACKGROUND: There are many risk factors for stunting, and studies most often corroborate complementary feeding practices as a significant risk factor. Information on the prevalence of optimal complementary feeding practices and factors that lend to caregivers meeting their requirements in Kisoro district, a district with high stunting rates, is mostly lacking. METHODOLOGY: An analytical cross-sectional study that used secondary data from a USAID-funded project. Entries for 384 caregivers of children aged 6-23 months in Kisoro district were abstracted from the project database. The data was analysed using SPSS version 20. The association between independent factors and optimal complementary feeding practices was determined using multivariable logistic regressions at the three levels of the Socio-Ecological Model. FINDINGS: Although 95% of the infants were introduced to semi-solid foods promptly, their diet was nutritionally inadequate as evidenced by the low minimum dietary diversity of 4.43%. Some of the key covariates associated with these outcomes included, the type of occupation (AOR = 21.21; CI = 2.03-221.26; p = 0.011), community groups (AOR = 0. 43; CI = 0.22-0.83; p = 0.012), not being married (AOR = 13.25; CI = 1.76-100.25; p = 0.012), age of the child (AOR = 2.21; CI = 1.1-4.45; p = 0.026); among others. CONCLUSION: The prevalence of MAD and MDD was very low in Kisoro district, even compared to national figures, putting these children at a very high risk of stunting. Increased advocacy is needed to support the community-level implementation of the IYCF guidelines.

Cost-effectiveness of GeneXpert Omni compared with GeneXpert MTB/Rif for point-of-care diagnosis of tuberculosis in a low-resource, high-burden setting in Eastern Uganda: a cost-effectiveness analysis based on decision analytical modelling.

OBJECTIVE: To determine the cost-effectiveness of Xpert Omni compared with Xpert MTB/Rif for point-of-care diagnosis of tuberculosis among presumptive cases in a low-resource, high burden facility. DESIGN: Cost-effectiveness analysis from the provider's perspective. SETTING: A low-resource, high tuberculosis burden district in Eastern Uganda. PARTICIPANTS: A provider's perspective was used, and thus, data were collected from experts in the field of tuberculosis diagnosis purposively selected at the local, subnational and national levels. METHODS: A decision analysis model was contracted from TreeAge comparing Xpert MTB/Rif and Xpert Omni. Cost estimation was done using the ingredients' approach. One-way deterministic sensitivity analyses were performed to identify the most influential model parameters. OUTCOME MEASURE: The outcome measure was incremental cost per additional test diagnosed expressed as the incremental cost-effectiveness ratio. RESULTS: The total cost per test for Xpert MTB/Rif was US$14.933. Cartridge and reagent kits contributed to 67% of Xpert MTB/Rif costs. Sample transport costs increased the cost per test of Xpert MTB/Rif by $1.28. The total cost per test for Xpert Omni was $16.153. Cartridge and reagent kits contributed to over 71.2% of Xpert Omni's cost per test. The incremental cost-effectiveness ratio for using Xpert Omni as a replacement for Xpert MTB/Rif was US$30.73 per additional case detected. There was no dominance noted in the cost-effectiveness analysis, meaning no strategy was dominant over the other. CONCLUSION: The use of Xpert Omni at the point-of-care health facility was more effective but with an increased cost compared with Xpert MTB/Rif at the centralised referral testing facility.

Integrating hepatitis B care and treatment with existing HIV services is possible: cost of integrated HIV and hepatitis B treatment in a low-resource setting: a cross-sectional hospital-based cost-minimisation assessment.

BACKGROUND: Hepatitis B and HIV care share health system challenges in the implementation of primary prevention, screening, early linkage to care, monitoring of therapeutic success and long-term medication adherence. SETTING: Arua regional referral hospital (RRH) and Koboko district hospital (DH), the West Nile region of Uganda. DESIGN: A cross-sectional hospital-based cost minimisation study from the providers' perspective considers financial costs to measure the amount of money spent on resources used in the stand-alone and integrated pathways. DATA SOURCES: Clinic inputs and procurement invoices, budgetary documents, open market information and expert opinion. Data were extracted from 3121 files of HIV and hepatitis B virus (HBV) monoinfected patients from the two study sites. OBJECTIVE: To estimate provider costs associated with running an integrated HBV and HIV clinical pathway for patients on lifelong treatment in low-resource setting in Uganda. OUTCOME MEASURES: The annual cost per patient was simulated based on the total amount of resources spent for all the expected number of patient visits to the facility for HBV or HIV care per year. RESULTS: Findings showed that Arua hospital had a higher cost per patient in both clinics than did Koboko Hospital. The cost per HBV patient was US$163.59 in Arua and US$145.76 in Koboko while the cost per HIV patient was US$176.52 in Arua and US$173.23 in Koboko. The integration resulted in a total saving of US$36.73 per patient per year in Arua RRH and US$17.5 in Koboko DH. CONCLUSION: The application of the integrated Pathway in HIV and HBV patient management could improve hospital cost efficiency compared with operating stand-alone clinics.