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A patient centred, solution-focused approach, DIALOG+ was assessed for effectiveness among patients with severe mental illness (SMI) and epilepsy in Uganda. Fourteen clinicians and 168 patients attending Butabika National Mental Referral Hospital and outreach clinics in Kampala, Uganda were randomised equally to receive DIALOG ​+ ​once a month for six months or an active control (DIALOG scale only). The primary outcome was subjective quality of life measured by the Manchester Short Assessment of Quality of life (MANSA) at six months and secondary outcomes assessed at six and twelve months. A generalised linear model with a fixed effect for treatment and the baseline MANSA score and a random effect for clinicians to account for clustering was used to analyse effectiveness of the intervention. The primary outcome was assessed in 154 out of 168 patients (91.7%). Patients in the DIALOG ​+ ​arm had significantly higher subjective quality of life with a medium Cohen's d effect size of 0.55 and higher adherence to medication after 6 months as compared to the control group. DIALOG ​+ ​intervention could be a therapeutically effective option for improving quality of life for patients with severe mental illness and epilepsy with the potential to enhance routine review meetings in low-resource settings., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Background: COVID-19-related lockdowns and other public health measures may have differentially affected the quality of life (QOL) of older people with and without human immunodeficiency virus (HIV) in rural Uganda., Methods: The Quality of Life and Aging with HIV in Rural Uganda study enrolled people with and without HIV aged over 49 from October 2020 to October 2021. We collected data on COVID-19-related stressors (behavior changes, concerns, interruptions in health care, income, and food) and the participants' QOL. We used linear regression to estimate the associations between COVID-19-related stressors and QOL, adjusting for demographic characteristics, mental and physical health, and time before vs after the lockdown during the second COVID-19 wave in Uganda. Interaction between HIV and COVID-19-related stressors evaluated effect modification., Results: We analyzed complete data from 562 participants. Mean age was 58 (standard deviation (SD) = 7); 265 (47%) participants were female, 386 (69%) were married, 279 (50%) had HIV, and 400 (71%) were farmers. Those making ≥5 COVID-19-related behavior changes compared to those making ≤2 had worse general QOL (estimated linear regression coefficient (b) = - 4.77; 95% confidence interval (CI) = -6.61, -2.94) and health-related QOL (b = -4.60; 95% CI = -8.69, -0.51). Having access to sufficient food after the start of the COVID-19 pandemic (b = 3.10, 95% CI = 1.54, 4.66) and being interviewed after the start of the second lockdown (b = 2.79, 95% CI = 1.30, 4.28) were associated with better general QOL. Having HIV was associated with better health-related QOL (b = 5.67, 95% CI = 2.91,8.42). HIV was not associated with, nor did it modify the association of COVID-19-related stressors with general QOL., Conclusions: In the context of the COVID-19 pandemic in an HIV-endemic, low-resource setting, there was reduced QOL among older Ugandans making multiple COVID-19 related behavioral changes. Nonetheless, good QOL during the second COVID-19 wave may suggest resilience among older Ugandans., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

Introduction: Alcohol use is a global driver of HIV infection and disease progression, mediated through risky behaviour and poor antiretroviral adherence. Most studies about the burden of alcohol use among people living with HIV (PLWH)/AIDS have been done in adult populations, but less is known about young people with HIV, especially in low-income and middle-income countries (LMICs), despite the high level of alcohol use in these settings. The aim of this review is to collate evidence on the prevalence of, and factors associated with, alcohol use disorder (AUD) among young adults (aged 15-24 years) living with HIV/AIDS in LMICs., Methods and Analysis: Two experienced librarians will conduct an independent article search in PubMed, PsycINFO, Embase and Web of Science databases, using relevant Medical Subject Headings terms and Boolean operators ('AND', 'OR'). We will include English-language articles that were published in peer-reviewed journals from 1 January 2000, to 25 July 2022, that documented the prevalence of AUD among young people (15-24 years) living with HIV in LMICs. We shall exclude systematic review articles and qualitative studies. Two independent reviewers will screen the articles for eligibility and data will be extracted onto a preset Excel spreadsheet. Data analysis will be done using Stata V.14.0. Heterogeneity will be assessed by use of the I 2 statistic and data will be pooled in meta-analyses where appropriate. Publication bias will be assessed using the funnel plot., Ethics and Dissemination: Ethical approval is not needed as this systematic review will be based on published studies. Findings from this study will be disseminated via submission for publication in a peer-reviewed journal, at conference presentations, and made available to health professionals, scientists and policy makers. Our data set can be made available on request., Registration Details: PROSPERO, CRD42022308955., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The way societies comprehend and interpret aging has been in constant flux, mainly as life expectancy benchmarks increase and worldwide dynamics transform. Similar to many other nations, Uganda is experiencing this demographic shift. People aged 60 and above, who form a mere 2.7% of Uganda's population, are gradually emerging as a segment worth attention. This surge in life expectancy, which has increased from 50 to 63 years over the last decade, indicates a significant transformation in healthcare, lifestyles, and societal structures. Given this backdrop, there is a pressing need to delve deeper into the perceptions and experiences of this age cohort, especially in Central Uganda. This area mirrors the national trends., Methods: This study adopted a rigorous methodological approach. Individuals aged 60 years and above were selected through purposive sampling, which aimed to draw out rich and diverse narratives. These participants participated in seven in-depth Focus Group Discussions (FGDs) held in Wakiso District. To ensure accuracy in representation, all discussions were first transcribed in Luganda, the local dialect, before careful translation to English., Results: The participants presented a broad age spectrum from 62 to 90 years. The demographic data revealed a majority of female participants (54%), and a noteworthy statistic was that over half (51%) lacked a steady income source. Meticulous thematic analysis uncovered three themes. First, the journey of ageing encompasses physical, psychological, and social shifts, such as diminishing mobility, deteriorating health, and mounting social isolation. Second, the brighter side of ageing manifests in intangibles such as accumulated wisdom and a profound sense of life's accomplishments. The third theme echoed the harsher realities of aging, highlighting struggles with maintaining independence, looming financial challenges, and the sting of social exclusion.

This article sets out to investigate alcohol and substance use (ASU) among adolescents living with HIV (ALWH) in the sub-Saharan African setting of Uganda. A cross-sectional analysis of the records of 479 adolescents (aged between 12and 17 years) attending the study, "Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)" was undertaken. ASU was assessed through both youth self-report and caregiver report using the Diagnostic and Statistical Manual of Mental Disorders-5 referenced instruments, the Youth Inventory-4R and the Child and Adolescent Symptom Inventory-5 (CASI-5). Rates and association with potential risk and outcome factors were investigated using logistic regression models. The rate of ASU was 29/484 (5.9%) with the most frequently reported ASU being alcohol 22/484 (4.3%) and marijuana 10/484 (2.1%). Functional impairment secondary to ASU was reported by 10/484 (2.1%) of the youth. ASU was significantly associated with urban residence, caregiver psychological distress and the psychiatric diagnosis of post-traumatic stress disorder. On associations with negative outcomes, ASU was significantly associated with only "ever had sex". Health care for ALWH in sub-Saharan Africa should include ASU prevention and management strategies. [ABSTRACT FROM AUTHOR]

Background: Substance use among people living with HIV is associated with poor health, social, and psychological outcomes. This study assessed the prevalence of substance use and associated factors among youth attending HIV care and treatment centers (CTCs) in Dodoma, Tanzania., Methods: This cross-sectional study was carried out in Dodoma, Tanzania, from February to April 2020 among youth aged 15-24 attending HIV CTCs. Data was collected using sociodemographic, WHO ASSIST Version 3.0, BDI II, and SERAD questionnaires. Data analysis was done using Stata 17. Descriptive statistics were used to summarize continuous and categorical variables. Univariable and multivariable logistic regression analyses were conducted to determine factors independently associated with substance use., Results: The prevalence of substance use was relatively low (6.6%). Older youth (20 to 24 years) were 2% less likely to use substances compared to the younger ones (15 to 19 years) (AOR: 0.07; 95% CI 0.01, 0.83). There were statistically significant decreasing odds of substance use with every year increase in age at HIV diagnosis (OR: 1.66; 95% CI 1.14, 2.41). Being unemployed was statistically significantly associated with decreased odds of substance use among this population (OR: 0.03; 95% CI 0.02, 0.33). Youth who had detectable viral loads were significantly more likely to use substances compared to those with undetectable viral loads (AOR: 12.9; 95% CI 1.07, 156.05)., Conclusions: Despite the low prevalence of substance use found in this study, it is important to note that late age of HIV diagnosis, employment, and detectable viral load negatively impacted HIV positive youth with regards to substance use. It is recommended that CTCs emphasize routine screening for substance use among youth who have detectable viral loads., (© 2022. The Author(s).)

Introduction: Neurocognitive impairment (NCI) is commonly exhibited among patients experiencing their first episode of psychosis. However, there are few resources in many low-income countries, such as Uganda, that allow for the administration of extensive neurocognitive test batteries for the detection of NCI. NeuroScreen is a brief tablet-based neurocognitive assessment battery that can be administered by all levels of healthcare staff. We examined the validity of NeuroScreen to assess neurocognition and detect NCI in first-episode psychosis (FEP) patients in Uganda., Methods: We enrolled 112 participants FEP patients and matched controls at Butabika Mental Referral Hospital. Each participant completed NeuroScreen and a traditionally administered neurocognitive battery: the MATRIC Consensus Cognitive Battery (MCCB). We examined correlations between participant performance on NeuroScreen and the MCCB. A ROC curve determined sensitivity and specificity of NeuroScreen to detect NCI as determined by MCCB criterion., Results: There was a large, statistically significant correlation between overall performance on NeuroScreen and the MCCB [ r (112) = 0.64, p  < .001]. Small to large correlations were found between tests in the MCCB and NeuroScreen batteries. The ROC curve of NeuroScreen performance to detect MCCB-defined NCI had an area under curve of 0.80 and optimal sensitivity and specificity of 83 % and 60 %, respectively., Conclusion: There was a moderate positive correlation between overall performance on both batteries. NeuroScreen shows promise as a valid assessment battery to assess neurocognition and detect NCI in FEP patients in Uganda. Further studies of NeuroScreen in healthy individuals and in a range of mental disorders are recommended., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Published by Elsevier Inc.)

Background: Children in Sub-Saharan Africa are burdened by significant unmet mental health needs. Across the region, high rates of poverty, HIV/AIDS, food insecurity, stigma, and an inadequate health safety net system exacerbate serious child behavioral health needs and impede an effective response. Disruptive behavioral disorders are particularly concerning as they persist through adolescence and adulthood. Hence, addressing the context-specific social influences on child behavioral health is critical given that children in the region comprise more than half of the total regional population. Against this backdrop, this study protocol describes a randomized clinical trial that will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial, and context-specific drivers affect the mental health of children in Uganda., Methods: The study uses an experimental, longitudinal design across 30 cluster-randomized primary schools to compare single and combination intervention options; influences of economic empowerment and family strengthening on economic, perceptual, and functioning mediators; and context-specific moderators. The study will be conducted with 900 Ugandan children in mid-upper primary school (10-14 years). The three study conditions ( n = 300 each) are: (1) economic empowerment only (EE only), (2) multiple family group-based family strengthening only (MFG-based FS only), and (3) combined EE + MFG-based FS. The interventions will be provided for 12 months; and assessments will occur at baseline, 12, 24, and 36 months., Conclusion: Children in Sub-Saharan Africa are burdened by significant unmet mental health needs, including disruptive behavior disorders that persist through adolescence and adulthood if left untreated. The proposed study will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial and context-specific drivers affect the mental health of children in mid-upper primary schools in Uganda. Findings from this study can inform group, community, and population approaches that are needed for scalable solutions to address the social drivers negatively impacting child behavioral health in low-resource settings, including in Sub-Saharan Africa., Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [NCT053 68714]., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ssewamala, McKay, Sensoy Bahar, Nabunya, Neilands, Kiyingi, Namatovu, Guo, Nakasujja and Mwebembezi.)

We investigated the prevalence and risk factors for frailty among people with HIV (PWH) in rural Uganda (n = 55, 47% male, mean age 44 years). Frailty was defined according to the Fried criteria with self-reported physical activity level replacing the Minnesota Leisure Time Activity Questionnaire. Alternate classifications for physical activity utilized were the sub-Saharan Africa Activity Questionnaire and the International Physical Activity Questionnaire. Eleven participants (19%) were frail. Frail participants were older (p < 0.001), less likely to be on antiretroviral therapy (p = 0.03), and had higher rates of depression (p < .001) and HIV-associated neurocognitive disorder (p = 0.003). Agreement between physical activity measures was sub-optimal. Prevalence of frailty was high among PWH in rural Uganda, but larger sample sizes and local normative data are needed.

Introduction: With improved HIV treatment availability in sub-Saharan Africa, the population of older people with HIV (PWH) is growing. In this qualitative study, we intended to understand (1) the lived experiences of ageing people in rural Uganda, with and without HIV, (2) their fears and health priorities as they grow older., Methods: We conducted 36 semi-structured interviews with individuals with and without HIV in Mbarara, Uganda from October 2019 to February 2020. Interview guide topics included priorities in older age, physical functioning in daily activities, social functioning, HIV-related stigma and the impact of multimorbidity on health and independence. Interviews were conducted in Runyankole, transcribed, translated and inductively coded thematically by two researchers with tests for inter-coder reliability., Results: The respondents were purposively sampled to be evenly divided by sex and HIV serostatus. The median age of respondents was 57 (49-73). Two-thirds were married or cohabitating, 94% had biological children and 75% cited farming as their primary livelihood. Overall, PWH considered themselves as healthy or healthier than people without HIV (PWOH). PWH rarely considered their HIV status a barrier to a healthy life, but some reported a constant sense of anxiety as it relates to their long-term health. Irrespective of HIV status, nearly all respondents noted concerns about memory loss, physical pain, reductions in energy and the effect of these changes on their ability to complete physical tasks like small-scale farming, and activities of daily living important to the quality of life, such as participating in community groups. Increasing reliance on others for social, physical and financial support was also a common theme. The most prevalent health concern among participants involved the threat of non-communicable diseases and perceptions that physical functioning may diminish., Conclusions: In rural Uganda, we found that PWH consider themselves to be healthy and do not anticipate a different ageing experience from PWOH. Common priorities shared by both groups included the desire for physical and financial independence, health maintenance and social support for daily functioning and social needs. Entities supporting geriatric care in Uganda would benefit from attention to concerns about functional limitations and reported needs as people age with and without HIV., (© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Background: Psychotic disorders contribute to significant morbidity and mortality partly due to the chronicity of the illness and high relapse rates. Delivering psycho-education messages about disease etiology, their signs and symptoms and the benefits of treatment adherence have been shown to improve clinical outcomes among individuals with psychoses. However, little has been done to examine the feasibility and efficacy of this intervention in low resourced settings., Objective: Our primary objective will be to determine the feasibility of recruiting and retaining patients with a first episode psychosis (FEP) and for the secondary objective, we will determine the preliminary efficacy of psycho-education on illness self-management, stigma, adherence to medications and symptom severity., Hypothesis: We hypothesize that (i) we will recruit 70% of eligible participants and accrue a sample size of 80 over 20-weeks, retaining 80% of the sample size for 24 weeks, (ii) the intervention will lead to improvement in clinical outcomes (described above)., Methods: We will recruit 80 adult patients who have been diagnosed with a FEP, received antipsychotic medication at Butabika Hospital and reside within 21km from the Hospital. Trained village health team (VHTs) members will deliver 6 psycho-education sessions to 40 participants and their family members (intervention arm). Participants in the control arm (n = 40) will receive routine care. We will document how feasible it will be to recruit and retain participants over 24 weeks and document the preliminary efficacy of the intervention on illness self-management, stigma, adherence to medications and severity of symptoms., Data Analysis: We will document the proportion of participants who consent and get recruited, the proportion of those who will get retained and reasons for drop out. We will conduct an intention to treat analysis comparing the groups at weeks 4, 12, 24 and assess the effect of the intervention on the clinical outcomes (described above). We will use the Bonferroni approach to correct for multiple comparisons., Trial Registration: Clinical trials.gov registration number: NCT04602585., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Cognitive impairment is common in first-episode psychosis patients and often associated with poor quality of life and functional impairment. However, most literature on this association is from high income countries and not low resource countries like Uganda. We aimed to determine the association between cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients., Methods: At Butabika national psychiatric hospital of Uganda, we enrolled 94 first-episode psychosis patients aged 18-60 years with a confirmed first-episode of psychosis and no previous treatment with antipsychotic medication. Neuropsychological assessment was performed using the MATRICS consensus cognitive battery (MCCB). Quality of life and functional impairment were assessed using the brief version of the World Health Organisation Quality of Life scale (WHOQOL-BREF) and the MINI International Neuropsychiatric Inventory (MINI) respectively. Linear regression analyses determined the association between impairment in different cognitive domains with various quality of life and functional impairment domains while controlling for age, gender and level of education., Results: High scores in the reasoning and problem solving cognitive domain were associated with better quality of life in the psychological domain of WHOQOL-BREF (p = 0.029). For functional impairment, high cognitive scores in the domains of speed of processing (p = 0.018), reasoning and problem solving (p = 0.015), working memory (p = 0.017) and visual learning and memory (p = 0.002) were associated with psychosis "having a greater impact on other members of the family" on the MINI. Higher scores in the social cognition domain were associated with "less aggressive and disruptive behaviour" (p = 0.003)., Conclusion: Cognitive impairment in Ugandan first-episode psychotic patients is associated with both poorer quality of life and functional impairment. Remediation of cognitive function may be a plausible intervention to improve outcomes in Ugandan first-episode psychosis patients., (© 2022. The Author(s).)

Background: Worldwide, two million babies are stillborn and 1.8 million babies die before completing seven days of life. Approximately 4% of pregnant women in Uganda experience perinatal death. The response following a perinatal death tends to be socio-culturally constructed. Investigating the unique personal experiences of parents from a low-income setting with unique cultural beliefs and practices is crucial for the design and implementation of appropriate interventions., Objective: To describe the lived experiences of parents following perinatal death in Lira district, Northern Uganda., Methods: A qualitative study was carried out drawing on the tenets of descriptive phenomenology. We conducted 32 in-depth interviews in Lira district, Northern Uganda between August 2019 and September 2020 with 18 women and 14 men who had experienced a stillbirth or an early neonatal death within the preceding 2 years. Participants were selected from different families and interviewed. A local IRB approved the study. All in-depth interviews were audio-recorded, transcribed, translated, and data were analysed using a content thematic approach. Key findings were discussed based on Worden's Four Tasks of Mourning theory., Results: The themes that emerged from the analyses included reaction to the perinatal loss and suggestions for support. The participants' immediate reactions were pain, confusion, and feelings of guilt which were aggravated by the unsupportive behaviour of health care providers. Men cumulatively lost financial resources in addition to facing multiple stressful roles. Delayed reactions such as pain and worries were triggered by the sight of similar-age-babies, subsequent pregnancy losses, and marital challenges. Participants recommended emotional support and management of postnatal complications for parents faced with perinatal loss., Conclusion: Losing a baby during the perinatal period in a resource-constrained setting negatively affected both gender. In addition, men suffered the loss of financial resources and the burden of multiple stressful roles. Acknowledging the pain and offering support to the grieving parents reinforce their coping with a perinatal loss. In addition to family and community members, health care providers need to provide emotional support and postnatal care to parents who experience perinatal death., (© 2022. The Author(s).)

Background: HIV infection results in immunometabolic reprogramming. While we are beginning to understand how this metabolic reprogramming regulates the immune response to HIV infection, we do not currently understand the impact of ART on immunometabolism in people with HIV (PWH)., Methods: Serum obtained from HIV-infected ( n = 278) and geographically matched HIV seronegative control subjects ( n = 300) from Rakai Uganda were used in this study. Serum was obtained before and ~2 years following the initiation of ART from HIV-infected individuals. We conducted metabolomics profiling of the serum and focused our analysis on metabolic substrates and pathways assocaited with immunometabolism., Results: HIV infection was associated with metabolic adaptations that implicated hyperactive glycolysis, enhanced formation of lactate, increased activity of the pentose phosphate pathway (PPP), decreased β-oxidation of long-chain fatty acids, increased utilization of medium-chain fatty acids, and enhanced amino acid catabolism. Following ART, serum levels of ketone bodies, carnitine, and amino acid metabolism were normalized, however glycolysis, PPP, lactate production, and β-oxidation of long-chain fatty acids remained abnormal., Conclusion: Our findings suggest that HIV infection is associated with an increased immunometabolic demand that is satisfied through the utilization of alternative energetic substrates, including fatty acids and amino acids. ART alone was insufficient to completely restore this metabolic reprogramming to HIV infection, suggesting that a sustained impairment of immunometabolism may contribute to chronic immune activation and comorbid conditions in virally suppressed PWH.

Achieving universal HIV test-and-treat will require targeted interventions for those with worse outcomes, including advanced HIV. We conducted qualitative, semi-structured interviews with healthcare workers (HCWs) and people living with HIV (PLWH) at 5 HIV clinics in Kampala, Uganda, to understand barriers to care. PLWH enrolled started/restarted on HIV treatment ≤3 months prior. PLWH were grouped as 1) "ART-experienced" or those restarted therapy after ≥12 months off, 2) ART naïve CD4 count <100 cells/uL "late presenters" or 3) ART naïve CD4 count >350 cells/uL "early presenters". In-depth interviews were conducted in Luganda, translated, and transcribed verbatim. Between May and August 2017, 58 PLWH and 20 HCWs were interviewed. High stigma and low social support emerged as themes among all as barriers to care. Alcohol abuse was a barrier for men. Fear of domestic violence and abandonment were barriers for women, limiting disclosure of their HIV status to their male partners. Clinic factors such as rapport with staff, distance, efficiency, and privacy impacted care. Future interventions to decrease delayed ART initiation should target stigma and social support. Assisted disclosure, contact tracing, and alcohol abuse treatment should be implemented. Strengthening client support, reducing wait times, and increasing privacy assurances would improve care-seeking behaviors.

Background: HIV-associated neurocognitive disorders remain prevalent despite effective antiretroviral therapy (ART), but there are limited longitudinal data on people living with HIV (PLWH) in sub-Saharan Africa. We examined neuropsychological (NP) performance in PLWH in a longitudinal study in Uganda., Methods: Participants enrolled through the Rakai Community Cohort Study (400 ART-naive PLWH and 400 matched HIV-negative persons) were administered NP assessments. In 2017, PLWH who had initiated ART underwent a 2-year follow-up assessment. Demographically adjusted Z-scores for each NP test were established using data from the HIV- controls. Multivariable linear and logistic regressions were conducted to examine group differences in NP performance. Mixed-effects regressions were conducted to examine ART-related changes in NP outcomes., Results: Of 333 PLWH who returned for their 2-year follow-up visit, 312 (94%) had initiated ART. Those on ART had a mean age of 35.6 years (SD ± 8.5 years) and mean education of 5.4 years (SD ± 3.3 years); 49% were women. ART-associated NP improvements occurred in verbal learning and memory (P's < 0.05), motor (P's < 0.01), and some measures of processing speed (P = 0.002), whereas there were declines in attention/working memory (P's < 0.001) and semantic fluency (P < 0.001). Pre-ART CD4 count and efavirenz use were associated with a more impaired change in NP performance., Conclusions: PLWH in this resource-limited setting showed improved neurocognitive performance on most NP tests after ART initiation. However, the declines in attention/working memory and fluency performance, as well as relationship to efavirenz, warrant further study.

We investigated changes in cognitive function and physical health and behavioural outcomes (HIV disease progression, health-seeking behaviour, adherence to HIV medications and risky sexual behaviour) at baseline and 12 months later among 1126 Ugandan adults living with HIV. Overall, cognitive function improved from baseline to follow-up, except for gait speed, which was slower at follow-up compared to baseline. There were improvements in physical health and behavioural outcomes by follow-up, with greater improvements among individuals on ART compared to those not on ART. Change in gait speed over time significantly predicted risky sexual behaviours at follow-up. This is the first study to investigate the longitudinal relationships between cognitive function and health outcomes among Ugandan adults living with HIV and provide insights into the possible links between cognitive function and negative clinical and behavioural health outcomes in people living with HIV. [ABSTRACT FROM AUTHOR]

Introduction: The number of children living with HIV is increasing worldwide and is a major public health concern as they grow into adolescence and young adulthood with increasing access to antiretroviral therapy (ART) especially in the African region. There is a pressing need to transfer them from paediatric to adult care which has implications for their well-being. The objective of this scoping review is to systematically review published and unpublished literature to understand the extent and type of evidence in relation to the transition of adolescents to adult HIV clinics in the African region., Methods and Analysis: Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Review) guidelines for conducting a scoping review, we will systematically search online bibliographic databases including PubMed, EMBASE, Google Scholar and bibliographies of pertinent articles. This will be supplemented by searches in grey literature databases. Two reviewers will independently review all articles to determine if they meet eligibility criteria. Any conflicts will be resolved after discussion with a third reviewer to ensure accurate and reliable data collection. Both quantitative and qualitative results will be extracted from all included articles and synthesised in a narrative form in response to the review questions., Ethics and Dissemination: The scoping review does not require ethics approval as we will collect and review existing literature and materials. The results will be disseminated through a peer-reviewed publication, conference presentations and stakeholder meetings to support clinicians, health experts and policy makers develop guidelines and evidence-based transition protocols favourable for the populations in the African region to minimise challenges associated with the transition process., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 Quinn CM et al.)

Children in Uganda are at risk for significant cognitive sequelae from severe malaria. Computerized cognitive rehabilitation training (CCRT) represents a potential method to improve working memory, behavior, and executive functioning, cognitive domains most at risk following severe malaria. The primary aim of this study was to complete a secondary analysis of data from a concluded CCRT randomized control trial in order to compare the training efficiency of a commonly used CCRT program under conditions of titrated (adaptive) or non-titrated (non-adaptive) training and with children with increasing malaria severity to determine how various factors may affect potential CCRT improvement. A total of 201 school-aged children (66.2% boys) who were either healthy (n = 102) or previously diagnosed with severe or cerebral malaria (n = 99) were randomized into two active treatment arms (titrated and non-titrated learning). Each child received 24 one-hour sessions of training over 8 weeks using Captain's Log® CCRT by BrainTrain, which includes a comprehensive set of CCRT tasks. Children generally benefited from CCRT over the 24 training sessions, but titrated CCRT showed a clear advantage over non-titrated. Severity of illness or factors such as BMI, did not moderate CCRT performance indicators. These findings support our hypothesis that titrated CCRT would result in steeper improvement in learning, but do not support our hypothesis that history of recent significant illness would affect learning proficiency. Findings were evident across all CCRT performance scores, even given that children were from generally rural, low-resource settings and were generally unfamiliar with computers. ABBREVIATIONS: Computerized Cognitive Rehabilitation Training (CCRT); Mental Processing Index (MPI); Home Observation for the Measurement of the Environment (HOME); Socioeconomic Status (SES); least square means (LSM).

Background: Uganda's population, though, largely characterized by young people, has seen the number of people aged 60 and over grow from 686,000 twenty years ago, to 1,433,596 in 2014. Effective caring for the well-being of this population requires strategic and deliberate planning that involves Quality Of Life (QoL) assessments. QoL assessments among the elderly are important in evaluating the efficacy of strategies, such as health interventions, welfare programs, health care and well-being of the elderly. However, elderly in Uganda face several challenges, ranging from loneliness, poor housing, lack of social and financial support and poor health. These may negatively affect older persons' quality of life and consequently their perceptions and attitudes towards aging., Methods: The study was carried out in 2019 in the communities of Nansana and Busukuma town councils in Wakiso district, Uganda. The participants were 380 people 60 years and older. To establish the association between perceptions of ageing and QoL, this study utilized a locally adapted version of the Older Person's Quality of Life Questionnaire (OPQOL) and the Brief Ageing Perceptions Questionnaire (B-APQ). The OPQOL assesses three domains of QoL: Health QoL (HQoL); Social economic QoL (SQoL); and Psychosocial QoL (PQoL). The B-APQ assesses perceptions about physical age, participation in social activities, and perceptions about ability to regulate emotions as one ages. Pearson's Chi-square tests were used to characterize the relationship between the perceptions and quality of life., Results: The majority of the respondents, 61% (95%CI 56.7-64.8), had negative perceptions towards ageing. Eighty six percent had poor HQoL, 90% poor SQoL and 83% poor PQoL. There was a significant association between good HQoL and positive perception about participation in social activities (X2 = 7.3670, P = 0.007) as well as with positive perception on regulation of emotions (X2 = 18.1803, P<0.001). There was a significant association between good SQoL and positive perception about participation in social activities (X2 = 5.3472, P = 0.021), as well with positive perception on regulation of emotions (X2 = 10.5128, P<0.001). A significant association between good PQoL and positive perception on regulation of emotions (X2 = 9.2414, P= 0.002)., Conclusion: Positive perceptions of ageing are associated with good QoL. Directly addressing perceptions of ageing could be a low cost and effective strategy to improve the QoL of older persons in SSA., Competing Interests: Competing Interest The authors declare no conflict of interest.

Introduction: The MATRICS consensus cognitive battery (MCCB) is the gold standard for neuropsychological assessment in psychotic disorders but is rarely used in low resource settings. This study used the MCCB to determine the prevalence, profile and associations of various exposures with cognitive impairment in Ugandan first-episode psychosis patients., Methods: Patients and matched healthy controls were recruited at Butabika Hospital in Uganda. Clinical variables were first collated, and after the resolution of psychotic symptoms, a neuropsychological assessment of seven cognitive domains was performed using the MCCB. Cognitive impairment was defined as two standard deviations (SD) below the mean in one domain or 1SD below the mean in two domains. Descriptive statistics determined the prevalence and profile of impairment while regression models determined the association between various exposures with cognitive scores while controlling for age, sex and education., Results: Neuropsychological assessment with the MCCB found the burden of cognitive impairment in first-episode psychosis patients five times that of healthy controls. The visual learning and memory domain was most impaired in first-episode psychosis patients, while it was the working memory domain for the healthy controls. Increased age was associated with impairment in the domains of the speed of processing (p < 0.001) and visual learning and memory (p = 0.001). Cassava-rich diets and previous alternative and complementary therapy use were negatively associated with impairment in the visual learning (p = 0.04) and attention/vigilance domains (p = 0.012), respectively. There were no significant associations between sex, history of childhood trauma, or illness severity with any cognitive domain., Conclusion: A significant burden of cognitive impairment in Ugandan first-episode psychosis patients is consistent with prior data from other contexts. However, the profile of and risk factors for impairment differ from that described in such work. Therefore, interventions to reduce cognitive impairment in FEP patients specific to this setting, including dietary modifications, are required., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors.)

We tested a model of dyadic interdependence in depression symptoms experienced by female caregivers living with HIV in Uganda (n = 288) and behavioral problems of their HIV-infected (n = 92) and perinatally HIV-exposed uninfected (HEU) children (n = 196). Three repeated measures of caregiver depression symptoms and child neurodevelopment and behavioral outcomes were related to their own outcomes at a previous time point (actor effects), and the outcomes of the other member of the dyad (partner effects). Caregiver depression and child behavioral problem were interdependent over the 24 months of observation. Caregiver depression at T n predicted child's behavioral problems at T n+1 (coefficient = 0.1220, SE = 0.0313, p < 0.01); child behavioral problems at T n predicted maternal depression at T n+1 (coefficient = 0.0984, SE = 0.0253, p < 0.01). Results suggest the importance of services addressing behavioral needs of affected children and mental health of their mothers., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Background: Depression is a major cause of the global disease burden and globally affects 350-400 million persons making it the largest contributor to years lived with disability. Among of patients with chronic physical illnesses like tuberculosis, depression affects up to 25-33% of individuals. There are limited studies on the comorbidity of depressive illness and tuberculosis in the Ugandan setting. Our aim was to determine the prevalence and factors associated with depressive illness in patients with tuberculosis in Mulago Hospital, Uganda., Methods: This was a cross sectional study involving 308 consecutively sampled participants aged 18 years and above diagnosed with tuberculosis attending the tuberculosis clinic in Mulago Hospital, Uganda. Consecutive sampling was done for a sample size of 308 participants. Participants had the following instruments administered to them; the Socio-demographic questionnaire, the Mini Neuropsychiatric Interview (MINI) to diagnose depressive illness and the Patient Health Questionnaire- 9 to rate the severity of depression. Data was entered using Epi-Data. Descriptive, bivariate and multivariate analyses were done with the Statistical Package for Social Sciences (SPSS)., Results: the prevalence of depressive illness was 23.7% (95% confidence interval 19.3-28.9). Depressive illness was independently associated with low education level (AOR = 0.39, 95%CI = 0.21-0.72, p = 0.003), being in the intensive phase of TB treatment (AOR = 2.34, 95%CI = (1.27-4.33), p = 0.007) and family history of depressive illness (AOR = 5.42, 95%CI = 2.02-14.54, p = 0.001). On the PHQ, 60.3% had moderate to severe depression., Conclusion: Depressive illnesses should be screened and managed among patients with TB., Recommendation: Depression should be routinely screened and managed among patients with Tuberculosis., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population., Competing Interests: No competing interests were disclosed., (Copyright: © 2021 Quinn CM et al.)

Depression is common following HIV infection and often improves after ART initiation. We aimed to identify distinct dimensions of depression that change following ART initiation in persons with HIV (PWH) with minimal comorbidities (e.g., illicit substance use) and no psychiatric medication use. We expected that dimensional changes in improvements in depression would differ across PWH. In an observational cohort in Rakai, Uganda, 312 PWH (51% male; mean age = 35.6 years) completed the Center for Epidemiologic Studies-Depression (CES-D) scale before and up to 2 years after ART initiation. Twenty-two percent were depressed (CES-D scores ≥ 16) pre-ART that decreased to 8% after ART. All CES-D items were used in a latent class analysis to identify subgroups with similar change phenotypes. Two improvement phenotypes were identified: affective-symptom improvement (n = 58, 19%) and mixed-symptom improvement (effort, appetite, irritability; n = 41, 13%). The affect-improvement subgroup improved on the greatest proportion of symptoms (76%). A third subgroup was classified as no-symptom changes (n = 213, 68%) as they showed no difference is symptom manifestation from baseline (93% did not meet depression criteria) to post-ART. Factors associated with subgroup membership in the adjusted regression analysis included pre-ART self-reported functional capacity, CD4 count, underweight BMI, hypertension, female sex(P's < 0.05). In a subset of PWH with CSF, subgroup differences were seen on Aβ-42, IL-13, and IL-12. Findings support that depression generally improves following ART initiation; however, when improvement is seen the patterns of symptom improvement differ across PWH. Further exploration of this heterogeneity and its biological underpinning is needed to evaluate potential therapeutic implications of these differences., (© 2021. Journal of NeuroVirology, Inc.)

Background: Literature shows a high prevalence of psychological distress (PD) as well as common mental disorders (CMD) such as major depressive disorders (MDD), generalized anxiety disorders (GAD), post-traumatic stress disorders (PTSD), and substance misuse disorders (SUD) among people exposed to disasters and pandemics like the COVID-19. Moreover, CMD are associated with increased mortality (mainly through suicide) and morbidity (loss of productivity). A number of countries have made deliberate efforts to identify and manage CMD in light of COVID-19. However, low levels of mental health literacy (MHL) manifested by the individual's unawareness of CMD symptoms, limited human and mental health infrastructure resources, and high levels of mental illness stigma (MIS) are barriers to integration of mental health care in general health care during pandemics and epidemics such as the COVID-19., Objectives: For the proposed study, we will determine effectiveness of a psycho-education intervention delivered by village health team (VHT) members., Methods: We will employ a cluster randomized trial design in 24 villages in central Uganda. We will collect baseline data to and document the prevalence of MHL, PD, MDD, PTSD, GAD, and SUD. We will distribute information education and communication materials (IEC) aimed at improving MHL to 420 adult individuals in the intervention arm (n = 12 villages). In the control arm (n = 12 villages), VHTs will distribute ministry of health COVID-19 information leaflets to 420 participants. Within 7 days of distributing the materials, research assistants will conduct a follow-up interview and assess for the same parameters (MHL, PD, MDD, PTSD, GAD, and SUD). We will use an intention to treat analysis to estimate the effectiveness of the psycho-education intervention., Discussion: Findings from this research will guide policy and practice regarding the integration of mental health services in the community in the context of epidemic preparedness and response., Trial Registration: ClinicalTrials.gov NCT04616989 . Registered on 05 November 2020., (© 2021. The Author(s).)

Background: Severe malaria is associated with long-term mental health problems in Ugandan children. This study investigated the effect of a behavioural intervention for caregivers of children admitted with severe malaria, on the children's mental health outcomes 6 months after discharge., Methods: This randomized controlled trial was conducted at Naguru Hospital in Kampala, Uganda from January 2018 to July 2019. Caregiver and child dyads were randomly assigned to either a psycho-educational arm providing information about hospital procedures during admission (control group), or to a behavioural arm providing information about the child's possible emotions and behaviour during and after admission, and providing age appropriate games for the caregiver and child (intervention group). Pre- and post-intervention assessments for caregiver anxiety and depression (Hopkins Symptom Checklist) and child mental health problems (Strength and Difficulties Questionnaire and the Child Behaviour Checklist) were done during admission and 6 months after discharge, respectively. T-tests, analysis of covariance, Chi-Square, and generalized estimating equations were used to compare outcomes between the two treatment arms., Results: There were 120 caregiver-child dyads recruited at baseline with children aged 1.45 to 4.89 years (mean age 2.85 years, SD = 1.01). The intervention and control groups had similar sociodemographic, clinical and behavioural characteristics at baseline. Caregiver depression at baseline, mother's education and female child were associated with behavioural problems in the child at baseline (p < 0.05). At 6 months follow-up, there was no difference in the frequency of behavioural problems between the groups (6.8% vs. 10% in intervention vs control groups, respectively, p = 0.72). Caregiver depression and anxiety scores between the treatment arms did not differ at 6 months follow-up., Conclusion: This behavioural intervention for caregivers and their children admitted with severe malaria had no effect on the child's mental health outcomes at 6 months. Further studies need to develop interventions for mental health problems after severe malaria in children with longer follow-up time. Trail registration ClinicalTrials.gov Identifier: NCT03432039.

Background: Individual and group level interventions have the largest effect on outcomes in patients with the first episode of psychosis. The quality of these individual and group level interventions provided to first-episode psychosis patients in Uganda is unclear., Aim: To determine the quality of the individual and group level interventions provided to first episode psychosis patients in Uganda., Setting: The study was performed at the only tertiary psychiatric hospital in Uganda., Methods: A retrospective chart review of recently discharged adult in-patients with the first episode of psychosis was performed. The proportion of participants who received different essential components for individual and group level interventions were calculated. From the different proportions, the quality of the services across the individual and group interventions was determined using the first-episode psychosis services fidelity scale (FEPS-FS). The FEPS-FS assigns a grade of 1-5 on a Likert scale depending on the proportion of patients who received the different components of the intervention. Twelve essential components across the individual and group interventions were assessed and their quality quantified., Results: The final sample included 156 first-episode psychosis patients. The median age was 27 years (inter-quartile range [IQR] [24-36]) and 55% of the participants were female. All 12 essential components had poor quality with the range of scores on the FEPS-FS between one and three. Only one essential component assessed (use of single antipsychotics) had moderate quality., Conclusion: Amongst current services at the Butabika National Referral Mental Hospital in Uganda, the essential components for individual and group level interventions for psychotic disorders are of poor quality. Further studies are required on how the quality of these interventions can be improved., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2021. The Authors.)

Background: Uganda has one of the highest HIV/AIDS rates and poor mental health services. Children and adolescents in communities with persistent poverty, disease (including HIV/AIDS), and violence, are more likely to suffer from chronic mental health problems. Combined, these characteristics negatively impact communities' response to HIV and mental health beginning with children, adolescents, and young adults. Yet, there is limited research capacity in child and adolescent mental health (CAMH), especially in the HIV/AIDS context in Uganda. Hence, this NIH-funded research training program aims to: (1) train three cohorts of early-career investigators at universities or research institutions in Uganda; (2) connect fellows with committed mentors; and (3) define key factors for successful mentorship and training of new investigators. Methods: CHILD-GRF is a multi-component program that engages selected young investigators in year-round activities for 3 years. Paired with mentors from Washington University in St. Louis and academic institutions in Uganda, fellows participate in a 6-week intensive summer training each year. Year 1 focuses on didactic learning and mentorship. In Year 2, fellows design and conduct their pilot study. Year 3 is devoted to presenting pilot study findings, manuscript preparation/ submission and extramural grant writing. Discussion: CHILD-GRF seeks to provide a solid foundation for the development and implementation of evidence-based HIV prevention and mental health interventions for youth and families impacted by HIV/AIDS. By producing a sustainable network of well-trained individuals in key research institutions, this program contributes to improving CAMH and HIV prevention efforts, both of which have public health implications., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Ssewamala, Sensoy Bahar, Nakasujja, Abente, Nabunya, Peer, Zmachinski, Fragale and McKay.)

People with HIV (PWH) taking antiretroviral therapy (ART) have persistent cognitive impairment. The prevalence of cognitive impairment is higher in women with HIV (WWH) compared to men with HIV (MWH), possibly due to sex differences in immune function. Here we report sex differences in cerebrospinal fluid (CSF) immune markers in relation to cognitive performance. A subset of 83 PWH on ART (52% WWH; mean age = 37.6 years, SD = 7.9) from the Rakai community cohort study Cohort and Rakai Health Sciences Program supported clinics in rural Uganda completed a neuropsychological (NP) assessment and a lumbar puncture. CSF was used to measure 16 cytokines/chemokines. Individual NP test z-scores were generated based on local normative data. A series of least absolute shrinkage and selection operator (lasso) regressions examined associations between CSF inflammatory markers and NP outcomes. Overall, there were no sex differences in CSF inflammatory marker levels. However, MWH displayed more associations between inflammatory markers and cognitive performance than WWH. Among MWH, inflammatory markers were associated with a number of cognitive domains, including attention, processing speed, fluency, executive function, learning and memory. MIP-1β, INF-γ, GM-CSF, IL-7 and IL-12p70 were associated with multiple domains. Among WWH, few inflammatory markers were associated cognition. Degree of associations between CSF inflammatory biomarkers and cognitive performance varied by sex in this young, ART-treated, Ugandan cohort. Further investigation into sex-specific inflammatory mechanisms of cognitive impairment among PWH is warranted to inform sex-specific management strategies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Neurological disorders are common in sub-Saharan African, but accurate neuroepidemiologic data are lacking from the region. We assessed a neuroepidemiological screening tool in a rural Ugandan cohort with high HIV prevalence., Methods: Participants were recruited from the Rakai Neurology Study in rural Rakai District, Uganda. A nurse administered the tool and a sociodemographic survey. 100 participants returned for validation examinations by a neurologist (validation cohort). The diagnostic utility and validity of the instrument were calculated and characteristics of those with and without neurological disorders compared., Results: The tool was administered to 392 participants, 48% female, 33% people with HIV, average age 35.1 ± 8.5 years. 33% of the study cohort screened positive for neurologic disorders. These participants were older [mean (SD): 38.3 (9.7) vs. 33.5 (7.1) years, p < 0.001], had a lower Karnofsky score [89.8 (8.4) vs. 93.9 (7.5), p < 0.001] and had a lower body mass index [21.8 (3.3) vs. 22.8 (3.7), p = 0.007] than those who screened negative. Amongst the validation cohort, 54% had a neurological abnormality of which 46% were symptomatic. The tool was 57% sensitive and 74% specific for detecting any neurological abnormality and 80% sensitive and 69% specific for symptomatic abnormalities., Conclusions: We found a lower sensitivity and similar specificity for the screening tool compared with two previous studies. The lower validity in this study was likely due in part to the high percentage of asymptomatic neurological abnormalities detected. This screening tool will require further refinement and cultural contextualization before it can be widely implemented across new populations., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Children with neurological disorders are more likely to present with autism spectrum disorder (ASD) symptoms and get an ASD diagnosis. Despite the large burden of childhood neurological disorders in Uganda, there is limited information on ASD amongst children with neurological disorders in Uganda., Aim: The aim of this study was to determine the prevalence and factors associated with ASD symptoms amongst children attending the paediatric neurology clinic., Setting: The study was conducted at the paediatric neurology clinic of Mulago National Referral Hospital in Uganda., Methods: This was a cross-sectional study of 318 children aged 2-9 years. After obtaining consent, a socio-demographic questionnaire and the Social Communication Questionnaire were administered to the caregivers of the children. Additional questions were administered to assess the prenatal, birth and postnatal characteristics of the children. Sample characteristics were described using frequencies and means. Bivariate analysis was carried out using chi-square test and Fisher's exact test. Multiple logistic regression models were used to assess which factors were independently associated with ASD symptoms., Results: The mean age of the children was 5 years and 58.2% were males. The prevalence of significant ASD symptoms was found to be 45%. Factors negatively associated with significant ASD symptoms were female sex (odds ratio [OR] 0.48 [95% CI 0.24, 0.98]) and ability to speak (OR 0.09 [95% CI 0.04, 0.2]). The history of delayed developmental milestones was positively associated with significant ASD symptoms (OR 3.3 [95% CI 1.59, 6.84])., Conclusion: The prevalence of ASD symptoms is high in children with neurological disorders. Children, especially those with delayed developmental milestones, should routinely be screened for ASD., Competing Interests: The authors declare they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2021. The Authors.)

In this summary paper, we review the body of research contained in this special issue, The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda, and corollary recommendations for a way forward. We review key findings and conclusions for the studies, which tell a story of culture and care-seeking through discussions and data gleaned from a rich research landscape traversing community village dwellings, shared communal areas, churches, and urban hospitals. The voices and perspectives of over 16,000 study participants inclusive of people living with epilepsy, their neighbors and healthcare workers, traditional healers, and faith leaders are reported. From this, we synthesize findings and prioritize a set of recommendations to advance epilepsy care in Uganda. Progress will require infrastructure strengthening, multilevel educational investments, and an ambitious, extensive program of community sensitization. These proposed priorities and actions outline a way forward through formidable but surmountable challenges but require harmonized efforts by government and other relevant stakeholders, scholars, clinicians, and community leaders. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Epilepsy, a neurological disorder with effective biomedical treatment, remains largely untreated in Uganda. Potential reasons for this treatment gap (TG) include limited access to trained providers and clinics, social stigmata of seizures, cultural beliefs, or lack of public understanding of epilepsy as a treatable condition. The current study aimed to formally evaluate barriers faced by people with epilepsy (PWE) in Uganda when seeking biomedical care., Methods: In a cross-sectional study, 435 participants drawn from a community prevalence study were enrolled. We included participants reporting a history of recurrent seizures suggestive of epilepsy, who completed a survey about barriers to obtaining care for their symptoms. Principal axis factor analysis (PFA) using a promax rotation was conducted for data reduction. Frequencies of barrier factors were compared across those who did not seek care for epilepsy (n = 228), those who sought care from biomedical facilities (n = 166), and those who sought care from a traditional or pastoral healer (n = 41)., Results: The PFA yielded a five-factor solution: 1) logistical and actual costs; 2) treatment effectiveness; 3) influence of the opinion of others; 4) doctors' care; and 5) contextual factors impacting decision-making. Variables related to logistical and actual costs were most endorsed. Comparison of groups by care sought did not reveal a difference in endorsement of factors, with the exception that those who sought biomedical care were more likely to endorse factors related to doctors' care compared with those that sought care from traditional or pastoral healers (P = .005)., Conclusions: People with repetitive seizures in Uganda report several barriers to obtaining biomedical care in Uganda, with those related to practical and actual costs endorsed the most. It is imperative that interventions developed to reduce the TG in Uganda consider these practical issues to improve access to effective epilepsy care. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Objective: This study sets out to describe the current demographics of people with epilepsy (PWE) attending hospital-based care in Uganda and the epilepsy treatment practices within three of the largest Ugandan public referral hospitals., Methods: In a six-month prospective cohort study, 626 children and adults attending epilepsy clinics at Mulago National Referral Hospital, Butabika National Referral Mental Hospital and Mbarara Regional Referral Hospital were enrolled. Using a study questionnaire, data were collected at baseline and at 3 weeks, 3 months, and 6 months following enrollment. Specific data surrounding individual patient demographics, clinical characteristics and severity of epilepsy, and treatment of epilepsy with antiepileptic drugs (AEDs) were collected., Results: Female patients totaled to 50.8%, with a nearly equal gender distribution at each hospital. There was no statistical difference in gender or age between sites. The majority of PWE had completed primary school, with less than 15% of patients completing more than a secondary education. Seizure severity was high, with most patients having multiple seizures per week at the initial onset of epilepsy, and greater than 90% of patients reporting a loss of consciousness with seizures. The majority of patients (54.95%) also reported a developmental or learning delay. Most patients were on 1 AED (46.01%) or 2 AEDs (36.90%), with carbamazepine being the most frequently prescribed AED. There was a trend towards improved seizure severity over the follow-up period, as assessed by the corresponding Personal Impact of Epilepsy Scale (PIES) subscale., Conclusions: People with epilepsy attending hospital-based care in Uganda tend to have severe forms of epilepsy requiring management with AEDs. Current hospital-based practices show a positive trend for seizure burden and quality of life of PWE in Uganda. Further interventions to improve overall access to biomedical care are required to continue to advance the management of PWE across all communities. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Epilepsy is a global public health concern, with the majority of cases occurring in lower- and middle-income countries where the treatment gap remains formidable. In this study, we simultaneously explore how beliefs about epilepsy causation, perceived barriers to care, seizure disorder characteristics, and demographics influence the initial choice of healthcare for epilepsy and its impact on attaining biomedical care (BMC)., Methods: This study utilized the baseline sample (n = 626) from a prospective cohort study of people with epilepsy (PWE) attending three public hospitals in Uganda (Mulago National Referral Hospital, Butabika National Referral Mental Hospital, and Mbarara Regional Referral Hospital) for epilepsy care. Patient and household demographics, clinical seizure disorder characteristics, and sociocultural questionnaires were administered. Logistic regression and principal component analyses (PCA) were conducted to examine associations with the choice of primary seizure treatment., Results: The sample was 49% female, and 24% lived in rural settings. A biomedical health facility was the first point of care for 355 (56.7%) participants, while 229 (36.6%) first sought care from a traditional healer and 42 (6.7%) from a pastoral healer. Preliminary inspection of candidate predictors using relaxed criteria for significance (p < 0.20) identified several factors potentially associated with a greater odds of seeking BMC first. Demographic predictors included older caredriver (decision-maker for the participant) age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: [0.99, 1.02], p-value: 0.09), greater caredriver education level (OR = 1.21, 95% CI: [1.07, 1.37], p-value = 0.003), and lower ratio of sick to healthy family members (OR = 0.77 [0.56, 1.05], P = 0.097). For clinical predictors, none of the proposed predictors associated significantly with seeking BMC first. Self-report causation predictors associated with a greater odds of seeking BMC first included higher belief in biological causes of epilepsy (OR = 1.31 [0.92, 1.88], P = 0.133) and lower belief in socio-spiritual causes of epilepsy (OR = 0.68 [0.56, 0.84], P < 0.001). In the multivariate model, only higher caredriver education (OR = 1.19 [1.04, 1.36], P = 0.009) and lower belief in socio-spiritual causes of epilepsy (OR = 0.69 [0.56, 0.86], P < 0.01) remained as predictors of seeking BMC first. Additionally, PCA revealed a pattern which included high income with low beliefs in nonbiological causes of epilepsy as being associated with seeking BMC first (OR = 1.32 [1.12, 1.55], p = 0.001). Despite reaching some form of care faster, individuals seeking care from traditional or pastoral healers experienced a significant delay to eventual BMC (P < 0.001), with an average delay of more than two years (traditional healer: 2.53 years [1.98, 3.24]; pastoral care: 2.18 [1.21, 3.91])., Conclusions: Coupled with low economic and educational status, belief in spiritual causation of epilepsy is a dominant determinant of opting for traditional or pastoral healing over BMC, regardless of concurrent belief in biological etiologies. There is a prolonged delay to eventual BMC for PWE who begin their treatment seeking with nonallopathic providers, and although nonallopathic healers provide PWE with benefits not provided by BMC, this notable delay likely prevents earlier administration of evidence-based care with known efficacy. Based on these findings, initiatives to increase public awareness of neurobiological causes of epilepsy and effectiveness of biomedical drug treatments may be effective in preventing delays to care, as would programs designed to facilitate cooperation and referral among traditional, faith-based, and biomedical providers. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Objective: In Uganda, causal attributions for epilepsy reflect a variety of beliefs and impact care-seeking behavior, perpetuate stigma, and undermine the effectiveness of interventions to narrow the epilepsy treatment gap. The objective of this study was to characterize beliefs about seizure etiology to gain a better understanding of how epilepsy is conceptualized in the community in order to inform culturally appropriate educational policies and interventions., Methods: In a community-based study, 15,383 participants were surveyed about beliefs related to 15 potential causes for epilepsy. Principal axis factor analysis (PFA) was performed to identify causative factors and then utilized to classify singular versus pluralistic belief systems related to epilepsy etiology. Analysis of variance (ANOVA) and Mann-Whitney U-tests were conducted to examine the differences in background characteristics across the etiology belief groups., Results: Three main causative factors emerged from the PFA: biological, sociospiritual, and biospiritual. Among those endorsing at least one factor (n = 13,036), the biological factor was endorsed most frequently as a potential cause for epilepsy (88.0%), followed by the sociospiritual (63.4%), then biospiritual (47.6%). Review of the patterns of endorsement found that only 22.2% endorsed the biological factor alone, 6.7% the sociospiritual factor alone, and 2.8% the biospiritual factor alone (total 31.7%). The remainder endorsed a combination of two or all three factors as being potentially causal, and most (65.7%) endorsed a pluralistic combination inclusive of a biological etiology. Group comparisons showed that endorsing only the biological factor was associated with the highest levels of education (p < 0.01), the pluralistic group had the highest ratio of people in the household who needed assistance to those that could provide aid (p < 0.01), and there were significant differences in income across specific groups (p < 0.01)., Conclusions: Pluralistic attributions for epilepsy are common in Uganda, with the majority of community members drawing from biomedical and traditional concepts to construct complex explanations for seizures that transcend discrete belief categories traditionally depicted in the literature. These findings emphasize the need to understand cultural beliefs about epilepsy in order to design contextually specific interventions and education programs, which respect the fundamental beliefs and values of the community. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The objective of the study was to characterize and compare the attitudes, beliefs, and perceptions about epilepsy across community and patient cohorts in Uganda., Methods: This was a descriptive study utilizing two samples: a randomly selected, national survey community sample and a hospital-based patient sample of people with epilepsy (PWE) and their caregivers attending clinic settings in Kampala and Mbarara, Uganda for epilepsy care. Both samples were surveyed about their beliefs about epilepsy, its treatment, and people who have the illness. Multivariate linear regression was used to examine group differences and variables associated with specific beliefs., Results: Among the 15,818 community survey participants who participated in this study, 435 study participants reported symptoms suggestive of recurrent seizures, and all 626 subjects in the hospital-based sample had confirmed epilepsy. Results revealed significant differences across groups in their endorsement of epilepsy as a contagion; 37% of people in the community unaffected by epilepsy, and 39% of people with suspected epilepsy who did not seek care believed that epilepsy was contagious by touch, in contrast to 8% of PWE or their caregivers attending regular hospital-based care. Higher educational attainment and income, and seeking regular hospital-based medical care were associated with less endorsement of epilepsy as a contagion, while age, education, income, area of residence, and presence of seizure symptoms, were significant predictors of support or belief in the basic rights of PWE. Study participants within the community who screened negative for seizures placed the most restrictions on rights for PWE. To varying degrees, the samples all endorsed the effectiveness of allopathic, traditional, and religious providers, and the use of pharmaceutical drugs, traditional rituals and herbs, and prayer., Conclusions: People with epilepsy who are attending biomedical care for routine epilepsy care think differently about epilepsy, its treatment, and the rights of those with the disease than the general population. Within the community setting, more erroneous beliefs and negative attitudes about epilepsy and PWE persist, and they not only contribute to stigma but also interfere with the patients' health-seeking behavior. Further confounding the care of PWE, the pluralistic healthcare system in Uganda is evident in endorsements spanning biomedical, traditional, and religious treatment methods. Focused awareness campaigns utilizing local epilepsy societies are needed to promote epilepsy health literacy, to favorably impact acceptance and opportunities for PWE in Uganda, and to facilitate efficient uptake of biomedical care. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Epilepsy is a disease that is stigmatized globally. Several studies have introduced sensitization efforts to reduce stigma towards people with epilepsy (PWE) in various settings. Although sensitization efforts have shown some evidence of improved attitudes towards epilepsy, progress has been limited. This systematized literature review summarizes the existing literature concerning interventions that reduce stigma towards PWE. By conducting an overview of existing interventions, we aimed to consolidate knowledge and outcomes of existing efforts as well as highlight gaps and directions for future interventions., Methods: We searched MEDLINE (via PubMed) and Embase for English-language studies published between January 1, 1970 and November 15, 2017 that focused on stigma reduction strategies for PWE in any global setting. Studies were included if they described a stigma reduction intervention for epilepsy. Studies were excluded if they were reviews, editorials, conference proceedings, abstracts, or did not discuss a stigma reduction intervention. We thematically grouped studies based on type(s) of intervention(s) addressed and summarized interventions, outcome measures, and results for each study included in the review., Results: Of the 1975 initial citations, 32 studies met our inclusion criteria. Interventions clustered into four broad categories including public awareness interventions, policy-based interventions, school-based interventions, and interventions that targeted PWE themselves as well as their caregivers and peers. Efficacy of these interventions as reported by the authors was mixed. Many studies did not use validated outcome measures to assess stigma., Conclusions: Although intervention efforts have been made towards epilepsy stigma reduction at many levels, stigma towards and discrimination against PWE prevail worldwide. About 75% of the studies included in this review were conducted in high-income countries (HICs) despite the disproportional need in low- and middle-income countries (LMICs). Furthermore, robust outcome measures to assess efficacy in stigma reduction for interventions are lacking, calling into question the validity of reported outcomes for both positive and null findings. Therefore, more work is needed in both developing effective stigma reduction strategies, especially in LMICs, and validating tools to measure their efficacy. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Inc.)

Background : Perinatal mortality in Uganda remains high at 38 deaths/1,000 births, an estimate greater than the every newborn action plan (ENAP) target of ≤24/1,000 births by 2030. To improve perinatal survival, there is a need to understand the persisting risk factors for death. Objective : We determined the incidence, risk factors, and causes of perinatal death in Lira district, Northern Uganda. Methods : This was a community-based prospective cohort study among pregnant women in Lira district, Northern Uganda. Female community volunteers identified pregnant women in each household who were recruited at ≥28 weeks of gestation and followed until 50 days postpartum. Information on perinatal survival was gathered from participants within 24 hours after childbirth and at 7 days postpartum. The cause of death was ascertained using verbal autopsies. We used generalized estimating equations of the Poisson family to determine the risk factors for perinatal death. Results : Of the 1,877 women enrolled, the majority were ≤30 years old (79.8%), married or cohabiting (91.3%), and had attained only a primary education (77.7%). There were 81 perinatal deaths among them, giving a perinatal mortality rate of 43/1,000 births [95% confidence interval (95% CI: 35, 53)], of these 37 were stillbirths (20 deaths/1,000 total births) and 44 were early neonatal deaths (23 deaths/1,000 live births). Birth asphyxia, respiratory failure, infections and intra-partum events were the major probable contributors to perinatal death. The risk factors for perinatal death were nulliparity at enrolment (adjusted IRR 2.7, [95% CI: 1.3, 5.6]) and maternal age >30 years (adjusted IRR 2.5, [95% CI: 1.1, 5.8]). Conclusion : The incidence of perinatal death in this region was higher than had previously been reported in Uganda. Risk factors for perinatal mortality were nulliparity and maternal age >30 years. Pregnant women in this region need improved access to care during pregnancy and childbirth.

Background: Severe anaemia is a global public health challenge commonly associated with morbidity and mortality among children < 5 years of age in Sub-Saharan Africa. However, less is known about the behavioural performance of children < 5 years surviving severe anaemia in low resource settings. We investigated social-emotional and adaptive behaviour in children < 5 years diagnosed with severe anaemia in Northern Uganda., Methods: We conducted a hospital based prospective cohort study among children 6-42 months who were treated for severe anaemia (n = 171) at Lira Regional Referral Hospital, Uganda. Socio-emotional and adaptive behaviour were assessed 14 days post discharge using the Bayley Scales of Infant and Toddler Development, 3rd edition. Age-adjusted z-scores for each domain were calculated using scores from healthy community children (n = 88) from the same environment for each age category. Multiple linear regression was used to compare z-scores in the social-emotional and adaptive behaviour scales between the two groups after adjusting for weight-for-age z-score, social economic status, mother's education, father's education and father's employment on all the scales., Results: Compared with healthy community controls, children with severe anaemia had poorer [adjusted mean scores (standard error)], socio-emotional [- 0.29, (0.05) vs. 0.01, (0.08), P = 0.002]; but not overall/ composite adaptive behaviour [- 0.10, (0.05) vs. - 0.01, (0.07), P = 0.343]. Within the adaptive behaviour subscales, children with SA displayed significantly poorer scores on the community use [adjusted mean score (standard error)], [- 0.63, (0.10) vs. - 0.01, (0.13), P < 0.001]; and leisure [- 0.35, (0.07) vs. - 0.02, (0.07), P = 0.036] skills., Conclusion: This study suggests that severe anaemia in children < 5 years is associated with poor social-emotional scores in the short-term post clinical recovery in Northern Uganda. We recommend long-term follow-up to determine the course of these problems and appropriate interventions to reduce the behavioural burden among children < 5 years surviving severe anaemia in Uganda.