Prevalence of probable substance use disorders among children in Ugandan health facilities.

BACKGROUND: Globally, there is a concerning surge in the prevalence of substance use among adolescents and children, creating a substantial public health problem. Despite the magnitude of this issue, accessing healthcare explicitly for substance use remains challenging, even though many substance users frequently visit healthcare institutions for other health-related issues. To address this gap, proactive screening for substance use disorders has emerged as a critical strategy for identifying and engaging patients at risk of substance use. The purpose of this study was to investigate the prevalence of probable alcohol and other substance use disorders, and associated factors, among children aged 6 to 17 years old attending health facilities in Mbale, Uganda. METHODS: We conducted a health facility cross-sectional study, involving 854 children aged 6-17 years. The prevalence of probable alcohol and other substance use disorders was assessed using a validated Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) screening tool. Univariable and multivariable modified Poisson regression analyses were performed using STATA 15 software. RESULTS: The overall prevalence of probable alcohol use disorders (AUD) and other substance use disorders (SUD) was 27.8% (95% CI 1.24-1.31) while that of probable AUD alone was 25.3% (95% CI 1.22-1.28). Peer substance use (APR = 1.24, 95% CI 1.10-1.32), sibling substance use (APR = 1.14, 95% CI 1.06-1.23), catholic caregiver religion (APR = 1.07 95% CI 1.01-1.13), caregiver income of more than $128 (APR = 0.90, 95% CI 0.82-0.98), having no parental reprimand for substance use (APR = 1.05, 95% CI 1.01-1.10) and having no knowledge of how to decline an offer to use substances (APR = 1.06, 95% CI 1.01-1.12) were found to be significantly associated with probable AUD/SUD. CONCLUSIONS: Our findings suggest a high prevalence of probable AUD and SUD among children and adolescents visiting healthcare facilities for other conditions, along with a strong link between AUD and SUD prevalence and social factors. The implication for our healthcare system is to actively screen for and treat these conditions at primary healthcare facilities.

Development and validation of an intervention package to improve lifejacket wear for drowning prevention among occupational boaters on Lake Albert, Uganda.

BACKGROUND: Occupational drowning is a growing public health concern globally. The human cost of fishing is highest in sub-Saharan Africa. Although lifejackets prevent drowning, the majority of boaters in Uganda do not wear them. We developed and validated a peer-to-peer training manual to improve lifejacket wear among occupational boaters on Lake Albert, Uganda. METHODS: The intervention was developed in three stages. In stage one, we conducted baseline studies to explore and identify aspects of practices that need to change. In stage two, we held a stakeholder workshop to identify relevant interventions following the intervention functions of the behaviour change wheel (BCW). In stage three, we developed the content and identified its implementation strategies. We validated the intervention package using the Content Validity Index for each item (I-CVI) and scale (S-CVI/Ave). RESULTS: Seven interventions were identified and proposed by stakeholders. Training and sensitisation by peers were unanimously preferred. The lowest I-CVI for the content was 86%, with an S-CVI/Ave of 98%. This indicates that the intervention package was highly relevant to the target community. CONCLUSION: The stakeholder workshop enabled a participatory approach to identify the most appropriate intervention. All the proposed interventions fell under one of the intervention functions of the BCW. The intervention should be evaluated for its effectiveness in improving lifejacket wear among occupational boaters.

Adherence to antiretroviral and cancer chemotherapy, and associated factors among patients with HIV-cancer co-morbidity at the Uganda Cancer Institute: a cross sectional study.

BACKGROUND: Human Immunodeficiency Virus is a major global public health issue affecting millions of people, and sub-Saharan Africa where Uganda lies is disproportionately affected. There has been an increase in cancer among HIV patients which has resulted into use of co-medications that sometimes affect ART and cancer chemotherapy adherence. We aimed to determine adherence to antiretroviral and cancer chemotherapy and the associated factors among patients with HIV-cancer co-morbidity at the Uganda Cancer Institute. METHODS: We conducted a cross-sectional study among 200 randomly selected adult cancer patients infected with HIV and attending the Uganda cancer institute. Antiretroviral and anti-cancer chemotherapy adherence with associated factors were assessed quantitatively. We collected the data using interviewer administered semi-structured questionnaires. Modified Poisson regression with robust standard errors was used to estimate the prevalence ratios (PR) and its 95% confidence intervals (CI) for the factors associated with adherence to Antiretroviral Therapy (ART) and cancer chemotherapy. RESULTS: Overall, 54% of the study participants adhered to both ART and chemotherapy, and 55% adhered to ART while 65% adhered to cancer chemotherapy. The mean age of the respondents was 42 (SD ± 11years), and a majority, 61% were males.More than half, 56.5% were married and at least 45% had attained a primary level of education. Patients with good adherence to antiretroviral therapy and chemotherapy were 54%. No knowledge of cancer stage (PR = 0.4, 95% CI = 0.3-0.6, P < 0.0001), having an AIDS defining cancer (PR = 0.7, 95% CI = 0.5-0.9, P = 0.005), ART clinic in district not near Uganda Cancer Institute (PR = 0.7,95% CI = 0.8-1.0, P = 0.027) and affordability of cancer chemotherapy (PR = 1.4, 95% CI = 1.0-1.9, P = 0.037) were associated with adherence to both ART and cancer chemotherapy. CONCLUSION: Adherence to both ART and cancer chemotherapy was low. Factors significantly associated with adherence were: knowledge of the cancer stage by the patient, the type of cancer diagnosis, source of ART and affordability/ availability of medications. There is a need to provide information on the stage of cancer and adherence counseling to patients. Furthermore, Integration of HIV- cancer care will be necessary for efficient and effective care for the patients.

Lifejacket wear and the associated factors among boaters involved in occupational boating activities on Lake Albert, Uganda: a cross-sectional survey.

BACKGROUND: Drowning death rates in lakeside fishing communities in Uganda are the highest recorded globally. Over 95% of people who drowned from a boating activity in Uganda were not wearing a lifejacket. This study describes the prevalence of lifejacket wear and associated factors among boaters involved in occupational boating activities on Lake Albert, Uganda. METHODS: We conducted a cross-sectional survey, grounded on etic epistemology and a positivist ontological paradigm. We interviewed 1343 boaters across 18 landing sites on Lake Albert, Uganda. Lifejacket wear was assessed through observation as boaters disembarked from their boats and self-reported wear for those who 'always wore a life jacket while on the lake'. We used a mixed-effects multilevel Poisson regression, with landing site-specific random intercepts to elicit associations with lifejacket wear. We report adjusted prevalence ratios (PRs) at 95% confidence intervals. RESULTS: The majority of respondents were male, 99.6% (1338/1343), and the largest proportion, 38.4% (516/1343) was aged 20-29 years. Observed lifejacket wear was 0.7% (10/1343). However, self-reported wear was 31.9% (428/1343). Tertiary-level education (adjusted PR 1.57, 95% CI 1.29- 1.91), boat occupancy of at least four people (adjusted PR 2.12, 95% CI 1.28 - 3.52), big boat size (adjusted PR 1.55, 95% CI 1.13 - 2.12) and attending a lifejacket-use training session (adjusted PR 1.25, 95% CI 1.01 - 1.56) were associated with higher prevalence of self-reported lifejacket wear. Self-reported wear was lower among the 30-39 year-olds compared to those who were aged less than 20 years (adjusted PR 0.66, 95% CI 0.45 - 0.99). CONCLUSION: Lifejacket wear was low. Training on lifejacket use may improve wear among boaters involved in occupational boating activities on Lake Albert.

Determinants of lifejacket use among boaters on Lake Albert, Uganda: a qualitative study.

BACKGROUND: Drowning is a major cause of unintentional injury death worldwide. The toll is greatest in low and middle-income countries. Over 95% of people who drowned while boating in Uganda were not wearing a lifejacket. We explored the determinants of lifejacket use among boaters on Lake Albert, Uganda. METHODS: We conducted a qualitative enquiry with a hermeneutic phenomenological undertone leaning on relativism ontology and emic subjectivism epistemology. Focus group discussions (FGDs) and in-depth interviews (IDIs) were held with boaters in 10 landing sites. We explored experiences and perspectives on lifejacket use. We used thematic analysis technique to analyse data and report results according to the Consolidated Criteria for Reporting Qualitative Research. RESULTS: We recruited 88 boaters in 10 FGDs and 11 to take part in the IDIs. We identified three themes: motivators and opportunities for lifejacket use, barriers and threats to lifejacket use, and strategies to improve lifejacket use. Many boaters attributed their lifejacket use to prior experience or witness of a drowning. Perceived high costs of lifejackets, limited knowledge, reluctance to use lifejackets because of distrust in their effectiveness, and the belief that it is women who should wear lifejackets were among the barriers and threats. Participants mentioned the need for mandatory enforcement together with community sensitisations as strategies to improve lifejacket use. CONCLUSION: Determinants of lifejacket use among boaters include experience or witness of drowning, limited knowledge about lifejackets and distrust in the effectiveness of the available lifejackets. Mandatory lifejacket wearing alongside educational interventions might improve lifejacket use.

Multi-measure assessment of adherence to antiretroviral therapy among children under five years living with HIV in Jinja, Uganda.

BACKGROUND: Adherence to Antiretroviral Therapy (ART) is required to achieve HIV viral load suppression. However, children under 5 years in Jinja, Uganda, had been shown to have low HIV suppression rates. This study aimed to determine the level of ART non-adherence among these children and the associated factors. METHODS: Data for the cross-sectional study was collected from April to July 2019, from caregivers of 206 children under 5 years living with HIV who were attending health facilities in Jinja and had been on ART for at least 3 months. Non-adherence was measured using a Visual Analog Scale that assessed both dosing and timing non-adherence, and by determining the Proportion of Days Covered by the medication. A questionnaire administered to the caregivers was used to collect the data, together with medical record review. A child was only considered adherent if they had adherence greater than 95% on all the measures. The data was analysed using Modified Poisson Regression, taking a p-value less than 0.05 as statistically significant. RESULTS: Of the 206 children, 73.8% were older than 2 years, and 52.9% were female. Likewise, the majority of caregivers were female (93.7%). Using the combined adherence measure, 57.3% of the children were categorised as non-adherent. School/day-care attendance, Prevalence Ratio (PR) = 1.25 (p = 0.042), the caregiver having higher than a primary school education, PR = 0.72 (p = 0.044) and satisfaction with the quality of service at the health facility, PR = 0.97 (p < 0.001) were associated with non-adherence. Household food insecurity was also associated with non-adherence: PR = 1.55 (p = 0.011) for mild food insecurity, PR = 1.75 (p = 0.001) for moderate insecurity and PR = 1.48 (p = 0.015) for severe food insecurity. CONCLUSIONS: Children under 5 years in Jinja had a high level of ART non-adherence. It is important to engage schools to support adherence among children living with HIV. Addressing household food insecurity and improving the quality of paediatric ART services would also reduce the barriers to optimal adherence.

Cardiovascular disease prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda.

BACKGROUND: With the growing epidemic of Cardiovascular Disease (CVD) in sub-Saharan Africa, behavioural change interventions are critical in supporting populations to achieve better cardiovascular health. Population knowledge regarding CVD is an important first step for any such interventions. This study examined CVD prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda. METHODS: The study was cross-sectional in design conducted among adults aged 25 to 70 years as part of the baseline assessment by the Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa (SPICES) - project. Data were collected using pretested semi-structured questionnaires, and respondents categorized as knowledgeable if they scored at least five out of six in the knowledge questions. Data were exported into STATA version 15.0 statistical software for analysis conducted using mixed-effects Poisson regression with fixed and random effects and robust standard errors. RESULTS: Among the 4372 study respondents, only 776 (17.7%) were knowledgeable on CVD prevention. Most respondents were knowledgeable about foods high in calories 2981 (68.2%), 2892 (66.1%) low fruit and vegetable intake and high salt consumption 2752 (62.9%) as CVD risk factors. However, majority 3325 (76.1%) thought the recommended weekly moderate physical activity was 30 min and half 2262 (51.7%) disagreed or did not know that it was possible to have hypertension without any symptoms. Factors associated with high CVD knowledge were: post-primary education [APR = 1.55 (95% CI: 1.18-2.02), p = 0.002], formal employment [APR = 1.69 (95% CI: 1.40-2.06), p < 0.001] and high socio-economic index [APR = 1.35 (95% CI: 1.09-1.67), p = 0.004]. Other factors were: household ownership of a mobile phone [APR = 1.35 (95% CI: 1.07-1.70), p = 0.012] and ever receiving advice on healthy lifestyles [APR = 1.38 (95% CI: 1.15-1.67), p = 0.001]. CONCLUSIONS: This study found very low CVD knowledge with major gaps around recommended physical activity duration, diet and whether hypertension is asymptomatic. Observed knowledge gaps should inform suitable interventions and strategies to equip and empower communities with sufficient information for CVD prevention. TRIAL REGISTRATION: ISRCTN Registry ISRCTN15848572 , January 2019, retrospectively registered.

Acceptability of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: a qualitative study.

BACKGROUND: Cardiovascular diseases (CVDs) are on the rise in many low-and middle-income countries where 80% of related deaths are registered. Community CVD prevention programmes utilizing self-care approaches have shown promise in contributing to population level reduction of risk factors. However, the acceptability of these programmes, which affects their uptake and effectiveness, is unknown including in the sub-Saharan Africa context. This study used the Theoretical Framework of Acceptability to explore the prospective acceptability of a community CVD prevention programme in Mukono and Buikwe districts in Uganda. METHODS: This qualitative descriptive study was conducted in March 2019 among community health workers (CHWs), who would implement the intervention and community members, the intervention recipients, using eight focus group discussions. All discussions were audio-recorded, transcribed verbatim and analysed thematically guided by the theoretical framework. RESULTS: CHWs and community members reported high eagerness to participate in the programme. Whereas CHWs had implemented similar community programmes and cited health promotion as their role, community members looked forward to health services being brought nearer to them. Although the intervention was preventive in nature, CHWs and community members expressed high interest in treatments for risk factors and were skeptical about the health system capacity to deliver them. CHWs anticipated barriers in mobilising communities who they said sometimes may not be cooperative while community members were concerned about failing to access treatment and support services after screening for risk factors. The major cost to CHWs and community members for engaging in the intervention was time that they would have dedicated to income generating activities and social events though CHWs also had the extra burden of being exemplary. CHWs were confident in their ability to deliver the intervention as prescribed if well trained, supported and supervised, and community members felt that if provided sufficient information and supported by CHWs, they could change their behaviours. CONCLUSIONS: The community CVD prevention programme was highly acceptable among CHWs and community members in Mukono and Buikwe districts of Uganda amidst a few burdens and opportunity costs. Suggestions made by study participants to improve programme effectiveness informed programme design and implementation for impact.

Experiences and perceptions of youth living with HIV in Western Uganda on school attendance: barriers and facilitators.

BACKGROUND: The globally recognized socio-economic benefits of education have stirred many countries in Sub-Saharan Africa like Uganda to promote universal access to schooling by removing fiscal barricades for those in primary and secondary schools. However, the proportion of Youth Living With HIV/AIDS (YLWHA) missing school, studying with difficulties and dropping out of school in Uganda has been observed to be higher than that of other youth. This study aimed at understanding the barriers and facilitators for YLWHA in Uganda to attend school. METHODS: We conducted a qualitative inquiry with 35 purposively selected YLWHA aged 12 to 19 years, including 16 females at three accredited Antiretroviral Therapy (ART) treatment centres in Kabarole district in Western Uganda. Individual semi-structured interviews were tape-recorded, transcribed verbatim and subjected to thematic inductive analysis. RESULTS: We identified five main themes in which barriers to attend school were reported and four main themes in which facilitators were reported by participants. The main themes for barriers were: 1) management of ART and illnesses, 2) fear, negative thoughts and self-devaluation, 3) lack of meaningful and supportive relationships, 4) reactionary attitudes and behaviours from others at school, 5) financial challenges. The main themes for facilitators were: 1) practical support at school, home and community, 2) counselling, encouragement and spirituality, 3) individual coping strategies, 4) hopes, dreams and opportunities for the future. CONCLUSION: Most of the barriers reported arose from HIV-related stigma and financial challenges whose genesis transcends school boundaries. While YLWHA reported measures to cope, and support from other people, these were non-sustainable and on a limited scale due to disclosure apprehension at school and the indiscretion of those who learnt about their status. To promote supportive school environments for YLWHA, integrated curricular and extracurricular interventions are necessary to increase HIV knowledge, dispel misconceptions about HIV and consequently transform the school community from a stigmatizing one to a supportive one.

Health providers' experiences, perceptions and readiness to provide HIV services to men who have sex with men and female sex workers in Uganda - a qualitative study.

BACKGROUND: Access to HIV services among men who have sex with men (MSM) and female sex workers (FSWs) remains suboptimal globally. While the reasons for this dismal performance have been documented, limited evidence exists on the experiences, perceptions and readiness of health providers to provide HIV services to MSM and FSWs. METHODS: This analysis uses data collected from 48 key informants (health providers in public and private health facilities) as part of a larger study conducted in 12 districts of Uganda between October and December 2013. Data were collected on health providers' experiences and readiness to provide HIV services to MSM and FSWs and their perceptions on the effect of existing legislation on HIV services provision to MSM and FSWs. Data were captured verbatim, transcribed and analyzed following a thematic framework approach. RESULTS: All health providers reported that they had ever provided HIV services to FSWs and a majority of them were comfortable serving them. However, no health provider had ever served MSM. When asked if they would be willing to serve MSM, nearly three-quarters of the health providers indicated that they would be bound by the call of duty to serve them. However, some health providers reported that they "would feel very uncomfortable" handling MSM because they engage in "a culture imported into our country". A majority of the health providers felt that they did not have adequate skills to effectively serve MSM and called for specific training to improve their clinical skills. There were mixed reactions as to whether existing criminal laws would affect MSM or FSWs access to HIV services but there was agreement that access to HIV services, under the existing laws, would be more constrained for MSM than FSWs since society "does not blame FSWs [as much as it does] with MSM". CONCLUSION: A majority of the health providers were generally comfortable serving FSWs but there were strong homophobic tendencies towards MSM. A majority of the health providers lacked skills in how to handle MSM. Interventions aimed at improving health providers' skills in handling MSM while minimizing the negative attitude towards them are urgently needed.

An implementation science study to enhance cardiovascular disease prevention in Mukono and Buikwe districts in Uganda: a stepped-wedge design.

BACKGROUND: Uganda is experiencing a shift in major causes of death with cases of stroke, heart attack, and heart failure reportedly on the rise. In a study in Mukono and Buikwe in Uganda, more than one in four adults were reportedly hypertensive. Moreover, very few (36.5%) reported to have ever had a blood pressure measurement. The rising burden of CVD is compounded by a lack of integrated primary health care for early detection and treatment of people with increased risk. Many people have less access to effective and equitable health care services which respond to their needs. Capacity gaps in human resources, equipment, and drug supply, and laboratory capabilities are evident. Prevention of risk factors for CVD and provision of effective and affordable treatment to those who require it prevent disability and death and improve quality of life. The aim of this study is to improve health profiles for people with intermediate and high risk factors for CVD at the community and health facility levels. The implementation process and effectiveness of interventions will be evaluated. METHODS: The overall study is a type 2-hybrid stepped-wedge (SW) design. The design employs mixed methods evaluations with incremental execution and adaptation. Sequential crossover take place from control to intervention until all are exposed. The study will take place in Mukono and Buikwe districts in Uganda, home to more than 1,000,000 people at the community and primary healthcare facility levels. The study evaluation will be guided by; 1) RE-AIM an evaluation framework and 2) the CFIR a determinant framework. The primary outcomes are implementation - acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, coverage, and sustainability. DISCUSSION: The study is envisioned to provide important insight into barriers and facilitators of scaling up CVD prevention in a low income context. This project is registered at the ISRCTN Registry with number ISRCTN15848572. The trial was first registered on 03/01/2019.

"When they know that you are a sex worker, you will be the last person to be treated": Perceptions and experiences of female sex workers in accessing HIV services in Uganda.

BACKGROUND: HIV prevalence among female sex workers (FSWs) in high burden countries in sub-Saharan Africa varies between 24 and 72%, however their access to HIV services remains limited. This study explored FSWs' perspectives of the barriers and opportunities to HIV service access in Uganda. METHODS: The cross-sectional qualitative study was conducted between October and December 2013. Twenty-four focus group discussions were conducted with 190 FSWs in 12 districts. Data were analysed using manifest content analysis, using Atlas.ti software, based on the socio-ecological model. RESULTS: FSWs indicated that HIV services were available and these included condoms, HIV testing and treatment, and management of sexually transmitted infections. However, access to HIV services was affected by several individual, societal, structural, and policy related barriers. Individual level factors included limited awareness of some prevention services, fears, and misconceptions while societal stigma was prominent. Structural and policy level barriers included inconvenient hours of operation of the clinics, inflexible facility based distribution of condoms, interuptions in the supply of condoms and other commodities, and limited package of services with virtually no access to lubricants, HIV pre- and post-exposure prophylaxis, and support following client perpetrated violence. Policies such as partner testing and involvement at antenatal care, and using only one facility for antiretroviral drug refills hindered HIV service uptake and retention in care. FSWs had major concerns with the quality of services especially discrimination and rude remarks from providers, denial or delay of services, and potential for breach of confidentiality. However, some FSWs reported positive experiences including interface with friendly providers and participated in formal and informal FSW groups, which supported them to access health services. CONCLUSION: Despite availability of services, FSWs faced major challenges in access to services. Comprehensive multilevel interventions targeting individual, societal, structural and policy level barriers are required to increase access to HIVservices among FSWs in Uganda. Policy and institutional adjustments should emphasize quality friendly services and expanding the package of services to meet the needs of FSWs.

Schistosoma mansoni Infection and Its Related Morbidity among Adults Living in Selected Villages of Mara Region, North-Western Tanzania: A Cross-Sectional Exploratory Study.

Schistosoma mansoni is highly endemic in Tanzania and affects all age groups at different degrees. However, its control approach does not include adult individuals who are equally at risk and infected. To justify the inclusion of adult individuals in MDA programs in Tanzania, the present study focused on determining the prevalence of S. mansoni infection and its related morbidities among adult individuals. This was a cross sectional study conducted among 412 adult individuals aged 18-89 years living in selected villages of Rorya and Butiama districts located along the shoreline of the Lake Victoria. A pretested questionnaire was used to collect socio-demographic and socio-economic information of participants. Ultrasonographic examinations were conducted for all study participants using the Niamey protocol. A single stool sample was obtained from all study participants and examined for S. mansoni using the Kato-Katz technique. The study revealed a high prevalence of S. mansoni (56.3%), and the majority of infected individuals had a light intensity of infection. Ultrasonographic findings revealed that 22.4% of adult individuals had periportal fibrosis (PPF) (grade C-F), with 18.4% having grade C and D and 4% having grade E and F. Males had the highest prevalence of PPF (31.7% vs 10.8%, P<0.001). Organomegaly was common with 28.5% and 29.6% having splenomegaly and hepatomegaly, respectively. S. mansoni infection and its related morbidities included PPF, hepatomegaly, and splenomegaly were common among adult individuals. To reduce the level of transmission of S. mansoni infection, planned mass drug administration campaigns should include adult individuals living in these villages.

Effect of Repeated Anthelminthic Treatment on Malaria in School Children in Kenya: A Randomized, Open-Label, Equivalence Trial.

BACKGROUND: School children living in the tropics are often concurrently infected with plasmodium and helminth parasites. It has been hypothesized that immune responses evoked by helminths may modify malaria-specific immune responses and increase the risk of malaria. METHODS: We performed a randomized, open-label, equivalence trial among 2436 school children in western Kenya. Eligible children were randomized to receive either 4 repeated doses or a single dose of albendazole and were followed up during 13 months to assess the incidence of clinical malaria. Secondary outcomes were Plasmodium prevalence and density, assessed by repeat cross-sectional surveys over 15 months. Analysis was conducted on an intention-to-treat basis with a prespecified equivalence range of 20%. RESULTS: During 13 months of follow-up, the incidence rate of malaria was 0.27 episodes/person-year in the repeated treatment group and 0.26 episodes/person-year in the annual treatment group (incidence difference, 0.01; 95% confidence interval, -.03 to .06). The prevalence and density of malaria parasitemia did not differ by treatment group at any of the cross-sectional surveys. CONCLUSIONS: Our findings suggest that repeated deworming does not alter risks of clinical malaria or malaria parasitemia among school children and that school-based deworming in Africa may have no adverse consequences for malaria. CLINICAL TRIALS REGISTRATION: NCT01658774.

Plasmodium falciparum parasitaemia and clinical malaria among school children living in a high transmission setting in western Kenya.

BACKGROUND: Malaria among school children is increasingly receiving attention, yet the burden of malaria in this age group is poorly defined. This study presents data on malaria morbidity among school children in Bungoma county, western Kenya. METHOD: This study investigated the burden and risk factors of Plasmodium falciparum infection, clinical malaria, and anaemia among 2346 school children aged 5-15 years, who were enrolled in an individually randomized trial evaluating the effect of anthelmintic treatment on the risks of malaria. At baseline, children were assessed for anaemia and nutritional status and information on household characteristics was collected. Children were followed-up for 13 months to assess the incidence of clinical malaria by active detection, and P. falciparum infection and density evaluated using repeated cross-sectional surveys over 15 months. RESULTS: On average prevalence of P. falciparum infection was 42% and ranged between 32 and 48% during the five cross-sectional surveys. Plasmodium falciparum prevalence was significantly higher among boys than girls. The overall incidence of clinical malaria was 0.26 episodes per person year (95% confidence interval, 0.24-0.29) and was significantly higher among girls (0.23 versus 0.31, episodes per person years). Both infection prevalence and clinical disease varied by season. In multivariable analysis, P. falciparum infection was associated with being male, lower socioeconomic status and stunting. The risk of clinical malaria was associated with being female. CONCLUSION: These findings show that the burden of P. falciparum parasitaemia, clinical malaria and anaemia among school children is not insignificant, and suggest that malaria control programmes should be expanded to include this age group.

Reduced uptake of mass treatment for schistosomiasis control in absence of food: beyond a randomized trial.

BACKGROUND: Sustaining high uptake of praziquantel is key for long-term control of schistosomiasis. During mass treatment in 2013, we randomized 12 primary schools into two groups; one group received education messages for schistosomiasis prevention for two months prior to mass treatment, while the other, in addition to the education messages, received a pre-treatment snack shortly before mass treatment. The uptake of praziquantel in the snack schools was 94 % compared to 79 % in the non-snack schools. During mass treatment in 2014, no snack was provided. We compared the uptake of praziquantel in 2014 to that in 2013 and attempt to explain the reasons for the observed differences. METHODS: Serial cross sectional surveys were conducted among a random sample of children from the 12 primary schools, 1 month after mass treatment in 2013 and 2014 to measure uptake of praziquantel, reported side effects attributable to praziquantel and prevalence and intensity of schistosomiasis infection. Differences in the demographic and descriptive variables between the 2013 and 2014 samples were compared using chi squared tests for categorical variables and student's t-test for geometric mean intensity of S. mansoni infection. RESULTS: Uptake of praziquantel reduced from 93.9 to 78.0 % (p = 0.002) in the snack schools but was unchanged in the non-schools 78.7 and 70.4 % (p = 0.176). The occurence of side-effects attributable to praziquantel increased from 34.4 to 61.2 % (p = 0.001) in the snack schools but was unchanged in the non-snack schools; 46.9 and 53.2 % (p = 0.443). Although the prevalence of S. mansoni infection increased in both the snack and non-snack schools, the differences did not reach statistical significance;1.3 and 7.5 % (p = 0.051) and 14.1 and 22.0 % (p = 0.141), respectively. Similarly, the difference in the geometric mean intensity of S. mansoni infection in both the snack and non-snack schools was not statistically significant; 38.3 eggs per gram of stool (epg) and 145.7 epg (p = 0.197) and 78.4 epg and 322.5 epg (p = 0.120), respectively. CONCLUSION: Our results show that in absence of food, uptake of praziquantel reduced and the side-effects of the drug increased. However, the reduced uptake did not affect the prevalence and intensity of schistosomiasis among school children. Rescinding of the provision of the snack is what probably caused the reduction in uptake of treatment in the subsequent mass treatment cycle.

Implementation of infection control in health facilities in Arua district, Uganda: a cross-sectional study.

BACKGROUND: At least 1.4 million people are affected globally by nosocomial infections at any one time, the vast majority of these occurring in low-income countries. Most of these infections can be prevented by adopting inexpensive infection prevention and control measures such as hand washing. We assessed the implementation of infection control in health facilities and determined predictors of hand washing among healthcare workers (HCWs) in Arua district, Uganda. METHODS: We interviewed 202 HCWs that included 186 randomly selected and 16 purposively selected key informants in this cross-sectional study. We also conducted observations in 32 health facilities for compliance with infection control measures and availability of relevant supplies for their implementation. Quantitative data underwent descriptive analysis and multiple logistic regressions at 95 % confidence interval while qualitative data was coded and thematically analysed. RESULTS: Most respondents (95/186, 51 %) were aware of at least six of the eight major infection control measures assessed. Most facilities (93.8 %, 30/32) lacked infection control committees and adequate supplies or equipment for infection control. Respondents were more likely to wash their hands if they had prior training on infection control (AOR = 2.71, 95 % CI: 1.03-7.16), had obtained at least 11 years of formal education (AOR = 3.30, 95 % CI: 1.44-7.54) and had reported to have acquired a nosocomial infection (AOR = 2.84, 95 % CI: 1.03-7.84). CONCLUSIONS: Healthcare workers are more likely to wash their hands if they have ever suffered from a nosocomial infection, received in-service training on infection control, were educated beyond ordinary level, or knew hand washing as one of the infection control measures. The Uganda Ministry of Health should provide regular in-service training in infection control measures and adequate necessary materials.

Understanding low uptake of mass treatment for intestinal schistosomiasis among school children: a qualitative study in Jinja district, Uganda.

Despite attempts to control intestinal schistosomiasis through school-based mass drug administration (MDA) with praziquantel using school teachers in Uganda, less than 30% of the school children take the treatment in some areas. The aim of the study was to understand why the uptake of praziquantel among school children is low and to suggest strategies for improved uptake. This was a cross-sectional qualitative study in which 24 focus group discussions and 15 key informant interviews were conducted 2 months after MDA. The focus group discussions were held with school children in twelve primary schools and the key informant interviews were held with school teachers, sub-county health assistants and the District Vector Control Officer. The study shows that the low uptake of praziquantel among school children is a result of a complex interplay between individual, interpersonal, institutional, community and public policy factors. The individual and interpersonal factors underpinning the low uptake include inadequate information about schistosomiasis prevention, beliefs and attitudes in the community about treatment of schistosomiasis and shared concerns among children and teachers about the side-effects of praziquantel, especially when the drug is taken on an empty stomach. The institutional, policy and community factors include inadequate preparation and facilitation of teachers and the school feeding policy, which requires parents to take responsibility for providing their children with food while at school, yet many parents cannot meet the cost of a daily meal due to the prevailing poverty in the area. It is concluded that strategies to improve uptake of praziquantel among school children need to be multi-pronged addressing not only the preparation and motivation of teachers and health education for children, but also the economic and political aspects of drug distribution, including the school feeding policy.

Effectiveness of a pre-treatment snack on the uptake of mass treatment for schistosomiasis in Uganda: a cluster randomized trial.

BACKGROUND: School-based mass treatment with praziquantel is the cornerstone for schistosomiasis control in school-aged children. However, uptake of treatment among school-age children in Uganda is low in some areas. The objective of the study was to examine the effectiveness of a pre-treatment snack on uptake of mass treatment. METHODS AND FINDINGS: In a cluster randomized trial carried out in Jinja district, Uganda, 12 primary schools were randomized into two groups; one received education messages for schistosomiasis prevention for two months prior to mass treatment, while the other, in addition to the education messages, received a pre-treatment snack shortly before mass treatment. Four weeks after mass treatment, uptake of praziquantel was assessed among a random sample of 595 children in the snack schools and 689 children in the non-snack schools as the primary outcome. The occurrence of side effects and the prevalence and mean intensity of Schistosoma mansoni infection were determined as the secondary outcomes. Uptake of praziquantel was higher in the snack schools, 93.9% (95% CI 91.7%-95.7%), compared to that in the non-snack schools, 78.7% (95% CI 75.4%-81.7%) (p = 0.002). The occurrence of side effects was lower in the snack schools, 34.4% (95% CI 31.5%-39.8%), compared to that in the non-snack schools, 46.9% (95% CI 42.2%-50.7%) (p = 0.041). Prevalence and mean intensity of S. mansoni infection was lower in the snack schools, 1.3% (95% CI 0.6%-2.6%) and 38.3 eggs per gram of stool (epg) (95% CI 21.8-67.2), compared to that in the non-snack schools, 14.1% (95% CI 11.6%-16.9%) (p = 0.001) and 78.4 epg (95% CI 60.6-101.5) (p = 0.001), respectively. CONCLUSIONS: Our results suggest that provision of a pre-treatment snack combined with education messages achieves a higher uptake compared to the education messages alone. The use a pre-treatment snack was associated with reduced side effects as well as decreased prevalence and intensity of S. mansoni infection. TRIAL REGISTRATION: www.ClinicalTrials.gov NCT01869465

Delays in diagnosis and treatment of pulmonary tuberculosis in Wakiso and Mukono districts, Uganda.

BACKGROUND: Delay in tuberculosis (TB) diagnosis may worsen the disease and increase TB transmission. Therefore, timely diagnosis and treatment is critical in TB control. We aimed to assess the treatment delay of pulmonary TB and its determinants in two Ugandan districts where TB infection control (TBIC) guidelines were formerly implemented. METHODS: A facility based cross-sectional study was conducted in Mukono and Wakiso districts. Adult pulmonary TB patients within three months of initiating treatment were included in the study. Delays were categorized into unacceptable patient delay (more than 3 weeks from the onset of cough and the first consultation with a health care provider), health service (more than one week from the first consultation to the initiation of TB treatment) and total delay (more than 4 weeks since the onset of cough). The prevalences as well as predictors for the three delays were determined. RESULTS: We enrolled 158 sputum positive patients. Unacceptable patient delay was noted in 91 (58%) patients, a health service delay in 140 (88%) patients and a total delay in 140 (90%) patients. An independent predictor for patient delay was male gender (p < 0.001). First visiting a non-public health facility (p = 0.001) was an independent predictor of health service delay. CONCLUSION: There is still a significant TB diagnosis and treatment delay in Uganda. Most of the delay was caused by health system delay in the non-public health care sector. There is need for TB advocacy in the community, training of health workers in TBIC and strengthening public-private partnerships in TB control.