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The main objective of this study was to assess whether training of private health providers and community sensitization on the importance of effective prompt care seeking and the need for referral could improve treatment of sick children in the private health sector in Uganda. Private providers were trained to diagnose and treat sick children according to the integrated community case management (iCCM) guidelines. In the control arm, routine services were offered. The outcomes were seeking care within 24 hours of onset of symptoms and appropriate case management for malaria, pneumonia, and diarrhea among children aged < 5 years. A total of 10,809 sick children (5,955 in the intervention arm and 4,854 in the control arm) presented for diagnosis and treatment. The percentage seeking care within 24 hours of onset of symptoms was 45.4% (95% CI 36.0-48.8) in the intervention arm versus 43.9% (95% CI 38.1-49.8) in the control arm ( P = 0.04). Adherence to malaria rapid diagnostic test (mRDT) results was high, with 1,459 (94.3%) in the intervention arm versus 1,402 (83.0%) in the control arm ( P = 0.04). Appropriate treatment of mRDT-positive children with artemisinin-based combination therapy was seen in 93.1% (95% CI 88.5-97.7) in the intervention arm versus 85.1% (95% CI 78.6-91.7) in the control arm ( P = 0.03). Adherence to iCCM guidelines was very high: 89.1% of children with diarrhea in the intervention arm and 80.4% in the control arm were given oral rehydration salts and zinc ( P = 0.01). Of the children with a respiratory rate > 40 breaths/minute, 1,596 (85.1%) in the intervention arm versus 104 (54.5%) in the control arm were given amoxicillin ( P = 0.01). In conclusion, the intervention improved treatment of malaria, pneumonia, and diarrhea because of provider adherence to treatment guidelines. The policy implications of these findings are to initiate a dialogue at district and national levels on how to scale up the intervention in the private sector. NCT02450630 registered with ClinicalTrials.gov: May 9, 2015.

Staphylococci are a key component of the human microbiota, and they mainly colonize the skin and anterior nares. However, they can cause infection in hospitalized patients and healthy individuals in the community. Although majority of the Staphylococcus aureus strains are coagulase-positive, some do not produce coagulase, and the isolation of coagulase-positive non-S. aureus isolates in humans is increasingly being reported. Therefore, sound knowledge of the species and characteristics of staphylococci in a given setting is important, especially isolates from children and immunocompromised individuals. The spectrum of Staphylococcus species colonizing children in Uganda is poorly understood; here, we aimed to determine the species and characteristics of staphylococci isolated from children in Eastern Uganda. Seven hundred and sixty four healthy children less than 5 years residing in Iganga and Mayuge districts in Eastern Uganda were enrolled. A total of 513 staphylococci belonging to 13 species were isolated from 485 children (63.5%, 485/764), with S. aureus being the dominant species (37.6%, 193/513) followed by S. epidermidis (25.5%, 131/513), S. haemolyticus (2.3%, 12/513), S. hominis (0.8%, 4/513) and S. haemolyticus/lugdunensis (0.58%, 3/513). Twenty four (4.95%, 24/485) children were co-colonized by two or more Staphylococcus species. With the exception of penicillin, antimicrobial resistance (AMR) rates were low; all isolates were susceptible to vancomycin, teicoplanin, linezolid and daptomycin. The prevalence of methicillin resistance was 23.8% (122/513) and it was highest in S. haemolyticus (66.7%, 8/12) followed by S. aureus (28.5%, 55/193) and S. epidermidis (23.7%, 31/131). The prevalence of multidrug resistance was 20.3% (104/513), and 59% (72/122) of methicillin resistant staphylococci were multidrug resistant. Four methicillin susceptible S. aureus isolates and a methicillin resistant S. scuiri isolate were mupirocin resistant (high-level). The most frequent AMR genes were mecA, vanA, ant(4')-Ia, and aac(6')-Ie- aph(2'')-Ia, pointing to presence of AMR drivers in the community., Competing Interests: The authors have declared that no competing interests exist.

Background: Many patients with epilepsy in sub-Saharan Africa do not receive adequate treatment. The purpose of the study was to identify the health care providers where patients with epilepsy sought care and what treatment they received., Methods: A cross sectional study was conducted across 87 out of 312 villages in Masindi district. A total of 305 households having patients with epilepsy were surveyed using an interviewer administered questionnaire. Data was entered and analysed in Epi-info ver 7 for univariate and bivariate analysis, and in Stata SE ver 15.0 for multivariable analysis. Sequences of health providers consulted in care seeking, rationale and drugs used, and factors associated with choice of provider were assessed., Results: A total of 139 out of 305 (45.6%) households offered some treatment regimen at home when patients got symptoms of epilepsy with 44.6% (62/139) giving herbs and 18.0% (25/139) offering prayers. Eight different types of providers were consulted as first contact providers for treatment of epilepsy. Health centres received the highest percentage 35.4% (108/305) followed by hospitals 20.9% (64/305). A total of 192 of 305 (63.0%) households received anti-epileptic drugs, 13.1% (40/305) received prayers and 21.6% (66/305) received herbs at the first contact care seeking. Compared to a health centre as the first choice provider, other facilities more significantly visited were; hospitals if they were perceived as nearer (adj. Coeff 2.16, 95%CI 0.74, 3.59, p = 0.003), churches / mosques if cure for epilepsy was expected (adj. Coeff 1.91, 95%CI 0.38, 3.48, p = 0.014), and traditional healer for those aged ≥46 years (adj. Coeff 5.83, 95%CI 0.67, 10.99, p = 0.027), and friends/neighbour for traders (adj. Coeff 2.87, 95%CI 0.71, 5.04, p = 0.009)., Conclusion: Patients with epilepsy seek treatment from multiple providers with the public sector attending to the biggest proportion of patients. Engaging the private sector and community health workers, conducting community outreaches and community sensitization with messages tailored for audiences including the young, older epileptics, traditional healers as stakeholders, and traders could increase access to appropriate treatment for epilepsy.

Background: There is need for more timely data to inform interventions that address the growing noncommunicable disease (NCD) epidemic. With a global increase in mobile phone ownership, mobile phone surveys can bridge this gap., Objective: This study aimed to explore the acceptability and use of interactive voice response (IVR) surveys for surveillance of NCD behavioral risk factors in rural Uganda., Methods: This qualitative study employed user group testing (UGT) with community members. The study was conducted at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Eastern Uganda. We conducted four UGTs which consisted of different categories of HDSS members: females living in urban areas, males living in urban areas, females living in rural areas, and males living in rural areas. Participants were individually sent an IVR survey, then were brought in for a group discussion using a semistructured guide. Data were analyzed thematically using directed content analysis., Results: Participants perceived that IVR surveys may be useful in promoting confidentiality, saving costs, and raising awareness on NCD behavioral risk factors. Due to the clarity and delivery of questions in the local language, the IVR survey was perceived as easy to use. Community members suggested scheduling surveys on specific days and sending reminders as ways to improve their use for surveillance. Social issues such as domestic violence and perceptions toward unknown calls, technological factors including poor network connections and inability to use phones, and personal issues such as lack of access to phones and use of multiple networks were identified as barriers to the acceptability and use of mobile phone surveys. However, incentives were reported to motivate people to complete the survey., Conclusions: Community members reflected on contextual and sociological implications of using mobile phones for surveillance of NCD behavioral risk factors. The opportunities and challenges that affect acceptability and use of IVR surveys should be considered in designing and implementing surveillance programs for NCD risk factors., (©Charles Garrett Ssemugabo, Elizeus Rutebemberwa, Dan Kajungu, George W Pariyo, Adnan A Hyder, Dustin G Gibson. Originally published in JMIR Formative Research (http://formative.jmir.org), 03.12.2019.)

Background: Staphylococcus aureus carriage is a known risk factor for staphylococcal disease. However, the carriage rates vary by country, demographic group and profession. This study aimed to determine the S. aureus carriage rate in children in Eastern Uganda, and identify S. aureus lineages that cause infection in Uganda., Methods: Nasopharyngeal samples from 742 healthy children less than 5 years residing in the Iganga/Mayuge Health and Demographic Surveillance Site in Eastern Uganda were processed for isolation of S. aureus. Antibiotic susceptibility testing based on minimum inhibitory concentrations (MICs) was determined by the BD Phoenix™ system. Genotyping was performed by spa and SCCmec typing., Results: The processed samples yielded 144 S. aureus isolates (one per child) therefore, the S. aureus carriage rate in children was 19.4% (144/742). Thirty one percent (45/144) of the isolates were methicillin resistant (MRSA) yielding a carriage rate of 6.1% (45/742). All isolates were susceptible to rifampicin, vancomycin and linezolid. Moreover, all MRSA were susceptible to vancomycin, linezolid and clindamycin. Compared to methicillin susceptible S. aureus (MSSA) isolates (68.8%, 99/144), MRSA isolates were more resistant to non-beta-lactam antimicrobials -trimethoprim/sulfamethoxazole 73.3% (33/45) vs. 27.3% (27/99) [p < 0.0001]; erythromycin 75.6% (34/45) vs. 24.2% (24/99) [p < 0.0001]; chloramphenicol 60% (27/45) vs. 19.2% (19/99) [p < 0.0001]; gentamicin 55.6% (25/45) vs. 25.3% (25/99) [p = 0.0004]; and ciprofloxacin 35.6% (16/45) vs. 2% (2/99) [p < 0.0001]. Furthermore, 42 MRSA (93.3%) were multidrug resistant (MDR) and one exhibited high-level resistance to mupirocin. Overall, 61 MSSA (61.6%) were MDR, including three mupirocin and clindamycin resistant isolates. Seven spa types were detected among MRSA, of which t037 and t064 were predominant and associated with SCCmec types I and IV, respectively. Fourteen spa types were detected in MSSA which consisted mainly of t645 and t4353., Conclusions: S. aureus carriage rate in healthy children in Eastern Uganda is high and comparable to rates for hospitalized patients in Kampala. The detection of mupirocin resistance is worrying as it could rapidly increase if mupirocin is administered in a low-income setting. S. aureus strains of spa types t064, t037 (MRSA) and t645, t4353 (MSSA) are prevalent and could be responsible for majority of staphylococcal infections in Uganda.

Background: Decision-makers need up to date information on risk factors for effective prevention and control of non-communicable diseases (NCDs). Currently available surveys are infrequent and costly to implement. The objective of the study was to explore perceptions on using an interactive voice response (IVR) survey for data collection on NCD risk factors., Methods: Five focus group discussions (FGDs), including rural and urban, elderly and young adults, male and female groups; and eleven key informant interviews (KIIs) of researchers and NCD policy makers were conducted. Respondents were audio recorded and data were transcribed into text. Data were entered into QDA miner software for analysis. Meaningful units were generated and then merged into codes and categories. Quotes are presented highlighting findings., Results: At the individual level, age, gender, disability, past experience and being technology literate were perceived as key determinants on whether respondents would accept an IVR survey. Receiving the IVR at a time at which people are usually available to take calls increases participation. However, technological accessibility like presence of a mobile network signal and possession of mobile phones were critical for use of IVR. Participants recommended that community sensitization activities be provided, IVR be conducted at appropriate times and frequency, and that incentives may improve survey participation., Conclusions: IVR has the potential to quickly collect data from a wide geographic scope. However, caution needs to be taken to ensure that certain categories of people are not excluded because of their location, ability, age or gender. Sensitization prior to the survey, proper timing and structured incentives could increase participation., (2019 mHealth. All rights reserved.)

Background: The global proliferation of mobile phones offers opportunity for improved non-communicable disease (NCD) data collection by interviewing participants using interactive voice response (IVR) surveys. We assessed whether airtime incentives can improve cooperation and response rates for an NCD IVR survey in Bangladesh and Uganda., Methods: Participants were randomised to three arms: a) no incentive, b) 1X incentive or c) 2X incentive, where X was set to airtime of 50 Bangladesh Taka (US$0.60) and 5000 Ugandan Shillings (UGX; US$1.35). Adults aged 18 years and older who had a working mobile phone were sampled using random digit dialling. The primary outcomes, cooperation and response rates as defined by the American Association of Public Opinion Research, were analysed using log-binomial regression model., Results: Between 14 June and 14 July 2017, 440 262 phone calls were made in Bangladesh. The cooperation and response rates were, respectively, 28.8% (353/1227) and 19.2% (580/3016) in control, 39.2% (370/945) and 23.9% (507/2120) in 50 Taka and 40.0% (362/906) and 24.8% (532/2148) in 100 Taka incentive groups. Cooperation and response rates, respectively, were significantly higher in both the 50 Taka (risk ratio (RR) 1.36, 95% CI 1.21 to 1.53) and (RR 1.24, 95% CI 1.12 to 1.38), and 100 Taka groups (RR 1.39, 95% CI 1.23 to 1.56) and (RR 1.29, 95% CI 1.16 to 1.43), as compared with the controls. In Uganda, 174 157 phone calls were made from 26 March to 22 April 2017. The cooperation and response rates were, respectively, 44.7% (377/844) and 35.2% (552/1570) in control, 57.6% (404/701) and 39.3% (508/1293) in 5000 UGX and 58.8% (421/716) and 40.3% (535/1328) in 10 000 UGX groups. Cooperation and response rates were significantly higher, respectively in the 5000 UGX (RR 1.29, 95% CI 1.17 to 1.42) and (RR 1.12, 95% CI 1.02 to 1.23), and 10 000 UGX groups (RR 1.32, 95% CI 1.19 to 1.45) and (RR 1.15, 95% CI 1.04 to 1.26), as compared with the control group., Conclusion: In two diverse settings, the provision of an airtime incentive significantly improved both the cooperation and response rates of an IVR survey, with no significant difference between the two incentive amounts., Trial Registration Number: NCT03768323., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Lack of data for timely decision-making around the prevention and control of non-communicable diseases (NCDs) presents special challenges for policy makers, especially in resource-limited settings. New data collection methods, including pre-recorded Interactive Voice Response (IVR) phone surveys, are being developed to support rapid compilation of population-level disease risk factor information in such settings. We aimed to identify information that could be used to optimize consent approaches for future mobile phone surveys (MPS) employed in Uganda and, possibly, similar contexts., Methods: We conducted an in-depth qualitative study with key stakeholders in Uganda about consent approaches, and potential challenges, for pre-recorded IVR NCD risk factor surveys. Semi-structured interviews were conducted with 14 key informants. A contextualized thematic approach was used to interpret the results supported by representative quotes., Results: Several potential challenges in designing consent approaches for MPS were identified, including low literacy and the lack of appropriate ways of assessing comprehension and documenting consent. Communication with potential respondents prior to the MPS and providing options for callbacks were suggested as possible strategies for improving comprehension within the consent process. "Opt-in" forms of authorization were preferred over "opt-out". There was particular concern about data security and confidentiality and how matters relating to this would be communicated to MPS respondents., Conclusions: These local insights provide important information to support optimization of consent for MPS, whose use is increasing globally to advance public health surveillance and research in constructive ways., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Methicillin resistant Staphylococcus aureus (MRSA) strains were once confined to hospitals however, in the last 20 years MRSA infections have emerged in the community in people with no prior exposure to hospitals. Strains causing such infections were novel and referred to as community-associated MRSA (CA-MRSA). The aim of this study was to determine the MRSA carriage rate in children in eastern Uganda, and to investigate coexistence between CA-MRSA and hospital-associated (HA-MRSA)., Methods: Between February and October 2011, nasopharyngeal samples (one per child) from 742 healthy children under 5 years in rural eastern Uganda were processed for isolation of MRSA, which was identified based on inhibition zone diameter of ≤19 mm on 30 μg cefoxitin disk. SCC mec and spa typing were performed for MRSA isolates., Results: A total of 140  S. aureus isolates (18.9%, 140/742) were recovered from the children of which 5.7% (42/742) were MRSA. Almost all (95.2%, 40/42) MRSA isolates were multidrug resistant (MDR). The most prevalent SCC mec elements were types IV (40.5%, 17/42) and I (38.1%, 16/42). The overall frequency of SCC mec types IV and V combined, hence CA-MRSA, was 50% (21/42). Likewise, the overall frequency of SCC mec types I, II and III combined, hence HA-MRSA, was 50% (21/42). Spa types t002, t037, t064, t4353 and t12939 were detected and the most frequent were t064 (19%, 8/42) and t037 (12%, 5/42)., Conclusion: The MRSA carriage rate in children in eastern Uganda is high (5.7%) and comparable to estimates for Mulago Hospital in Kampala city. Importantly, HA-MRSA (mainly of spa type t037) and CA-MRSA (mainly of spa type t064) coexist in children in the community in eastern Uganda, and due to high proportion of MDR detected, outpatient treatment of MRSA infection in eastern Uganda might be difficult., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

Background: People with pulmonary tuberculosis are at risk of developing chronic respiratory disorders due to residual lung damage. To date, the scope of the problem in high-burden tuberculosis countries is relatively unknown., Methods: Chronic respiratory symptoms (cough and phlegm lasting >2 weeks) and radiological lung abnormalities were compared between adults with and without a history of tuberculosis among the general population of Uganda. Multivariable regression models were used to estimate odds ratios (ORs) with adjustment for age, gender, smoking, education, setting, and region. Random effects models accounted for village clustering effect., Results: Of 45293 invited people from 70 villages, 41154 (90.9%) participated in the survey. A total of 798 had a history of tuberculosis and, among them, 16% had respiratory symptoms and 41% X-ray abnormalities. Adjusted ORs showed strong evidence for individuals with a history of tuberculosis having increased risk of respiratory symptoms (OR, 4.02; 95% confidence interval [CI], 3.25-4.96) and X-ray abnormalities (OR, 17.52; 95% CI, 14.76-20.79), attributing 6% and 24% of the respective population risks., Conclusions: In Uganda, a history of tuberculosis was a strong predictor of respiratory symptoms and lung abnormalities, before older age and smoking. Eliminating tuberculosis disease could reduce the prevalence of chronic respiratory symptoms as much as eliminating smoking., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Between 1986 and 2006, the Acholi region in Uganda experienced armed conflict which disrupted the health system including human resources. Deployment of health workers during and after conflict raises many challenges for managers due to issues of security and staff shortage. We explored how deployment policies and practices were adapted during the conflict and post-conflict periods with the aim of drawing lessons for future responses to similar conflicts., Methods: A cross-sectional study with qualitative techniques for data collection to investigate deployment policy and practice during the conflict and post-conflict period (1986-2013) was used. The study was conducted in Amuru, Gulu and Kitgum districts in Northern Uganda in 2013. Two large health employers from Acholi were selected: the district local government and Lacor hospital, a private provider. Twenty-three key informants' interviews were conducted at the national and district level, and in-depth interviews with 10 district managers and 25 health workers. This study focused on recruitment, promotions, transfers and bonding to explore deployment policies and practices., Results: There was no evidence of change in deployment policy due to conflict, but decentralisation from 1997 had a major effect for the local government employer. Lacor hospital had no formal deployment policy until 2001. Health managers in government and those working for Lacor hospital both implemented deployment policies pragmatically, especially because of the danger to staff in remote facilities. Lacor hospital introduced bonding agreements to recruit and staff their facilities. While managers in both organisations implemented the deployment policies as best as they could, some deployment-related decisions could lead to longer-term problems., Conclusion: It may not be possible or even appropriate to change deployment policy during or after conflict. However, given sufficient autonomy, local managers can adapt deployment policies appropriately to need, but they should also be supported with the necessary human resource management skills to enable them make appropriate decisions for deployment.

Background: Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals., Methods: Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another., Results: Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals' diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another., Conclusions: Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.

Background : The Bloomberg Data for Health Initiative Research and Development Arm at Johns Hopkins University Bloomberg School of Public Health, has thus far collected NCD risk factor data from more than 13,000 citizens of three LMICs (Bangladesh, Tanzania and Uganda), and has actively worked to improve capacity with partners worldwide. Objective : This paper focuses on how a research project, can also act as a capacity building activity through its research into collecting non-communicable disease risk factor data using different mobile phone modalities. Methods : This paper evaluates the activities undertaken by the project using the ESSENCE Planning Monitoring and Evaluation Framework for Research Capacity Strengthening. Results : The project was able to successfully integrate meaningful capacity development activities across all partners. Training, networking, sharing resources, joint data collection, and analysis across individual, organizational and project levels were some of the strategies used. The ESSENCE framework allowed a good assessment strategy for this type of work. Conclusions : This paper highlights the value of making capacity development a high priority for digital health research activities, while also considering the need to monitor and evaluate those activities in order for them to be meaningful and sustainable. It also considers how to utilize the ESSENCE Framework to evaluate capacity development activities through research, and how best to adapt the Framework to different programs.

Background: Our objective was to describe the clinical presentation of new diabetes patients in a rural hospital, to enhance clinical detection in low resource settings., Methods: A case series assessment of 103 new diabetes patients consecutively enrolled at Iganga Hospital in rural Eastern Uganda was conducted. All underwent a basic clinical assessment through the clinic's routine procedures. Following diagnosis, variables pertinent to the study (symptoms, blood pressure, anthropometry, and blood glucose) were secondarily abstracted from their clinical records., Results: Fiftty two percent of new diabetes patients were female. The mean age was 49 years (SD=14.4). Two clinical symptoms were present in almost all new patients: Frequent urination (100%) and frequent thirst (79%). Moderately occurring symptoms (i.e. 25-50% of patients) included blurred vision, frequent eating and frequent sweating. The mean duration of symptoms was 1.4 years; 48% had high blood pressure while 46% were overweight. Random blood sugar was normal for 25% of patients. The majority (71%) were classified as having 'moderate illness' at diagnosis. Severe illness was significantly lower among patients aged 40 or older compared to younger patients (OR 0.1; 95% CI 0.03-0.35)., Conclusion: Out-patients aged 40-65 years should be prioritised for early diabetes diagnosis and associated risk factors in this setting.

Background: Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda., Methods: This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews ( n = 35 ). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13)., Results: Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage., Conclusion: The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up ., Competing Interests: Ethical approval was granted by Makerere University, School of Public Health, Institutional Review Board (IRB). Permission to conduct research was granted by The Uganda National Council of Science and Technology (UNCST) under instrument: No.HS1512. All interview participants signed a written informed consent form before participating in the study. Not applicable The authors declare that they have no competing interests.

Background: Policy implementation remains an under researched area in most low and middle income countries and it is not surprising that several policies are implemented without a systematic follow up of why and how they are working or failing. This study is part of a larger project called Supporting Policy Engagement for Evidence-based Decisions (SPEED) for Universal Health Coverage in Uganda. It seeks to support policymakers monitor the implementation of vital programmes for the realisation of policy goals for Universal Health Coverage. A Policy Implementation Barometer (PIB) is proposed as a mechanism to provide feedback to the decision makers about the implementation of a selected set of policy programmes at various implementation levels (macro, meso and micro level). The main objective is to establish the extent of implementation of malaria, family planning and emergency obstetric care policies in Uganda and use these results to support stakeholder engagements for corrective action. This is the first PIB survey of the three planned surveys and its specific objectives include: assessment of the perceived appropriateness of implementation programmes to the identified policy problems; determination of enablers and constraints to implementation of the policies; comparison of on-line and face-to-face administration of the PIB questionnaire among target respondents; and documentation of stakeholder responses to PIB findings with regard to corrective actions for implementation., Methods/design: The PIB will be a descriptive and analytical study employing mixed methods in which both quantitative and qualitative data will be systematically collected and analysed. The first wave will focus on 10 districts and primary data will be collected through interviews. The study seeks to interview 570 respondents of which 120 will be selected at national level with 40 based on each of the three policy domains, 200 from 10 randomly selected districts, and 250 from 50 facilities. Half of the respondents at each level will be randomly assigned to either face-to-face or on-line interviews. An integrated questionnaire for these interviews will collect both quantitative data through Likert scale-type questions, and qualitative data through open-ended questions. And finally focused dialogues will be conducted with selected stakeholders for feedback on the PIB findings. Secondary data will be collected using data extraction tools for performance statistics., Discussion: It is anticipated that the PIB findings and more importantly, the focused dialogues with relevant stakeholders, that will be convened to discuss the findings and establish corrective actions, will enhance uptake of results and effective health policy implementation towards universal health coverage in Uganda., Competing Interests: The study protocol was approved by the Higher Degrees, Research and Ethics Committee of Makerere University School of Public Health (Reference: 339) and the Uganda National Council for Science and Technology (Reference SS4201).The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Mobile phone ownership and access have increased rapidly across low- and middle-income countries (LMICs) within the last decade. Concomitantly, LMICs are experiencing demographic and epidemiologic transitions, where non-communicable diseases (NCDs) are increasingly becoming leading causes of morbidity and mortality. Mobile phone surveys could aid data collection for prevention and control of these NCDs but limited evidence of their feasibility exists., Objective: The objective of this paper is to describe a series of sub-studies aimed at optimizing the delivery of interactive voice response (IVR) and computer-assisted telephone interviews (CATI) for NCD risk factor data collection in LMICs. These sub-studies are designed to assess the effect of factors such as airtime incentive timing, amount, and structure, survey introduction characteristics, different sampling frames, and survey modality on key survey metrics, such as survey response, completion, and attrition rates., Methods: In a series of sub-studies, participants will be randomly assigned to receive different airtime incentive amounts (eg, 10 minutes of airtime versus 20 minutes of airtime), different incentive delivery timings (airtime delivered before survey begins versus delivery upon completion of survey), different survey introductions (informational versus motivational), different narrative voices (male versus female), and different sampling frames (random digit dialing versus mobile network operator-provided numbers) to examine which study arms will yield the highest response and completion rates. Furthermore, response and completion rates and the inter-modal reliability of the IVR and CATI delivery methods will be compared., Results: Research activities are expected to be completed in Bangladesh, Tanzania, and Uganda in 2017., Conclusions: This is one of the first studies to examine the feasibility of using IVR and CATI for systematic collection of NCD risk factor information in LMICs. Our findings will inform the future design and implementation of mobile phone surveys in LMICs., (©Dustin G Gibson, George William Pariyo, Adaeze C Wosu, Abigail R Greenleaf, Joseph Ali, Saifuddin Ahmed, Alain B Labrique, Khaleda Islam, Honorati Masanja, Elizeus Rutebemberwa, Adnan A Hyder. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 05.05.2017.)

Background: Public health facilities are usually the first to receive interventions compared to private facilities, yet majority of health seeking care is first done with the latter. This study compared the capacity to manage acute febrile illnesses in children below 5 years in private vs public health facilities in order to design interventions to improve quality of care., Methods: A survey was conducted within 57 geographical areas (parishes), from August to October 2014 in Mukono district, central Uganda. The survey comprised both facility and health worker assessment. Data were collected on drug stocks, availability of treatment guidelines, diagnostic equipment, and knowledge in management of malaria, pneumonia and diarrhoea, using a structured questionnaire., Results: A total of 53 public and 241 private health facilities participated in the study. While similar proportions of private and public health facilities stocked Coartem, the first-line anti-malarial drug, (98 vs 95%, p = 0.22), significantly more private than public health facilities stocked quinine (85 vs 53%, p < 0.01). Stocks of obsolete anti-malarial drugs, such as chloroquine, were reported in few public and private facilities (3.7 vs 12.5%, p = 0.06). Stocks of antibiotics-amoxycillin and gentamycin were similar in both sectors (≥90% for amoxicillin; ≥50 for gentamycin). Training in malaria was reported by 65% of public health facilities vs 56% in the private sector, p = 0.25), while, only 21% in the public facility and 12% in the private facilities, p = 0.11, reported receiving training in pneumonia. Only 55% of public facilities had microscopes. Malaria treatment guidelines were significantly lacking in the private sector, p = 0.01. Knowledge about first-line management of uncomplicated malaria, pneumonia and diarrhoea was significantly better in the public facilities compared to the private ones, though still sub-optimal., Conclusion: Deficiencies of equipment, supplies and training exist even in public health facilities. In order to significantly improve the capacity to handle acute febrile illness among children under five, training in proper case management, availability of supplies and diagnostics need to be addressed in both sectors.

Background: In Uganda, referral of sick children seeking care at public health facilities is poor and widely reported. However, studies focusing on the private health sector are scanty. The main objective of this study was to assess referral practices for sick children seeking care at private health facilities in order to explore ways of improving treatment and referral of sick children in this sector., Methods: A survey was conducted from August to October 2014 in Mukono district, central Uganda. Data was collected using a structured questionnaire supplemented by Focus Group Discussions and Key Informant interviews with private providers and community members., Results: A total of 241 private health facilities were surveyed; 170 (70.5%) were registered drug shops, 59 (24.5%) private clinics and 12 (5.0%) pharmacies. Overall, 104/241 (43.2%) of the private health facilities reported that they had referred sick children to higher levels of care in the two weeks prior to the survey. The main constraints to follow referral advice as perceived by caretakers were: not appreciating the importance of referral, gender-related decision-making and negotiations at household level, poor quality of care at referral facilities, inadequate finances at household level; while the perception that referral leads to loss of prestige and profit was a major constraint to private providers., Conclusion: In conclusion, the results show that referral of sick children at private health facilities faces many challenges at provider, caretaker, household and community levels. Thus, interventions to address constraints to referral of sick children are urgently needed.

Background: Community health workers (CHWs) have the potential to reduce child mortality by improving access to care, especially in remote areas. Uganda has one of the highest child mortality rates globally. Moreover, rural areas bear the highest proportion of this burden. The optimal performance of CHWs is critical. In this study, we assess the performance of CHWs in managing malaria, pneumonia, and diarrhea in the rural district of Lira, in northern Uganda., Designs: A cross-sectional mixed methods study was undertaken to investigate the performance of 393 eligible CHWs in the Lira district of Uganda. Case scenarios were conducted with a medical officer observing CHWs in their management of children suspected of having malaria, pneumonia, or diarrhea. Performance data were collected using a pretested questionnaire with a checklist used by the medical officer to score the CHWs. The primary outcome, CHW performance, is defined as the ability to diagnose and treat malaria, diarrhea, and pneumonia appropriately. Participants were described using a three group performance score (good vs. moderate vs. poor). A binary measure of performance (good vs. poor) was used in multivariable logistic regression to show an association between good performance and a range of independent variables. The qualitative component comprised seven key informant interviews with experts who had informed knowledge with regard to the functionality of CHWs in Lira district., Results: Overall, 347 CHWs (88.3%) had poor scores in managing malaria, diarrhea, and pneumonia, 26 (6.6%) had moderate scores, and 20 (5.1%) had good scores. The factors that were positively associated with performance were secondary-level education (adjusted odds ratio [AOR] 2.72; 95% confidence interval [CI] 1.50-4.92) and meeting with supervisors in the previous month (AOR 2.52; 95% CI 1.12-5.70). Those factors negatively associated with CHW performance included: serving 100-200 households (AOR 0.24; 95% CI 0.12-0.50), serving more than 200 households (AOR 0.22; 95% CI 0.10-0.48), and an initial training duration lasting 2-3 days (AOR 0.13; 95% CI 0.04-0.41). The qualitative findings reinforced the quantitative results by indicating that refresher training, workload, and in-kind incentives were important determinants of performance., Conclusions: The performance of CHWs in Lira was inadequate. There is a need to consider pre-qualification testing before CHWs are appointed. Providing ongoing support and supervision, and ensuring that CHWs have at least secondary education can be helpful in improving their performance. Health system managers also need to ensure that the CHWs' workload is moderated as work overload will reduce performance. Finally, although short training programs are beneficial to some degree, they are not sufficient and should be followed up with regular refresher training., Competing Interests: and funding All the authors declare no conflict of interest. The field training of the lead author (Philip Wanduru) that led to this study was funded by Makerere University School of Public Health through Cooperative Agreement Number: 5U2GGH000817-03 (‘Provision of Comprehensive HIV/AIDS services and developing national capacity to manage HIV/AIDS Programs in Uganda’) from the US-Centers for Disease Control and Prevention. The African Field Epidemiology Network (AFENET) financed the manuscript writing workshop that led to the production of a complete draft of this manuscript. The contents of this article are however solely the responsibility of the authors and do not necessarily represent the views of the US-Centers for Disease Control and Prevention, Makerere University School of Public Health or AFENET.

Background: Uganda's under-five mortality is high, currently estimated at 66/1000 live births. Poor referral of sick children that seek care from the private sector is one of the contributory factors. The proposed intervention aims to improve referral and uptake of referral advice for children that seek care from private facilities (registered drug shops/private clinics)., Methods/design: A cluster randomized design will be applied to test the intervention in Mukono District, central Uganda. A sample of study clusters will implement the intervention. The intervention will consist of three components: i) raising awareness in the community: village health teams will discuss the importance of referral and encourage households to save money, ii) training and supervision of providers in the private sector to diagnose, treat and refer sick children, iii) regular meetings between the public and private providers (convened by the district health team) to discuss the referral system. Twenty clusters will be included in the study, randomized in the ratio of 1:1. A minimum of 319 sick children per cluster and the total number of sick children to be recruited from all clusters will be 8910; adjusting for a 10 % loss to follow up and possible withdrawal of private outlets., Discussion: The immediate sustainable impact will be appropriate treatment of sick children. The intervention is likely to impact on private sector practices since the scope of the services they provide will have expanded. The proposed study is also likely to have an impact on families as; i) they may appreciate the importance of timely referral on child illness management, ii) the cost savings related to reduced morbidity will be used by household to access other social services. The linkage between the private and public sectors will create a potential avenue for delivery of other public health interventions and improved working relations in the two sectors. Further, improved quality of services in the private sector will improve provider confidence and hopefully more clientelle to the private practices., Trial Registration: NCT02450630 Registration date: May/9 th /2015.

Background: Most tuberculosis (TB) case management guidelines emphasize microbiological cure as treatment goal without highlighting quality of life outcomes. This study assessed health-related quality of life (HRQoL) and related factors in the pre-treatment, intensive and continuation phases of anti-TB therapy among sputum smear positive pulmonary TB patients in Mbale region, Eastern Uganda., Methods: In this cross-sectional study, questionnaires and 36-Item Short-Form Health Survey Version 2.0 (UK English SF36v2) forms were administered to 210 participants of whom 64.8 % were males. The mean age was 35.48 ± 12.21 years. For each of the three treatment phases, different patients were studied. Responses were translated into the standard 00-100 scale. Means and standard deviations were used to express HRQoL as physical composite scores (PCS) and mental composite scores (MCS). Analysis of variance was used to compare scores across phases. Multiple linear regression methods were used to model relationships between predictor variables and HRQoL for each treatment phase., Results: HRQoL scores were different across treatment phases. General health (38.8 ± 17.5) and mental health (52.7 ± 18.6) had the lowest and highest sub-scale scores respectively. Mean PCS scores in pretreatment, intensive and continuation phases were 29.9 ± 19.4, 41.9 ± 14.2 and 62.2 ± 18.8 respectively. Mean MCS scores in the pretreatment, intensive and continuation phases were 38.8 ± 18.3, 49.4 ± 13.1 and 60.6 ± 18.8 respectively. Prior to treatment initiation, having an informal occupation (β = -28.66 (<0.001) was associated with poor HRQoL. Being unmarried (β = 11.94, p = 0.028) and belonging to the highest tertile of socioeconomic status (SES) (β = 14.56, p = 0.007) were associated with good HRQoL in the intensive phase. In the continuation phase, SES (β = 10.83, p = 0.021 for MCS and β = 13.14, p = 0.004 for PCS) predicted good HRQoL. Older age (β = -0.43 p = 0.013 for PCS and β = -0.36 p = 0.040 for MCS) was associated with poor HRQoL., Conclusions: TB treatment improved patients' perceived health and having means of income was particularly associated with high HRQoL. Strategies to strengthen treatment support that include income generation and specific close monitoring of older patients may help improve overall TB treatment experience, by sustaining acceptable levels of physical, social and emotional functioning.

Background: Nodding syndrome is a neurological disorder which had affected about 3000 children with over 170 deaths in northern Uganda by 2012. With limited data on health seeking, the study aimed to assess the health seeking behavior and associated factors among caretakers of children with nodding syndrome in Pader district., Methods: A mixed methods cross sectional study was conducted in July 2013 among 249 caretakers of children with nodding syndrome in three sub-counties of Pader. Respondents were consecutively interviewed using semi-structured questionnaires. Eleven key informants were additionally interviewed. We determined the associations of various factors with health care seeking and obtained adjusted odds ratios and 95% confidence intervals using logistic regression model. Quantitative data was analysed using Stata version 12 while qualitative data was analysed manually and quotes reported., Results: Most caretakers, 78.3% (195/249) sought care first from a health facility, 12.9% (32/249) visited traditional healers and 8.8% (22/249) self-medicated. Of those who sought care from a health facility, 50% sought care after a month. Factors associated with improved care seeking included: Time taken to reach care 1-3 hours; adjusted odds ratio = 6.4 (95% CI = 2.96-14.03), time spent in care above five years; adjusted odds ratio = 12.0 (95% CI: 1.24-117.73) and changed care seeking place; adjusted odds ratio = 17.2 (95% CI: 3.64-81.67)., Conclusion/ Recommendation: Caretakers sought care from multiple places. One in five caretakers still sought care outside a formal health facility. Many respondents who sought care first from health facilities went late, at least one month after symptoms onset. Factors associated with health seeking included distance, duration in treatment and not having changing care provider. There is need for massive sensitization of community to enhance prompt care seeking. More research is needed to elucidate the cause, thus finding the treatment for nodding syndrome, to prevent "wandering in hope".

Background: Private facilities are the first place of care seeking for many sick children. Involving these facilities in child health interventions may provide opportunities to improve child welfare. The objective of this study was to assess the potential of rural and urban private facilities in diagnostic capabilities, operations and human resource in the management of malaria, pneumonia and diarrhoea., Methods: A survey was conducted in pharmacies, private clinics and drug shops in Mukono district in October 2014. An assessment was done on availability of diagnostic equipment for malaria, record keeping, essential drugs for the treatment of malaria, pneumonia and diarrhoea; the sex, level of education, professional and in-service training of the persons found attending to patients in these facilities. A comparison was made between urban and rural facilities. Univariate and bivariate analysis was done., Results: A total of 241 private facilities were assessed with only 47 (19.5 %) being in rural areas. Compared to urban areas, rural private facilities were more likely to be drug shops (OR 2.80; 95 % CI 1.23-7.11), less likely to be registered (OR 0.31; 95 % CI 0.16-0.60), not have trained clinicians, less likely to have people with tertiary education (OR 0.34; 95 % CI 0.17-0.66) and less likely to have zinc tablets (OR 0.38; 95 % CI 0.19-0.78). In both urban and rural areas, there was low usage of stock cards and patient registers. About half of the facilities in both rural and urban areas attended to at least one sick child in the week prior to the interview., Conclusion: There were big gaps between rural and urban private facilities with rural ones having less trained personnel and less zinc tablets' availability. In both rural and urban areas, record keeping was low. Child health interventions need to build capacity of private facilities with special focus on rural areas where child mortality is higher and capacity of facilities lower.

Background: Malaria in pregnancy is a major public health problem in Uganda; and it is the leading cause of anaemia among pregnant women and low birth weight in infants. Previous studies have noted poor quality of care in the private sector. Thus there is need to explore ways of improving quality of care in the private sector that provides almost a half of health services in Uganda., Methods: A survey was conducted from August to October 2014 within 57 parishes in Mukono district, central Uganda. The selected parishes had a minimum of 200 households and at least one registered drug shop, pharmacy or private clinic. Data was collected using a structured questionnaire targeting one provider who was found on duty in each selected private health facility and consented to the study. The main variables were: provider characteristics, previous training received, type of drugs stocked, treatment and prevention practices for malaria among pregnant women. The main study outcome was the proportion of private health facilities who prescribe treatment of fever among pregnant women as recommended in the guidelines., Results: A total of 241 private health facilities were surveyed; 70.5 % were registered drug shops, 24.5 % private clinics and 5.0 % pharmacies. Treatment of fever among pregnant women in accordance with the national treatment guidelines was poor: 40.7 % in private clinics, decreasing to 28.2 % in drug shops and 16.7 % at pharmacies. Anti-malarial monotherapies sulphadoxine-pyrimethamine and quinine were commonly prescribed, often without consideration of gestational age. The majority of providers (>75 %) at all private facilities prescribed SP for intermittent preventive treatment but artemisinin-based combination therapy was prescribed: 8.3, 6.9 and 8.3 % respectively at drug shops, private clinics and pharmacies for prevention of malaria in pregnancy. Few facilities had malaria treatment guidelines; (44.1 % of private clinics, 17.9 % of drug shops, and 41.7 % at pharmacies. Knowledge of people at risk of malaria, P = 0.02 and availability of malaria treatment guidelines, P = 0.03 were the factors that most influenced correct treatment of fever in pregnancy., Conclusion: Treatment of fever during pregnancy was poor in this study setting. These data highlight the need to develop interventions to improve patient safety and quality of care for pregnant women in the private health sector in Uganda.

Objectives: The main objective of this study was to assess practices of antibiotic prescription at registered drug shops with a focus on upper respiratory tract infections among children in order to provide data for policy discussions aimed at improving quality of care and patient safety in the private health sector in Uganda., Methods: A survey was conducted within 57 parishes from August to October 2014 in Mukono District, Uganda. Data was captured on the following variables: drug shop characteristics, training of staff in management of pneumonia, availability of guidelines and basic equipment, available antibiotics, knowledge on treatment of pneumonia in children aged <5 years. The main study outcome was the proportion of private health facilities prescribing an antibiotic., Results: A total of 170 registered drug shops were surveyed between August and October 2014. The majority of drug shops, 93.5% were prescribing antibiotics, especially amoxicillin and trimethoprim-sulfamethoxazole (septrin). The professional qualification of a provider was significantly associated with this practice, p=0.04; where lower cadre staff (nursing assistants and enrolled nurses) overprescribed antibiotics. A third, 29.4% of drug shop providers reported that antibiotics were the first-line treatment for children with diarrhoea; yet the standard guideline is to give oral rehydration salts and zinc tablets. Only few providers, 8.2%, had training on antibiotics, with 10.6% on pneumonia case management. Further to this, 7.1% drug shops had WHO-Integrated Management of Childhood Illness guidelines, and a negligible proportion (<1%) had respiratory timers and baby weighing scales. Although the majority of providers, 82.4%, knew severe signs and symptoms of pneumonia, few, 17.6%, knew that amoxicillin was the first-line drug for treatment of pneumonia in children according to the guidelines., Conclusions: There is urgent need to regulate drug shop practices of prescribing and selling antibiotics, for the safety of patients seeking care at these outlets., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: There are health risks associated with wastewater and fecal sludge management and use, but little is known about the magnitude, particularly in rapidly growing urban settings of low- and middle-income countries. We assessed the point-prevalence and risk factors of intestinal parasite infections in people with different exposures to wastewater and fecal sludge in Kampala, Uganda., Methodology: A cross-sectional survey was carried out in September and October 2013, enrolling 915 adults from five distinct population groups: workers maintaining wastewater facilities; workers managing fecal sludge; urban farmers; slum dwellers at risk of flooding; and slum dwellers without risk of flooding. Stool samples were subjected to the Kato-Katz method and a formalin-ether concentration technique for the diagnosis of helminth and intestinal protozoa infections. A questionnaire was administered to determine self-reported signs and symptoms, and risk factors for intestinal parasite infections. Univariate and multivariate analyses, adjusted for sex, age, education, socioeconomic status, water, sanitation, and hygiene behaviors, were conducted to estimate the risk of infection with intestinal parasites and self-reported health outcomes, stratified by population group., Principal Findings: The highest point-prevalence of intestinal parasite infections was found in urban farmers (75.9%), whereas lowest point-prevalence was found in workers managing fecal sludge (35.8%). Hookworm was the predominant helminth species (27.8%). In urban farmers, the prevalence of Trichuris trichiura, Schistosoma mansoni, Ascaris lumbricoides, and Entamoeba histolytica/E. dispar was 15% and above. For all investigated parasites, we found significantly higher odds of infection among urban farmers compared to the other groups (adjusted odds ratios ranging between 1.6 and 12.9). In general, female participants had significantly lower odds of infection with soil-transmitted helminths and S. mansoni compared to males. Higher educational attainment was negatively associated with the risk of intestinal protozoa infections, while socioeconomic status did not emerge as a significant risk factor for any tested health outcome., Conclusions/significance: Urban farmers are particularly vulnerable to infections with soil-transmitted helminths, S. mansoni, and intestinal protozoa. Hence, our findings call for public health protection measures for urban farmers and marginalized communities, going hand-in-hand with integrated sanitation safety planning at city level.

Background: The integrated Community Case Management (iCCM) of childhood illnesses strategy has been adopted world over to reduce child related ill health and mortality. Community Health workers (CHWs) who implement this strategy need a regular supply of drugs to effectively treat children under 5 years with malaria, pneumonia and diarrhea. In this paper, we report the prevalence and factors influencing availability of medicines for managing malaria, pneumonia and diarrhea in communities in central Uganda., Methods: A cross sectional study was conducted among 303 CHWs in Wakiso district in central Uganda. Eligible CHWs from two randomly selected Health Sub Districts (HSDs) were interviewed. Questionnaires, check lists, record reviews were used to collect information on CHW background characteristics, CHW's prescription behaviors, health system support factors and availability of iCCM drugs. Multivariable logistic regression analysis was done to assess factors associated with availability of iCCM drugs., Results: Out of 300 CHWs, 239 (79.9%) were females and mean age was 42.1 (standard deviation =11.1 years). The prevalence of iCCM drug availability was 8.3% and 33 respondents (11%) had no drugs at all. Factors associated with iCCM drug availability were; being supervised within the last month (adjusted OR = 3.70, 95% CI 1.22-11.24), appropriate drug prescriptions (adjusted OR = 3.71, 95% CI 1.38-9.96), regular submission of drug reports (adjusted OR = 4.02, 95% CI 1.62-10.10) and having a respiratory timer as a diagnostic tool (adjusted OR =3.11, 95% CI 1.08-9.00)., Conclusions: The low medicine stocks for the community management of childhood illnesses calls for strengthening of CHW supervision, medicine prescription and reporting, and increasing availability of functional diagnostic tools.

Background: Human brucellosis is prevalent in both rural and urban Uganda, yet most cases of the disease in humans go unnoticed and untreated because of inaccurate diagnosis, which is often due to the disease not manifesting in any symptoms. This study was undertaken to describe trends in laboratory-confirmed human brucellosis cases at three health facilities in pastoralist communities in South-western, Uganda., Methods: Data were collected retrospectively to describe trends of brucellosis over a 10-year period (2003-2012), and supplemented with a prospective study, which was conducted from January to December 2013. Two public health facilities and a private clinic that have diagnostic laboratories were selected for these studies. Annual prevalence was calculated and linearly plotted to observe trends of the disease at the health facilities. A modified Poisson regression model was used to estimate the risk ratio (RR) and 95 % confidence intervals (CIs) to determine the association between brucellosis and independent variables using the robust error variance., Results: A total of 9,177 persons with suspected brucellosis were identified in the retrospective study, of which 1,318 (14.4 %) were confirmed cases. Brucellosis cases peaked during the months of April and June, as observed in nearly all of the years of the study, while the most noticeable annual increase (11-23 %) was observed from 2010 to 2012. In the prospective study, there were 610 suspected patients at two public health facilities. Of these, 194 (31.8 %) were positive for brucellosis. Respondents aged 45-60 years (RR = 0.50; CI: 0.29-0.84) and those that tested positive for typhoid (RR = 0.68; CI: 0.52-0.89) were less likely to have brucellosis., Conclusions: With the noticeable increase in prevalence from 2010 to 2012, diagnosis of both brucellosis and typhoid is important for early detection, and for raising public awareness on methods for preventing brucellosis in this setting.

Background: Brucellosis is a zoonotic disease of veterinary, public health, and economic significance in most developing countries, yet there are few studies that show integrated human and veterinary health care intervention focusing on integration at both activity and actors levels. The aim of our study, therefore, was to explore community perceptions on integration of animal vaccination and health education by veterinary and public health workers in the management of brucellosis in Uganda., Methods: This study used a qualitative design where six Focus Group Discussions (FGDs) that were homogenous in nature were conducted, two from each sub-county, one with the local leaders, and another with pastoralists and farmers. Five Key Informant Interviews (KIIs) with two public health workers and three veterinary extension workers from three sub-counties in Kiruhura district, Uganda were conducted. All FGDs were conducted in the local language and tape recorded with consent from the participants. KIIs were in English and later transcribed and analyzed using latent content data analysis method., Results: All the groups mentioned that they lacked awareness on brucellosis commonly known as Brucella and its vaccination in animals. Respondents perceived improvement in human resources in terms of training and recruiting more health personnel, facilitation of the necessary activities such as sensitization of the communities about brucellosis, and provision of vaccines and diagnostic tests as very important in the integration process in the communities. The FGD participants also believed that community participation was crucial for sustainability and ownership of the integration process., Conclusions: The respondents reported limited knowledge of brucellosis and its vaccination in animals. The community members believed that mass animal vaccination in combination with health education about the disease is important and possible if it involves government and all other stakeholders such as wildlife authorities, community members, local to national political leaders, as well as the technical personnel from veterinary, medical and public health sectors since it affects both humans and animals.

Background: In striving to contribute towards improved health outcomes, health research institutions generate and accumulate huge volumes of relevant but often underutilized data. This study explores activities undertaken by researchers from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), an international research institution that promotes the utilization of their findings in the policymaking processes in Bangladesh., Methods: The study used an exploratory case study design and employed qualitative methods to explore activities implemented to promote research utilization and the extent to which researchers felt that their findings contributed to the policymaking process. Data were collected between September and December 2011 through key informant interviews, focus group discussions with study investigators, and database and document reviews. We reviewed findings from 19 reproductive health studies conducted and completed by icddr,b researchers between 2001 and 2011. We interviewed 21 key informants, including 13 researchers, two policy makers, and six programme implementers. Data were entered into Microsoft Word and analyzed manually following a thematic framework approach. Following the World Health Organization/Turning Research into Practice (WHO/TRIP) framework, three case studies of how research findings were utilized in the policymaking processes in Bangladesh were documented., Results: Activities implemented to promote research utilization included conducting dissemination workshops, publishing scientific papers, developing policy briefs, providing technical assistance to policymakers and programme implementers, holding one-on-one meetings, and joining advocacy networks. The majority of the researchers (12 of 13) reported that their study findings were utilized to influence policymaking processes at different levels. However, some researchers reported being unaware of whether and how their findings were utilized. As regards actual utilization of research findings, the evidence from the three case studies indicate that research findings can be utilized instrumentally, conceptually and symbolically, and at different stages within the policymaking process, including agenda setting and policy formulation and implementation., Conclusions: The results show that research findings from icddr,b were promoted and utilized in health policymaking processes in Bangladesh using a variety of utilization approaches. These results suggest a need for using multiple approaches to promote utilization of research findings in health policymaking processes.

Introduction: West Africa is experiencing the largest ever reported Ebola outbreak. Over 20,000 people have been infected of which about 9000 have died. It is possible that lack of community understanding of the epidemic and lack of institutional memory and inexperienced health workers could have led to the rapid spread of the disease. In this paper, we share Uganda's experiences on how the capacity of health workers and other multidisciplinary teams can be improved in preparing and responding to Ebola outbreaks., Methods: Makerere University School of Public Health in collaboration with the Ministry of Health and the African Field Epidemiology Network (AFENET), trained health care workers and other multidisciplinary teams from six border districts of Uganda so as to increase their alertness and response capabilities towards Ebola. We used participatory training methods to impart knowledge and skills and guided participants to develop district epidemic response plans. Communities were sensitized about Ebola through mass media, IEC materials, and infection control and prevention materials were distributed in districts., Results: We trained 210 health workers and 120 other multidisciplinary team members on Ebola surveillance, preparedness and response. Evaluation results demonstrated a gain in knowledge and skills. Communities were sensitized about Ebola and Districts received person protective equipments and items for infection prevention. Epidemic Preparedness and Response plans were also developed., Conclusion: Training of multidisciplinary teams improves the country's preparedness, alertness and response capabilities in controlling Ebola. West African countries experiencing Ebola outbreaks could draw lessons from the Uganda experience to contain the outbreak.

Background: Lack of adherence to anti diabetic medication causes suboptimal blood sugar control among patients with diabetes and can lead to treatment failures, accelerated development of complications and increased mortality. This study assessed factors associated with adherence to anti diabetic medication in rural eastern Uganda., Methods: A cross sectional study was conducted among 521 patients with diabetes in Iganga and Bugiri hospitals between October 2012 and January 2013. Respondents were patients who were18 years and above and had been on diabetic treatment for not less than a month. Pretested questionnaires were used. Variables that were collected included socio-demographic characteristics, possible barriers to adherence, and self management efforts. Adherence was assessed using self reports. Descriptive and inferential statistics were done to determine adherence to anti diabetic medication and the associated factors., Results: The level of adherence to anti diabetic medication was 83.3% and factors that were independently associated with adherence were; having been on anti diabetic drugs for at least three years (OR = 1.89, 95% CI = 1.11 - 3.22), availability of diabetic drugs (OR = 2.59, 95% CI = 1.54 - 3.70), and having ever had diabetic health education (OR = 4.24, 95% CI =1.15 - 15.60)., Conclusion: About four in five patients adhere to anti-diabetic treatment. Strategies aimed at improving anti diabetic drug availability and providing health education could improve adherence.

Background: In Uganda, the main causes of death in children under 5 years of age are malaria and pneumonia--often due to delayed diagnosis and treatment. In preparation for a community case management intervention for pneumonia and malaria, the bacterial composition of the nasopharyngeal flora and its in vitro resistance were determined in children aged five or under to establish baseline resistance to commonly used antibiotics., Methods: In a population-based survey in April 2008, nasopharyngeal specimens were collected from 152 randomly selected healthy children under 5 years of age in the Iganga/Mayuge Health and Demographic Surveillance Site (HDSS). Medical history and prior treatment were recorded. Demographic characteristics and risk factors for carriage of resistant strains were obtained from the HDSS census. Bacteria were isolated and analysed for antibiotic susceptibility using disk diffusion and E test., Results: Streptococcus pneumoniae (S. pneumoniae) carriage was 58.6%, and, while most (80.9%) isolates had intermediate resistance to penicillin, none was highly resistant. Whereas no isolate was resistant to erythromycin, 98.9% were resistant to trimethoprim-sulphamethoxazole (co-trimoxazole)., Conclusions: In vitro resistance in S. pneumoniae to co-trimoxazole treatment was high, and the majority of isolates had intermediate resistance to penicillin. To inform treatment policies on the clinical efficacy of current treatment protocols for pneumonia in health facilities and at the community level, routine surveillance of resistance in pneumonia pathogens is needed as well as research on treatment efficacy in cases with resistant strains. Improved clinical algorithms and diagnostics for pneumonia should be developed.

Background: Despite the increasing investment in health-related research in Sub-Saharan Africa, a large gulf remains between what is known and what is practiced in health systems. Knowledge translation programs aim to ensure that a wide range of stakeholders are aware of and use research evidence to inform their health and health-care decision-making. The purpose of this study is to provide insight into the impacts on capacity building for knowledge translation and knowledge translation activities by a coalition of eight research groups in Africa., Methods/design: We will use a mixed methods approach. Key informant interviews and document reviews will be employed to evaluate changes in knowledge translation capacity and to evaluate the effects of knowledge translation on potential users of research. Quarterly teleconferences will be done to evaluate the impacts of knowledge translation activities on users of research. Using website tracking, we will be able to explore the influence of knowledge translation networking and dynamics of the knowledge translation network., Discussion: We have adopted the dynamic knowledge transfer model and the Landry framework to come up with a framework for this study so as to explore the capacity of producers and users of research to generate, disseminate, and use research findings, while highlighting their strengths and weaknesses. This information will be useful for guiding implementers that seek to build capacity on knowledge translation so as to promote the utilization of research findings for informing programs, practice, and policy.

Background: Lay community health workers (CHWs) have been widely used to provide curative interventions in communities that have traditionally lacked access to health care. Optimal performance of CHWs managing children with malaria, pneumonia and diarrhoea in communities is desired if a reduction in childhood morbidity and mortality is to be achieved. This study assessed factors influencing performance of CHWs managing malaria, pneumonia and diarrhoea under the Integrated Community Case Management (iCCM) programme in Wakiso district, central Uganda., Methods: A cross sectional study was conducted among 336 CHWs. Data was collected using interviews and record reviews. Performance was measured using composite scores based on the core activities of CHWs under the iCCM programme. These core activities included: treating children under five years, referring severely sick children including newborns, home visits, counseling caregivers on home care, record keeping and community sensitization. Descriptive and inferential statistics using odds ratios were done to determine factors influencing performance of CHWs., Results: Of the 336 respondents, 242 (72%) were females and the overall level of good performance was 21.7% (95% CI, 17.3-26.1%). Factors significantly associated with performance were: sex (females) (AOR 2.65; 95% CI, 1.29 -5.43), community support (AOR 2.29; 95% CI, 1.27-4.14), receiving feedback from health facilities (AOR 4.90; 95% CI, 2.52-9.51) and having drugs in the previous three months (AOR 2.99; 95% CI, 1.64-5.42)., Conclusion: Only one in every five CHWs performed optimally under the iCCM programme. Strategies to improve drug supply, community support and feedback provision from the formal health system are necessary to improve the performance of CHWs.

Background: Interventions for prevention of type 2 diabetes ought to be acceptable to target communities. We assessed perceptions about type 2 diabetes and lifestyle change among people afflicted or at high risk of this disease in a low income setting in Iganga Uganda., Methods: Twelve focus group discussions (FGDs) of eight participants each were conducted, balancing rural and peri-urban (near the Municipality) residence and gender. The FGDs involved people with suspected type 2 diabetes (based on fasting plasma glucose (FPG), people with suspected pre-diabetes and obese people with normal FPG. Content analysis was conducted., Results: Diabetes was perceived to be a very severe disease. Its severity was attributed to its incurability and its numerous health effects. Men were also concerned about reduced sexual performance. However, participants' strong concerns about the severity of diabetes were not reflected in their perceptions about the risk factors and lifestyles associated with it. While people with diabetes perceive obesity as 'sickness', those without diabetes perceive it as a sign of 'success'. Although participants are willing to change their diet, they mention numerous barriers including poverty, family size, and access to some foods. Because of their good taste, reduction of high risk foods like sugar and fried food is perceived as 'sacrificing a good life'. Increments in physical activity were said to be feasible, but only in familiar forms like domestic work. An over-arching theme emerged that 'lifestyle changes are viewed as sacrificing a good life'., Conclusions: Health promotion should target both community norms and individual awareness regarding obesity, physical activity and diet, and should address the notion that obesity and unhealthy foods represent a good life. Health educators should plan with clients on how to overcome barriers and misconceptions to lifestyle change, leveraging the pervasive perception of type 2 diabetes as a severe disease to motivate change.

Background: Brucellosis is the commonest zoonotic infection worldwide with symptoms similar to other febrile syndromes such as malaria and typhoid fever. It is often easily misdiagnosed, resulting in underreporting and misdirected treatments. Understanding of the factors that influence brucellosis care seeking is essential in enhancing its effective management. Our study sought to determine the factors associated with choice of provider in accessing care for brucellosis among pastoral communities in Uganda., Methods: This was a cross-sectional survey involving 245 randomly selected respondents previously diagnosed and treated for brucellosis, two months before the study. They were enrolled from three sub-counties neighboring Lake Mburo National Park between December 2012 to April 2013. Data on socio-demographics, availability, accessibility, affordability and acceptability of health services were collected. A multivariable logistic regression model was fitted to determine association between independent and outcome variables using odds ratios and 95% confidence intervals with p-value≤0.05 considered statistically significant., Results: Of the 245 respondents, 127(51.8%) sought health care at government facilities and the rest at private. Respondents who were less likely to choose a government facility were either single (OR: 0.50, CI: 0.26-0.97), had general weakness (OR: 0.09, CI: 0.01-0.72) or whom family took a decision (OR: 0.52, CI: 0.28-0.97). At multivariable analysis, choice of government facility was influenced by primary education (aOR: 0.46, CI: 0.22-0.97), having six to ten household members (aOR:3.71, CI:1.84-7.49), family advice (aOR:0.64, CI: 0.23-0.91), distance ≥10 kms (aOR:0.44, CI: 0.21-0.92), high costs at private clinics (aOR:0.01, CI:0.02-0.15) and no diagnosis at government facility (aOR:0.11, CI:0.01-0.97). Females were more likely to seek health care at government facilities, while those with tertiary education were less likely, after the first provider., Conclusions: Females and households with six to ten members were more likely to choose government facilities. Government facilities need to be equipped to attract more patients.

Background: Cervical cancer is the most common cancer affecting women in Uganda; yet community understanding of the disease is limited. We explored community perceptions, beliefs and knowledge about the local names, causes, symptoms, course, treatment, and prognosis of cervical cancer in order to inform targeted interventions to promote early help-seeking., Methods: Twenty four focus group discussions (FGD) with men and women aged 18 - 59 years and ten key informant interviews with persons aged ≥ 60 years were conducted at two sites in Gulu district between May and June 2012. A semi-structured interview guide informed by Kleinman's illness explanatory model and literature on community awareness of cervical cancer was used to collect data. Data analysis was supported with use of ATLAS.ti 6.1 in coding, organizing and tracking data segments. We used content analysis technique in data analysis and organised data into a structured format under distinct themes and categories., Results: Cervical cancer was known by the local name "two remo", meaning "an illness that manifests with bleeding." Respondents believed that early onset of sexual activity, multiple male sexual partners and multi-parity cause cervical cancer. Respondents in half of FGDs also reported that use of condoms and family planning pills and injections cause cervical cancer. Symptoms of cervical cancer reported included vaginal bleeding, watery vaginal discharge and lower abdominal and waist pain. Respondents in most of the FGDs and key informants perceived cervical cancer as a chronic illness and that it can be treated with both modern and traditional medicines. The majority thought that cervical cancer treatment was supportive; the illness is not curable., Conclusions: While some lay beliefs about the causes of cervical cancer suggest some understanding of aetiology of the disease, other perceived causes particularly those related to use of family planning and condoms are potentially hurtful to public health. Awareness campaigns to promote early help-seeking for cervical cancer symptoms need to be culturally-sensitive and context-specific; and include messages on symptoms, risk factors, course, treatment and prognoses.

Introduction: In Burkina Faso, 1230 women are diagnosed with cervical cancer every year and 838 die from the disease. Little is known about women's practices, knowledge and beliefs regarding cervical cancer. This study aims to describe women's practices regarding cervical cancer screening and to assess their knowledge and beliefs., Methods: Cross-sectional study was carried out in Ouagadougou from 1st to 31st December 2012 interviewing 840 women aged 20 to 50 years about their knowledge, beliefs and practices regarding cervical cancer. Cluster sampling was used. Univariate and multivariate logistic regression analysis were performed. Chi square test was used and p-value < 0.05 was considered., Results: Out of 840 women enrolled with mean age 29.5 ± 7.77 years, 66.31% were married, 59.28% have not been to school or left school at primary level. While 64.2% of participants heart about cervical cancer, 8.5% heart about Human papillomavirus, 69.05% don't know that cervical cancer is preventable. 90.4% of participants were worried to develop cervical cancer, 96.67% would accept to be screened and 11.07% were screened for cervical cancer. In multivariate analysis, heart about cervical cancer (OR = 5.7; 95% CI: 2.21-14.69), know contamination mode of HPV (OR = 3.81; 95% CI: 2.27-6.39), heart about HPV (OR = 2.05; 95% CI: 1.11-3.81) and use of oral contraceptive (OR = 2.06; 95% CI: 1.25-3.39) were independently associated with screening history with p < 0.05., Conclusion: Knowledge and belief regarding cervical cancer is limited among Ouagadougou women and screening rate is low. There is need to enhance health education regarding Human papillomavirus and cervical cancer.

Background: Home and community-based combined treatment of malaria and pneumonia has been promoted in Uganda since mid 2011. The combined treatment is justified given the considerable overlap between the symptoms of malaria and pneumonia among infants. There is limited evidence about the extent to which community-based care reduces healthcare-seeking costs at the household level in rural and urban settings. This paper assesses the rural-urban differences in direct and indirect costs of seeking care from formal health facilities compared to community medicine distributors (CMDs)., Methods: Exit interviews were conducted for 282 (159 rural and 123 urban) caregivers of children below five years who had received treatment for fever-related illnesses at selected health centres in Iganga and Mayuge districts. Data on the direct and indirect costs incurred while seeking care at the health centre visited were obtained. Using another tool, household level direct and indirect costs of seeking care from CMDs were collected from a total of 470 caregivers (304 rural and 166 urban). Costs incurred at health facilities were then compared with costs of seeking care from CMDs., Results: Household direct costs of seeking care from health facilities were significantly higher for urban-based caregivers than the rural (median cost = US$0.42 for urban and zero for rural; p < 0.0001). The same is true for seeking care from CMDs (p = 0.0038). Overall, caregivers travelled for an average of 75 min to reach health centres and spent an average of 80 min at the health centre while receiving treatment. However, households in rural areas travelled for a significantly longer time (p < 0.001 to reach health care facilities than the urban-based caregivers. Besides travelling longer distances, rural caregivers spent 150 min seeking care from health facilities compared to 30 min from CMDs., Conclusion: Time and monetary savings for seeking care from CMDs are significantly larger for rural than urban households. Thus, home and community-based treatment of child febrile illnesses is much more cost-saving for rural poor communities, who would spend more time travelling to health facilities - which time could be re-directed to productive and income-generating activities.

Background: Brucellosis is one of the most common zoonotic infections globally. Lack of knowledge about brucellosis may affect the health-seeking behavior of patients, thus leading to sustained transmission in these communities. Our study assessed knowledge and perceptions of brucellosis among pastoral communities adjacent to Lake Mburo National Park (LMNP), Kiruhura District, Uganda., Methods: A community cross-sectional questionnaire survey involving 371 randomly selected household heads from three sub-counties neighboring LMNP were interviewed between June and August 2012. Data collected included communities' knowledge on causes, symptoms, transmission, treatment, prevention and risk factors of brucellosis. Multivariable logistic regression analysis was performed to explore strength of association between overall knowledge of brucellosis and various individual factors using odds ratios and 95% confidence intervals., Results: Only 70 (19%) knew the symptoms of brucellosis in animals, and three quarters (279, 75.5%) mentioned joint and muscle pain as a common symptom in humans. Almost all participants (370, 99.3%) had ever heard about brucellosis, majority (311, 84.7%) believed it affects all sexes and two thirds (67.7%) of the respondents believed close proximity to wildlife contributes to the presence of the disease. Almost all (352, 95.4%) knew that brucellosis in humans could be treatable using modern drugs. The main routes of infection in humans such as consumption of unpasteurized dairy products were known by 97% (360/371); eating of half-cooked meat by 91.4% and eating contaminated pasture in animals by 97.4%. There was moderate overall knowledge of brucellosis 197 (53.1%). Factors associated with higher overall knowledge were being agro-pastoralists (aOR: 2.08, CI: 1.17-3.71) compared to pure pastoralists while those who reported that the disease was a health problem (aOR: 0.18, CI: 0.06-0.56) compared to those who said it was not were less likely to be knowledgeable., Conclusions: There was moderate overall knowledge of human and animal brucellosis among the participants. Majority of the participants believed that close proximity to wildlife contributes to the presence of the disease in the area. There is a need for collaboration between the public health, veterinary and wildlife sectors to provide health education on brucellosis for better management of the disease in the communities.

Background: Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda., Methods: Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Survey data underwent descriptive statistical analysis. Latent content analysis was used for qualitative data., Results: Of the 821 respondents in the survey, 96% (785/821) were mothers with a mean age of 26 years (95% CI 24-27). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents (24%, 95% CI 21-27). This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3-6 hours before receipt of services although this was more common at public facilities. Only 33% (95% CI 30-37) of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% (95% CI 27-34) of the survey respondents utilised these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. Charges ranged from US$ 0.2 to US$4 and these were more commonly reported at private (70%, 95% CI 65-76) than at public (58%, 95% CI 54-63) facilities. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities., Conclusions: Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, governments should strengthen health systems to cater for increasing urban populations.

Background: Health workers move between public and private organizations in both urban and rural areas during the course of their career. Depending on the proportion of the population served by public or private organizations in a particular setting, this movement may result in imbalances in the number of healthcare providers available relative to the population receiving care from that sector. However, both public and private organizations are needed as each sector has unique contributions to make to the effective delivery of health services., Objectives: To assess the effects of financial incentives and movement restriction interventions to manage the movement of health workers between public and private organizations in low- and middle-income countries., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (10 November 2012); EMBASE (7 June 2011); LILACS (9 June 2011); MEDLINE (10 November 2012); CINAHL (13 August 2012); and the British Nursing Index (13 August 2012)., Selection Criteria: Randomized controlled trials and non-randomized controlled trials; controlled before-and-after studies if pre- and post-intervention periods for study and control groups were the same and there were at least two units included in both the intervention and control groups; uncontrolled and controlled interrupted time series studies if the point in time when the intervention occurred was clearly defined and there were at least three or more data points before and after the intervention. Interventions included payment of special allowances, increasing salaries, bonding health workers, offering bursary schemes, scholarships or lucrative terminal benefits, and hiring people on contract basis., Data Collection and Analysis: Two review authors independently applied the criteria for inclusion and exclusion of studies to the titles and abstracts of all articles obtained from the search. The same two review authors independently screened the full reports of the selected citations. At each stage, we compared the results and resolved discrepancies through discussion with a third review author., Main Results: We found no studies that were eligible for inclusion in this review., Authors' Conclusions: We identified no rigorous studies on the effects of interventions to manage the movement of health workers between public and private organizations in low- and middle-income countries. Health worker availability is a key obstacle in delivery of health services. Interventions to make the health sector more responsive to the expectations of populations by having more health workers in the sector that serves most people would contribute to the more efficient use of the health workforce. More research is needed to assess the effect of increase in salaries, offering scholarships or bonding on movement of health workers in one sector compared with another.

Background: Efforts to improve access to treatment for common illnesses in children less than five years initially targeted malaria alone under the home management of malaria strategy. However under this strategy, children with other illnesses were often wrongly treated with anti-malarials. Integrated community case management of common childhood illnesses is now recommended but its effect on promptness of appropriate pneumonia treatment is unclear., Objectives: To determine the effect of integrated malaria and pneumonia management on receiving prompt and appropriate antibiotics for pneumonia symptoms and treatment outcomes as well as determine associated factors., Methods: A follow-up study was nested within a cluster-randomized trial that compared under-five mortality in areas where community health workers (CHWs) treated children with malaria and pneumonia (intervention areas) and where they treated children with malaria only (control areas). Children treated by CHWs were enrolled on the day of seeking treatment from CHWs (609 intervention, 667 control) and demographic, illness, and treatment seeking information was collected. Further information on illness and treatment outcomes was collected on day four. The primary outcome was prompt and appropriate antibiotics for pneumonia symptoms and the secondary outcome was treatment outcomes on day four., Results: Children in the intervention areas were more likely to receive prompt and appropriate antibiotics for pneumonia symptoms compared to children in the control areas (RR = 3.51, 95%CI = 1.75-7.03). Children in the intervention areas were also less likely to have temperature ≥37.5°C on day four (RR = 0.29, 95%CI = 0.11-0.78). The decrease in fast breathing between day one and four was greater in the intervention (9.2%) compared to the control areas (4.2%, p-value = 0.01)., Conclusions: Integrated community management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms and improves treatment outcomes., Trial Registration Isrctn: ISRCTN52966230.

Background: People diagnosed with diabetes mellitus are increasing in sub-Saharan Africa and prompt care seeking depends on perceptions of the illness., Objective: The objective was to explore perceptions of diabetes in rural areas., Method: We conducted a qualitative, explorative and descriptive study in rural eastern Uganda. Eight focus group discussions with community members were conducted. Community members were presented with a story about a person with diabetes symptoms and their perceptions of the diagnosis and treatment elicited. Four focus group discussions with people with diabetes and seven key informant interviews with health workers were conducted. Respondents were asked how the community interpreted symptoms of diabetes, its causes and whether it was curable. Manifest content analysis was used., Results: Some respondents thought people with diabetes symptoms had HIV or were bewitched. Causes of diabetes mentioned included consuming too much fatty food. Some respondents thought diabetes is transmitted through air, sharing utensils with or sitting close to people with diabetes. Some respondents thought that diabetes could heal fast whilst others thought it was incurable., Conclusion: Misdiagnosis may cause delay in seeking proper care. Preventive programmes could build on people's thinking that too much fatty food causes diabetes to promote diets with less fat. The perception of diabetes as a contagious disease leads to stigmatisation and affects treatment seeking. Seeing diabetes as curable could create patient expectations that may not be fulfilled in the management of diabetes. Rural communities would benefit from campaigns creating awareness of prevention, symptoms, diagnosis and management of diabetes.

Background: Following an outbreak of yellow fever in northern Uganda in December 2010, Ministry of Health conducted a massive emergency vaccination campaign in January 2011. The reported vaccination coverage in Pader District was 75.9%. Administrative coverage though timely, is affected by incorrect population estimates and over or under reporting of vaccination doses administered. This paper presents the validated yellow fever vaccination coverage following massive emergency immunization campaigns in Pader district., Methods: A cross sectional cluster survey was carried out in May 2011 among communities in Pader district and 680 respondents were indentified using the modified World Health Organization (WHO) 40 × 17 cluster survey sampling methodology. Respondents were aged nine months and above. Interviewer administered questionnaires were used to collect data on demographic characteristics, vaccination status and reasons for none vaccination. Vaccination status was assessed using self reports and vaccination card evidence. Our main outcomes were measures of yellow fever vaccination coverage in each age-specific stratum, overall, and disaggregated by age and sex, adjusting for the clustered design and the size of the population in each stratum., Results: Of the 680 survey respondents, 654 (96.1%, 95% CI 94.9 - 97.8) reported being vaccinated during the last campaign but only 353 (51.6%, 95% CI 47.2 - 56.1) had valid yellow fever vaccination cards. Of the 280 children below 5 years, 269 (96.1%, 95% CI 93.7 - 98.7) were vaccinated and nearly all males 299 (96.9%, 95% CI 94.3 - 99.5) were vaccinated. The main reasons for none vaccination were; having travelled out of Pader district during the campaign period (40.0%), lack of transport to immunization posts (28.0%) and, sickness at the time of vaccination (16.0%)., Conclusions: Our results show that actual yellow fever vaccination coverage was high and satisfactory in Pader district since it was above the desired minimum threshold coverage of 80% according to World Health Organization. Massive emergency vaccination done following an outbreak of Yellow fever achieved high population coverage in Pader district. Active surveillance is necessary for early detection of yellow fever cases.

Background: Development of resistance to first line antimalarials led to recommendation of artemisinin based combination therapies (ACTs). High adherence to ACTs provided by community health workers (CHWs) gave reassurance that community based interventions did not increase the risk of drug resistance. Integrated community case management of illnesses (ICCM) is now recommended through which children will access both antibiotics and antimalarials from CHWs. Increased number of medicines has been shown to lower adherence., Objective: To compare adherence to antimalarials alone versus antimalarials combined with antibiotics under ICCM in children less than five years., Methods: A cohort study was nested within a cluster randomized trial that had CHWs treating children less than five years with antimalarials and antibiotics (intervention areas) and CHWs treating children with antimalarials only (control areas). Children were consecutively sampled from the CHWs' registers in the control areas (667 children); and intervention areas (323 taking antimalarials only and 266 taking antimalarials plus antibiotics). The sampled children were visited at home on day one and four of treatment seeking. Adherence was assessed using self reports and pill counts., Results: Adherence in the intervention arm to antimalarials alone and antimalarials plus antibiotics arm was similar (mean 99% in both groups) but higher than adherence in the control arm (antimalarials only) (mean 96%). Forgetfulness (38%) was the most cited reason for non-adherence. At adjusted analysis: absence of fever (OR = 3.3, 95%CI =1.6-6.9), seeking care after two or more days (OR = 2.2, 95%CI = 1.3-3.7), not understanding instructions given (OR = 24.5, 95%CI = 2.7-224.5), vomiting (OR = 2.6, 95%CI = 1.2-5.5), and caregivers' perception that the child's illness was not severe (OR = 2.0, 95%CI = 1.1-3.8) were associated with non-adherence., Conclusions: Addition of antibiotics to antimalarials did not lower adherence. However, caregivers should be adequately counseled to understand the dosing regimens; continue with medicines even when the child seems to improve; and re-administer doses that have been vomited.

We compared use of community medicine distributors (CMDs) and drug use under integrated community case management and home-based management strategies in children 6-59 months of age in eastern Uganda. A cross-sectional study with 1,095 children was nested in a cluster randomized trial with integrated community case management (CMDs treating malaria and pneumonia) as the intervention and home-based management (CMDs treating only malaria) as the control. Care-seeking from CMDs was higher in intervention areas (31%) than in control areas (22%; P = 0.01). Prompt and appropriate treatment of malaria was higher in intervention areas (18%) than in control areas (12%; P = 0.03) and among CMD users (37%) than other health providers (9%). The mean number of drugs among CMD users compared with other health providers was 1.6 versus 2.4 in intervention areas and 1.4 versus 2.3 in control areas. Use of CMDs was low. However, integrated community case management of childhood illnesses increased use of CMDs and rational drug use.

Use of community health workers (CHWs) has been implemented the same way in urban and rural areas despite differences in availability of health providers and sociodemographic characteristics. A household survey was conducted in rural and urban areas in eastern Uganda, and all children who were febrile in the previous two weeks were assessed for their symptoms, treatment received at home, and when and where they first went for treatment. Rural children were more likely to use CHWs than urban children. Urban children received outside treatment more promptly, and used herbs at home less. Symptoms and proportion of children being taken out for treatment were similar. Children from the poorest households used CHWs less and private providers more than the middle quintiles. Drug shops and private clinics should be included in the community case management to cater for the poorest in rural areas and persons in urban areas.