Sexual behaviour among persons living with HIV/AIDS in Kampala, Uganda.

OBJECTIVE: To identify sexual behaviour and reproductive health needs of people living with HIV/AIDS (PLWHAs). DESIGN: A cross sectional study. SETTING: Joint Clinical Research Centre, Kampala Uganda. PARTICIPANTS: Three hundred and eighty PLWHAs, 50% of whom had initiated anti-retro viral therapy (ART). MAIN OUTCOME MEASURES: PLWHAs answered questions regarding sexual behaviour, number and type of sexual partners, symptoms of sexually transmitted infections, having been pregnant or causing a pregnancy, social demographic characteristics, consumption of alcohol, having biological children, desire for more children and use of condoms. RESULTS: In the past 12 months 227 (60%) of the PLWHAs were sexually active. Of the sexually active 42 (19%) never used a condom, and 92 (40%) used condoms inconsistently, thus 134 (35%) of PLWHAs engaged in high risk sex. Two hundred and sixty five (70%) said that PLWHAs can have healthy children and 115 (30%) desired more children with 21 (10%) of the women in the reproductive age group reporting a pregnancy and 22 (17%) of the men reporting having caused a pregnancy. Only three (7%) of the pregnancies were unplanned. Desire for more children was a strong independent predictor of engaging in high risk sex (Adjusted Odds Ratio 2.44, 95% CI 1.35-4.42). CONCLUSIONS: This study demonstrates that abstinence and use of condoms on their own may not be enough for HIV prevention among PLWHAs who desire children. Additional methods such as use of ART to reduce HIV infectiousness and sperm washing are needed.

Adherence to feeding guidelines among HIV-infected and HIV uninfected mothers in a rural district in Uganda.

OBJECTIVE: To describe the infant feeding behaviour of HIV-infected and HIV-uninfected mothers, and identify factors influencing adherence to infant feeding guidelines. DESIGN: Analytical cross-sectional study. SETTING: Bushenyi, rural district in South-western Uganda PARTICIPANTS: One hundred and ninety four mothers who had a child less than 12 months of age. About half, 94 (48.5%), of these were HIV-infected. MAIN OUTCOME MEASURES: Proportion of mothers who exclusively breastfed, complementary fed, replacement fed, and adhered to feeding guidelines. RESULTS: Most (84.5%, 164/194) of the mothers had ever breastfed their infants, the rest had exclusively replacement fed since birth. Among children less than six months who were breastfeeding, 31.5% (34/108) were exclusively breastfeeding and the rest were mixed feeding. HIV-infected mothers were more likely than HIV-uninfected mothers to exclusively breastfeed (Crude Odds Ratio [COR], 3.61, 95% Confidence Interval [CI] 1.42-9.21). For infants older than six months, complementary feeding was more common among HIV-uninfected (100%) than HIV-infected mothers (41.7%; P < 0.001). Among infants of all ages, none of the HIV-uninfected and 45% of HIV-infected mothers were replacement feeding (p < 0.001). More than a half (59.8%) of the mothers adhered to infant feeding guidelines. The only independent predictor of adherence after multivariate analysis was mother ever attending infant feeding counselling (AOR 9.03; 95% CI 4.03-20.25). Only 35% of mothers reported ever attending infant feeding counselling. CONCLUSIONS: Infant feeding counselling was associated with improved adherence to feeding guidelines. Since infant feeding counselling is low in this population there is need for scale-up of this essential service.

Factors associated with delayed diagnosis of HIV infection in Mukono District, Uganda.

OBJECTIVE: To identify factors associated with delayed diagnosis of HIV infection. DESIGN: Cross sectional study. SETTING: Mukono district, Uganda. SUBJECTS: Newly diagnosed HIV positive clients at ten HIV testing centres. Late testers were HIV positive clients who had AIDS according to World Health Organisation AIDS case definition. Early-testers did not have AIDS at diagnosis. MAIN OUTCOME MEASURES: Late testers were compared to early testers on socio-demographic characteristics, sexual behaviour, access of testing services, knowledge of care and support services for HIV/AIDS and attitude towards knowing HIV-status. RESULTS: Delayed diagnosis of HIV infection was independently associated with being over 25 years (adjusted odds ratio (AOR), 4.3; Confidence Interval (CI) 1.7-11.1), not being married (AOR, 2.4; CI 1.3-4.4), having no knowledge of testing services (AOR, 2.4; CI, 1.2 4.7), spending at least one hour travelling to a testing centre (AOR, 2.1; CI, 1.0-4.2), paying for HIV testing (AOR, 3.4; CI, 1.7-6.9) having had an illness two months before testing AOR 9.49; CI, 4.84-18.64) and having negative beliefs towards knowing one's HIV sero status (AOR, 5.7; CI, 1.0-30.8). CONCLUSION: Factors associated with delayed diagnosis of HIV infection in Mukono District of Uganda are; age over 25 years, not being married, having no knowledge of testing services, paying for HIV testing, travelling for at least one hour to a testing centre and having negative beliefs towards knowing one's HIV status. In order to increase access to testing there is need to offer free HIV testing and health education targeting people above 25 years and those not married.

Factors influencing adherence to exclusive breast feeding among HIV positive mothers in Kabarole district, Uganda.

OBJECTIVE: To identify the factors influencing adherence to exclusive breast feeding (EBF) among HIV positive mothers in Kabarole district, Uganda. DESIGN: Cross-sectional study. SETTING: Kabarore district, western Uganda. SUBJECTS: HIV infected women attending for psychosocial support that adhered or did not adhere to EBF. MAIN OUTCOME MEASURES: We compared personal factors, influence from other people, barriers and supports towards adherence to EBF among 139 HIV infected women who adhered and among 139 women who did not adhere to EBF using univariate and multivariate analyses. RESULTS: The independent predictors of adherence to EBF are: having formal education (Adjusted Odds Ratio [AOR] 2.21, 95% confidence interval [CI] 1.01-4.84), knowledge of EBF as a method of preventing mother to child transmission of HIV (AOR 2.53, CI 1.11-5.75), attending at least four antenatal infant feeding counselling sessions (AOR 3.86, CI 1.82-8.19), attending at least six postnatal counselling sessions (AOR 12.52, CI 3.89-40.30), health workers being consulted for breastfeeding problems (AOR 13.11, CI 3.75-45.81), mothers thinking that they are able to produce enough milk (AOR 3.92, CI 1.74-8.84), initiation of breastfeeding within one hour of birth (AOR 10.17, CI 4.52-22.88), getting support from the father to EBF (AOR 5.27, CI 1.87-14.81) and getting support from the family to EBF (AOR 4.54, CI 2.09-9.84). CONCLUSION: In order to improve adherence to EBF there is need to: involve the family especially fathers in infant feeding counselling and education, target less educated mothers for more intense infant feeding counselling using appropriate methods, intensify education on benefits of EBF and on how to produce enough milk and to encourage mothers to attend regularly for ante-natal and post-natal care.

Community perception of intestinal schistosomiasis in Busia district of Uganda.

OBJECTIVE: To elicit and understand peoples' perceptions of intestinal schistosomiasis that is a prerequisite for designing appropriate control strategies. DESIGN: Cross-sectional study using six focus group discussions (FGDs) and 432 semi-structured interviews (SSIs). SUBJECTS: Community members in Busia district of Uganda. MAIN OUTCOME MEASURES: Data was collected on causes, transmission, health seeking behaviour, hygiene behaviour and on prevention/control strategies for schistosomiasis. RESULTS: The symptoms of early intestinal schistosomiasis were poorly understood whereas those of late schistosomiasis were well appreciated. Cause and transmission of schistosomiasis were used interchangeably and schistosomiasis was mainly thought to be caused by drinking dirty or unboiled water. Schistosomiasis was perceived to be a treatable disease and modern medicines were said to be effective. Community members said that it is impossible to avoid contact with possible sources of infection for schistosomiasis as the lake was linked to livelihood of people. The groups that were particularly at increased risk of not participating in schistosomiasis prevention strategies included women, the uneducated and those involved in subsistence agriculture. CONCLUSIONS: In order to effectively control schistosomiasis in this district, there is need to adapt prevention and control strategies to peoples' livelihoods. There is also need to target the less advantaged groups (women, uneducated and subsistence farmers) for intense health education strategies aimed at increasing participation in the control of schistosomiasis.

Contraceptive use among in and out-of school adolescents in rural southwest Uganda.

OBJECTIVE: To compare the level of contraceptive use among in and out-of school rural Ugandan adolescents. DESIGN: Cross sectional survey. SETTING: Mbarara district. SUBJECTS: Five hundred in-school and 220 out-of school adolescents aged 15-19 years. MAIN OUTCOME MEASURE: Contraceptive use. RESULTS: Contraceptive prevalence was 171 (23.8%), with 99 (19.8%) among in-school and 72 (32.7%) in out-of school (OR=0.8, 95% CI=0.5-1.3). Of the 286 who had had sexual intercourse, 171 (59.8%) were current users with 99 (57.9%) in-school and 72 (42.1%) out-of school. The predominant method was the male condom with 80 (56.7%) in-school and 61 (43.3%) out-of-school (p=0.3). Sixty five (67%) of in-school aged 18-19 used contraceptives compared to those less than 18 years (OR=0.4, 95% CI=0.2-0.8). The out-of school who were urban residents 51(75%) were more likely to use contraceptives (OR=0.3, 95% CI=0.1-0.6). Out-of school with secondary education 37(84.1%) were more likely to use contraceptives (OR=0.2, 95% CI=0.1-0.5). Cost was a barrier for contraceptive use among in-school users 37(77.1%) (OR=2.6, 95% CI=1.7-5.4). Stigma surrounding their sexual activity was a barrier to out-of school 25 (58.1%) (OR=0.4, 95% CI=0.2-0.8). CONCLUSION: Contraceptive use among rural sexually active adolescents is low although the prevalence is higher in out-of school. Reorientation of contraceptive services to make them more accessible through strengthening of school health programme and establishment of out-of school adolescent health programme are urgently needed.

Intestinal schistosomiasis among preschool children along the shores of Lake Victoria in Uganda.

Schistosomiasis, a disease caused by Schistosoma trematode parasites, affects hundreds of millions of people and accounts for more than 40% of the global health burden due to neglected tropical diseases. In Uganda, intestinal schistosomiasis is endemic in 73 out of 112 districts and about 55% of the population of 36 million individuals are at risk. There is scanty information on the status and burden of schistosomiasis in preschool children less than six years of age in Uganda. This study aimed to assess the status of Schistosoma mansoni infections in children aged 1-5 years in Uganda. S. mansoni prevalence and intensity of infection were examined in 3058 children from 5 districts along Lake Victoria shoreline, eastern Uganda. For each child one stool sample was collected on three consecutive days. The Kato-Katz technique was used to prepare stool smears on slides for microscopic examination. Short interviews with a standardized pre-tested questionnaire prepared in the local language (Lusoga) were administered to each caregiver to identify risk factors associated with S. mansoni infection. An overall S. mansoni prevalence of 39.3% (95% CI: 38.0-41.1%) was estimated out of the 3058 stool samples examined. The geometric mean intensity of S. mansoni among the infected children was 273 (95% CI: 241-305) eggs per gram of faeces. Both prevalence and intensity of infection increased linearly with age (P<0.0001) and were highest in the age group 49-60 months. Majority (61%) of the children, especially in the age group 12-24 months (84.2%; 95% CI: 75.6-90.1%), were lightly infected. Short interviews with caregivers revealed that preschool children, 1-5 years old, get exposed to S. mansoni infested waters through bathing, playing or swimming. It is important that the Uganda national control programme for schistosomiasis takes preschool children into consideration and that health education on transmission of schistosomiasis is delivered to the endemic communities regularly.

Factors influencing the use of bed nets in Mbarara municipality of Uganda.

In order to identify independent predictors for bed net use, respondents from 643 households selected randomly from 21 clusters were interviewed in Mbarara municipality, Uganda. Respondents answered questions about demographic characteristics, social economic conditions, causes and transmission of malaria, beliefs about severity and complications of malaria, malaria morbidity and health care-seeking behavior, perceived control of malaria prevention, beliefs about utility of bed nets, perceived susceptibility to malaria, and whether they use bed nets or not. Univariate and multivariate logistic regression analyses were used to identify predictors for bed net use. Fifty-five percent (356 of 643) of the households had bed net users. The independent factors that favored bed net use were as follows: 1) age < 30 years, 2) ownership of a television, 3) having mosquito nets in ventilators of the house, 4) being a skilled worker or a professional, or owning a major business, 5) living in a permanent house, 6) believing that bed nets prevent malaria, 7) believing that bed nets are worth their cost, 8) not believing that convulsions cannot be cured by modern medicine, and 9) believing that bed nets are not expensive. The strongest predictors of bed net use are living in a permanent house and agreeing that bed nets are worth their cost, with adjusted odds ratios of 4.29 (95% confidence interval, 2.76-6.71) and 3.93 (95% confidence interval, 2.5-26.13), respectively. These data suggest that in order to increase the use of bed nets, the price of bed nets needs to be reduced and educational messages that stress the favorable use of bed nets need to be increased.

Control of tuberculosis in Uganda: a tale of two districts.

SETTING: Rakai and Mbarara districts, south-western Uganda. OBJECTIVE: To compare compliance and other treatment outcomes with tuberculosis (TB) treatment for Rakai and Mbarara districts, and to elucidate factors associated with the disparity. DESIGN: A retrospective cohort analysis of tuberculosis treatment outcomes for the period 1992-1996. Predictors for compliance were examined for 1995 using univariate and multivariate methods. RESULTS: Of the surviving patients, 57% finished treatment in Mbarara compared to 92% in Rakai. Enhanced compliance on univariate analysis was associated with being smear positive; previous TB treatment; use of short-course chemotherapy; return for repeat smear; no change of health unit; no change of district; registration in Rakai; and not being hospitalised. On multivariate analysis, being smear positive, previous TB treatment, hospitalisation and registration site were not significant. The highest risk for default was unit change after the intensive phase of treatment, with an adjusted odds ratio of 17.53. The highest differences in the two districts were for the hospitalisation and unit change rates, with corresponding odds ratios of 52 and 0.06. CONCLUSIONS: Initial hospitalisation of TB patients is not necessary for subsequent completion of treatment. Use of one health unit for both the intensive and continuation phase of treatment may improve compliance.

High compliance in an ambulatory tuberculosis treatment programme in a rural community of Uganda.

The increasing numbers of clinical tuberculosis in Uganda, mainly due to the human immunodeficiency virus (HIV) epidemic, means that it is no longer possible to hospitalise all TB patients, and the feasibility of ambulatory treatment needs to be assessed. A successful ambulatory TB treatment programme has been implemented in Rakai district. An annual cohort analysis for the period 1992-1996 showed that high completion rates were achieved. Of a total of 1659 TB patients, 92% of those surviving completed the prescribed treatment. Reasons for this high completion rate included: treating patients at one health unit, treating patients near their homes, training and supervision of health workers, and progressive use of short-course chemotherapy.

Factors influencing choice of delivery sites in Rakai district of Uganda.

In order to understand factors influencing choice of delivery sites in Rakai district of south-western Uganda, eight focus group discussions based on the Attitudes-Social influence-Self efficacy model were held with 32 women and 32 men. Semi-structured interviews were also held with 211 women from 21 random cluster samples who had a delivery in the previous 12 months (from 2 June 1997). Forty four percent of the sample delivered at home, 17% at traditional birth attendant's (TBA) place, 32% at public health units, and 7% at private clinics. Among the factors influencing choice of delivery site were: access to maternity services; social influence from the spouse, other relatives, TBAs and health workers; self-efficacy; habit (previous experience) and the concept of normal versus abnormal pregnancy. Attitudinal beliefs towards various delivery sites were well understood and articulated. Attendance of ante-natal care may discourage delivery in health units if the mothers are told that the pregnancy is normal. In order to make delivery safer, there is need to improve access to maternity services, train TBAs and equip them with delivery kits, change mother's self-efficacy beliefs, and involve spouses in education about safe delivery.

Psycho-social determinants for sexual partner referral in Uganda: quantitative results.

The purpose of this study was to investigate the factors influencing sexual partner referral using the Attitude-Social influence self-Efficacy model as a guiding theoretical framework. The data was collected in an interview survey with 236 women and 190 men attending a sexually transmitted disease clinic in Kampala, Uganda. Intention, attitude, subjective norm, self-efficacy, and past behaviour in relation to partner referral as well as partner type were collected at time 1. At time 2 (1 month later), sexual partner referral was assessed. Intention, self-efficacy, and previous behaviour predicted partner referral for women whereas intention, partner type and previous behaviour predicted partner referral for men. For the women the strongest predictors for intention were self-efficacy followed by attitude and partner type. For the men the strongest predictor was attitude followed by partner type and self-efficacy. Social influence was a better predictor of intention for women than for men. An analysis of underlying cognitive beliefs discriminating those who referred and those who did not refer the sexual partner showed that attitudinal beliefs were the most important for men whereas self-efficacy beliefs were the most important for women. The targeting of the gender-based discriminatory beliefs in intervention may improve compliance with sexual partner referral.

Lay people's perceptions of sexually transmitted infections in Uganda.

In order to understand lay people's perceptions of sexually transmitted infections (STIs) focus group discussions and semi-structured interviews were held with community members and patients with STIs in Mbarara and Kampala, Uganda. Symptoms of common STIs and the modes of transmission methods were known. STIs were perceived as naturalistic diseases caused by a tiny insect called akakoko or akawutka, although female infertility, one of the common complications of STIs, was perceived as a supernatural ailment. There was no stigma towards people with AIDS, although stigma towards people with other STIs was high. There were also strong negative attitudes towards the use of condoms. More than 60% of the patients interviewed had received treatment from the informal sector which included self-treatment and traditional healers. To reduce the incidence and complications of STIs, there may be a need to collaborate with the informal sector, to further evaluate the beliefs and practices identified in this study and to target them for health education.

PIP: This article aims to understand the perception of lay people in Uganda towards sexually transmitted infections (STIs). Focus group discussions and semi-structured interviews were conducted in the communities and statistical analysis through the Chi-square test was used to treat the data. Results showed that causes and modes of transmission of STIs were known to the people. An STI was perceived as a natural disease from an agent called "akakoko or akawuka," although female infertility, one of the common STI complications, was perceived as a supernatural ailment. People infected with HIV/AIDS were accepted by the society, but a person with another STI was stigmatized, in the sense that, they are infecting themselves when they already knew of AIDS. For STI prevention, avoiding and preventing sexual promiscuity was the most common method, but the people demonstrated a strong negative attitude towards the use of condom. Common among the respondents is the use of traditional healers for treating STIs and self-treatment of the disease.

Psychosocial determinants for sexual partner referral in Uganda: qualitative results.

In order to understand and elicit the psychosocial factors influencing compliance with sexual partner referral, 10 focus group discussions (FGDs) and 40 individual interviews based on the attitude-social influence-self efficacy (ASE) model were held in Mbarara District of Uganda. The focus groups were derived from both rural and urban areas. Informal interviews were held with 20 men and 20 women presenting with symptoms of a sexually transmitted disease (STD) at the outpatient department of Mbarara Hospital. The emerging outcome of attitudinal beliefs regarding health consequences of partner referral were mainly positive. However, outcome beliefs relating to the relationship with the partners were mainly negative. Social influence for sexual partner referral was from health-care providers, partner(s), friends and relatives. The self-efficacy beliefs were mainly negative especially among women. Barriers hampering sexual partner referral were related to poor quality of health care, gender relations and type of sexual partners. There is a need to target these beliefs and self-efficacy expectations in health education and STD counselling and for more research to evaluate the psychosocial determinants of sexual partner referral quantitatively.

Risk factors for recurrent sexually transmitted infections in Uganda.

OBJECTIVE: To identify predictors of recurrent sexually transmitted infections (STIs). DESIGN: A cross-sectional interview survey. SETTING: STD Clinic, Old Mulago Hospital, Kampala. METHODS: Eligible patients answered questions about their socio-demographic situation; STI symptoms; sexual behaviour; sexual partner referral; health seeking behaviour and whether they had a recurrent infection or not. Bivariate and multivariate stepwise logistic regression models were used to identify independent predictors of recurrent STIs. RESULTS: Fifty two (38%) out of 138 patients had recurrent STIs. On bivariate analysis the predictors of recurrent STIs were: being male; age > or = 25 years; inability to read in English; presenting with genital itching; attributing source of symptoms to sexual partner; not being asked to refer sexual partners at previous treatment site; having more than five lifetime partners; knowing how to use a condom; ever using a condom; and using a condom at least once in the previous three months. On multivariate analysis, independent risk factors for recurrent infection were: age > or = 25 years (Adjusted Odds Ratio [AOR] = 2.70, 95% CI 1.20, 5.88); inability to read English AOR = 3.09, (95% CI 1.38, 6.92); and having more than five, lifetime partners AOR = 2.56 (95% CI 1.11, 5.88). CONCLUSION: Reducing the number of sexual partners and targeting people who do not speak English with health education messages in the local language may reduce the frequency of recurrent STIs.

Contemporary treatment of tuberculosis in HIV prevalent countries in sub-Saharan Africa.

The HIV pandemic has been worst felt in sub-Saharan Africa. Tuberculosis is an opportunistic disease in the course of HIV infection and in the region, where the prevalence of both M. tuberculosis and HIV are very high, tuberculosis has become a major complication of HIV infection. The annual risk of tuberculosis infection remains high (1.5 to 2.5%) which is more than fifty times compared to the rates in Western Europe and the prevalence of HIV infection in tuberculosis patients ranges between 18 to 67%. More than 35% of the cases in most countries of sub-Saharan Africa are attributed to HIV. The tuberculosis treatment programmes in sub-Saharan Africa are overwhelmed with increasing number of clinical TB. This trend requires re-examination of the treatment strategy used in the region. There is need to replace streptomycin and thiacetazone in treatment regimens; provide effective short-course chemotherapy for all patients irrespective of their HIV status; use more of ambulatory treatment and expand the use of supervised intermittent therapy.

Chemoprophylaxis for tuberculosis in HIV-infected individuals in sub-Saharan Africa.

OBJECTIVE: To examine the role of chemoprophylaxis as a public health strategy for the control of tuberculosis in sub-Saharan Africa. DATA SOURCES: Published literature regarding efficacy, cost-effectiveness and operational feasibility of chemoprophylaxis programmes. STUDY SELECTION: Studies mainly published from countries in sub-Saharan Africa and other low income countries. DATA EXTRACTION: Manual search of journals and computer search of data bases. DATA SYNTHESIS: Latent infection with tuberculosis among adults in sub-Saharan Africa is more than 50% and HIV infection in the same age group is more than 10%. TB treatment programmes in the region are overwhelmed by increasing numbers of clinical TB. The efficacy and safety of isoniazid preventing TB among HIV infected individuals has been demonstrated in various studies. Though data on its cost-effectiveness is limited, computer modelling show that chemoprophylaxis for HIV associated tuberculosis is more cost-effective than chemotherapy. A national chemoprophylaxis programme need to achieve three broad objectives: HIV testing and counselling; tuberculin testing and exclusion of active TB; and to achieve high enough compliance rates. These objectives are best achieved by co-operation between National TB and AIDS control programmes. CONCLUSIONS: Because chemoprophylaxis for HIV associated TB makes economic and epidemiological sense, large national programmes should be initiated in sub-Saharan Africa. Operational research is necessary to define the best ways to deliver chemoprophylaxis to the majority of the HIV infected persons and to test the cost-effectiveness of chemoprophylaxis in established national programmes.

Factors influencing completion of treatment among tuberculosis patients in Mbarara District, Uganda.

An organised TB treatment programme was started in Uganda in 1989. A cohort analysis of treatment outcome among 1400 patients seen in Mbarara district in 1995 showed a very low compliance rate of 56% and this study attempted to look at operational factors that may be associated with this low compliance rate. The factors that are associated with enhanced completion of treatment include; being smear positive: use of short course chemotherapy; previous TB treatment; if patient returned for repeat smear; if patient did not change unit; and if patient did not change district. Gender and age were not associated with compliance. On unconditional logistic regression, previous TB treatment and being smear positive were found not to be statistically significant. Change of health unit after intensive phase showed the highest risk, with an adjusted odds ratio of 22.31. Of the significant factors only use of standard chemotherapy and change of health unit after intensive phase can be altered to improve compliance.

PIP: Tuberculosis (TB) causes considerable morbidity and mortality globally. The Uganda National Tuberculosis and Leprosy Program (NTLP) was launched in October 1989 in an attempt to coordinate and intensify TB control efforts in the country. The NTLP's main prevention and control strategy consists of case finding and chemotherapy. The retrospective cohort analysis of data on the treatment outcome of 1400 TB patients seen in Mbarara district in 1995 yielded a 56% compliance rate. The operational factors which may be associated with this low rate were subsequently investigated. The following factors were found to be associated with the enhanced completion of treatment: being smear positive, using short-course chemotherapy, having previously received TB treatment, being a return patient for repeat smear, being a patient who did not change unit, and being a patient who did not change district. Neither gender nor age was associated with compliance. Unconditional logistic regression found previous TB treatment and smear-positive status to be statistically insignificant. Change of health unit after the intensive phase of treatment showed the highest risk of default, with an adjusted odds ratio of 22.31. Of the significant factors, only the use of standard chemotherapy and change of health unit after the intensive phase can be changed to improve compliance.

Predictors for compliance with community directed ivermectin treatment in Bushenyi district of Uganda: qualitative results.

OBJECTIVE: To understand and elicit the factors influencing compliance with mass treatment with ivermectin for onchocerciasis control with a view of suggesting remedial measures. DESIGN: Qualitative methods using focus group discussion and individual key informant interviews. SETTING: Bushenyi district, Uganda. PARTICIPANTS: Fifty key informants who were local council chairpersons and community directed drug distributors (CDDs) for ivermectin. Five focus group discussions with community members. MAIN OUTCOME MEASURES: Explored knowledge about onchocerciasis and its treatment, consequences, benefits and perceived dangers of treatment with ivermectin. In addition the FGDs elicited information regarding social influence towards ivermectin treatment and who the source of social influences are. Perceived barriers and supports towards ivermectin treatment were also explored. The key informant interviews mainly elicited the problems they face in ivermectin distribution and their suggestions for improvement. RESULTS: Factors that could possibly influence mass treatment with ivermectin that were elicited include consequences of treatment, programme organization, charging for ivermectin distribution and programme/community support to the ivermectin drug distributors. CONCLUSIONS: These results are helpful in redirecting community education and in helping to design further quantitative research.

National immunisation days for polio eradication in Uganda: did immunisation cards increase coverage?

OBJECTIVE: To analyse the effect of cards and of vitamin A supplementation on coverage for National Immunisation Days (NIDs). DESIGN: A retrospective ecological study. SETTING: A countrywide NIDs coverage before and after introduction of the NIDs cards and vitamin A supplementation in all districts of Uganda. METHODS: NIDs for polio eradication commenced in Uganda in 1996. Two rounds, one month apart are implemented yearly. During the second round of 1998 NIDs, cards were introduced nationally and vitamin supplementation was introduced in 24 of the 45 districts. We compared NIDs coverage before and after NIDs cards and NIDs coverage in districts that implemented vitamin A to those that did not. RESULTS: After introduction of NIDs cards, the national coverage rose from 97.7% to 106.9%, an increase of 9.2%. In those districts that implemented vitamin A supplementation, the NIDs coverage rose from 100.1% to 111.5%, an increase of 10.4%. In those districts that did not implement vitamin A, the NIDs coverage rose by 6.7% from 94.5% to 102.2%. Before the introduction of cards and vitamin A in 1996 and 1997, the NIDs coverage was between 92-96%. CONCLUSION: NIDs cards and vitamin A supplementation could have increased the NIDs national coverage.

PIP: A retrospective ecological study was carried out to analyze the effect of cards and vitamin A supplementation on coverage for National Immunization Days (NIDs) in Uganda. Commenced in 1996, NIDs for polio eradication in Uganda are implemented twice a year, one month apart. During the second round of 1998 NIDs, cards were introduced nationally and vitamin A supplementation was introduced in 24 of the 45 districts. NIDs coverage before and after the introduction of cards and NIDs coverage in districts implementing and those not implementing vitamin A supplementation were compared. After introduction of NID cards, the national coverage increased by 9.2% (from 97.7% to 106.9%). In those districts that implemented vitamin A supplementation, a 10.4% rise in NIDs coverage was noted (from 100.1% to 111.5%). NIDs coverage in those districts that did not implement vitamin A supplementation rose from 94.5% to 102.2%, an improvement of 6.7%. Based on these findings, it was concluded that NIDs cards and vitamin A supplementation could have increased the NIDs national coverage.