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The aim of this study was to establish the prevalence of asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in key populations at increased risk of transmission of HIV. Additionally, we aimed to identify the associated risk factors for asymptomatic sexually transmitted infections (STIs) and evaluate the acceptability of self-collected samples. Asymptomatic people living with HIV (PLHIV) in the following categories were offered testing: discordant couples, young adults, pregnant patients and those attending the ‘most-at-risk-population’ clinic. Patients provided first-pass urine, self-collected vaginal swabs or both to test for NG and CT by polymerase chain reaction using BD ProbeTec™. Patients also completed an acceptability questionnaire, including the negative partner of an HIV-positive participant. Three hundred and sixty-three PLHIV had an STI screen. Asymptomatic STIs were only diagnosed in women (prevalence 5.7%), overall prevalence 3.9% ( n = 14). Factors independently associated with an STI in women were being under 25 years (OR 9.63 95% CI 1.56–59.5) and having more than one sexual partner (OR 8.06 95% CI 1.07–60.6). Four hundred and seven completed the acceptability questionnaire. More than 95% of patients found self-sampling easy and comfortable and 83.8% would believe the results. Women significantly preferred the option of self-sampling, 56.9% versus 29.3% of men ( p < 0.001). Acceptability of self-sampling was high. Young women with or at risk of HIV are an important target for STI testing regardless of symptoms. There is need for diagnostic tests that are inexpensive, rapid and accurate especially in resource-limited settings.

BackgroundEvidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings.MethodsWe identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.ResultsPerformance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.ConclusionFuture interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

There has been persistent decline in blue monkey (Cercopithecus mitis) population at Ngogo research site in the past 40 years for no clear reasons. In contrast, the populations of other nonhuman primates like the grey‐cheeked mangabeys (Lophocebus albigena) which share identical home ranges with blue monkeys have not been obviously affected. However, stakeholders attribute this decline to gastrointestinal parasitic diseases, hence the need to determine the profile of parasitic infections in blue monkeys and compare them to that of grey‐cheeked mangabeys within a shared home range. Faecal samples (n = 241) were subjected to diagnostic tests, namely sodium nitrate floatation and formol‐ether sedimentation before microscopic examination. 227 (94%) samples were parasite positive; six protozoa and 21 helminths were present. This implies that Ngogo hosts a high diversity of parasites which poses health risks to nonhuman primates. There was no significant statistical difference in the prevalence of the overall main pathogenic parasites between the two studied nonhuman primate species. Therefore, gastrointestinal parasites may not be the obvious cause of the proclaimed blue monkey population decline at Ngogo research site.

Background The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. Methods A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men. Results A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21–35 years) to 22 years (IQR, 18–29 years) (P for trend < .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28–.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time. Conclusions VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.

Background We assessed the utility of the International HIV Dementia Scale (IHDS) in detecting HIV-associated neurocognitive disorder (HAND) in Uganda in antiretroviral (ART)-naive and ART-experienced adults. Setting A longitudinal observational cohort study in Rakai, Uganda. Methods Three hundred ninety-nine HIV+ ART-naive adults underwent neurological, functional status, and neuropsychological assessments including the IHDS. Three hundred twelve participants who initiated ART were re-evaluated after 2 years. HAND stages [asymptomatic neurocognitive impairment, mild neurocognitive disorder, and HIV-associated dementia (HAD)] were determined based on Frascati criteria using local normative data. Sensitivity, specificity, and area under the ROC curve were determined for various IHDS thresholds (≤9, ≤ 9.5, and ≤10). Results At baseline, the participants' mean age was 35 years (SD ± 8), 53% were men, and 84% had less than a high school education. At baseline, sensitivity for detecting any HAND stage, symptomatic HAND [mild neurocognitive disorder, HAD], and HAD alone were maximized at IHDS ≤10 (81%, 83%, 92%, respectively). Among 312 individuals who returned for the 2-year follow-up and had initiated ART, a score of ≤10 provided a lower or equal sensitivity for detecting different stages of HAND (all HAND: 70%; symptomatic HAND: 75%; HAD: 94%). The area under the ROC curve was higher for ART-experienced versus ART-naive individuals. Conclusions The IHDS is a potentially useful screening tool for neurocognitive impairment in rural Uganda for both ART-naive and ART-experienced adults. A cutoff ≤10 demonstrates higher sensitivity for more severe HAND stages compared with less severe HAND. Future studies should focus on potential modifications to the IHDS to improve its specificity.

Background: Road traffic injuries (RTIs) are the leading cause of death among 15-29-year olds, of which 22% are pedestrians. In Uganda, pedestrians constitute 43% of RTIs. Over 52% of these injuries occur in Greater Kampala Metropolitan Area (GKMA). However, information on geospatial distribution of RTIs involving pedestrians and associated factors is scanty. We established the geospatial distribution of pedestrian injuries and associated factors in GKMA, Uganda. Methods: We conducted a mixed methods cross sectional study in three districts of GKMA. We used a structured questionnaire to interview 332 injured pedestrians at ten purposively selected health facilities from May to July 2017. We used a modified Australian Walkability Audit Tool to assess road characteristics and videography to capture road user behaviour at reported injury sites. Injury location (outcome) was categorized into three locations according to primary land use: residential areas, commercial/business areas and bar & entertainment areas. The injury hotspots were then mapped out using Quantum Geographic Information System (QGIS). Multinomial logistic regression was used to identify factors associated with injury location and adjusted prevalence ratios (APR) reported at 95% confidence interval. Results: Males represented 66.5% (221/332) of the sample. Pedestrian injuries were most prevalent among 15-29-year olds (45.5%, 151/332). Most (47.2%, 157/332) injuries occurred in commercial and business areas. Namasuba-Zana (13%, 43/332) followed by Nakawa-Kireka on Jinja road (9.7%, 32/332) had the highest number of injuries. Presence of speed humps was protective (APR=0.13, 95%CI 0.01-0.93). However, zebra crossings (APR=6.41, 95% CI: 1.14-36.08) and clear traffic (APR=6.39, 95%CI: 2.75-14.82) were associated with high prevalence of pedestrian injuries. Conclusion: Presence of speed humps was safer for pedestrians but zebra crossings and clear traffic had more than 6-fold risk for injuries. Findings suggest that constructing speed humps on the roads in busy areas and sensitizing motorists to respect zebra crossings could reduce pedestrian injuries.

BACKGROUND: Injuries are a significant public health problem but poorly quantified especially in low and middle-income countries. In Uganda, the burden of injuries is poorly quantified with most of the data reported being facility and mortality based. Many non-fatal injuries, therefore, remain unreported in communities. We conducted a household survey in Mbarara Municipality to identify and describe all non-fatal injury events and the associated factors. METHODS: We conducted a cross-sectional study of non-fatal injuries among 966 household members in Mbarara Municipality, from May to June 2017. The most recent non-fatal injury (within a six-month recall period; December 2016 to June 2017) resulting in loss of at least one day of usual daily operating activity was considered. We conducted a descriptive statistical analysis to estimate the counts and frequencies of non-fatal injuries. We identified factors associated with non-fatal injuries using a modified Poisson regression model. RESULTS: The prevalence of non-fatal injuries was 18.2% (176/966) with 92% (162/176) of the non-fatal injuries being unintentional. Falls 27.3% (48/176) were the most common cause of injury followed by road traffic injuries (RTI), 26.7% (47/176), burns 16.5% (29/176) and the least being poisoning 2.8% (5/176). Occupation as casual laborer (Adjusted PR=2.1, 95% CI: 1.2 - 3.7), urban residency (Adjusted PR=1.5, 95% CI: 1.1 - 1.9) and being a non-native of the study area (Adjusted PR=1.7, 95% CI: 1.3 - 2.3) were independently associated with non-fatal injuries. CONCLUSION: Almost one out of five people had suffered a non-fatal injury in the past six months in Mbarara Municipality. Majority of the non-fatal injuries were unintentional, caused by falls and RTIs, and were amongst casual labourers and urban residents. These findings reveal a gap in injury prevention in Uganda that needs to be addressed to improve the quality of life.

This study assessed the susceptibility of Anopheles mosquitoes to LLINs and IRS as vector control interventions used in Tororo and Busia district. Samples of Anopheles mosquito larvae were collected from various breeding grounds and reared in an insectary. Emerged adults were dissected under a stereoscopic microscope and identified using standardized morphological keys after respective bioassays on used LLINs and sprayed walls. A One-Way Analysis of Variance (ANOVA) was used to test for significant differences in the mean composition of mosquito species across the study area, mean variations, mortalities by net and wall type. Results showed that the Anopheles gambiae sensu lato revealed a higher mean of 78.33 ± 41.52, compared to Anopheles funestus (16.42 ± 24.87) which was lonely found in Busia district. Out of four brands of nets tested for insecticides susceptibility, 99% mortality was recorded for the insecticide concentration of 80 mg/m2 deltamethrin impregnated DAWA plus 2.0 nets. PermaNet 3.0 and Olyset recorded mortality rate of 95% and 93% at chemical concentrations of 50 mg/m2 and 525 mg/m2 permethrin respectively. PermaNet 2.0 recorded 67% mortality at 55 mg/m2 permethrin. The average number of Anopheles mosquitoes were more susceptible to 12.5 mg/m2 of Fludora fusion impregnated onto plastered painted walls at a rate of 100% as compared to the other types of walls after 2 weeks (6.86 ± 4.07) and 1 month of chemical spray (6.69 ± 4.01) varied insignificantly (t = 0.175, P = 0.861). Meanwhile, a disaggregated results by time of spray (T0 and T1) and exposure periods, showed that plastered painted wall, had higher mortalities followed by Brick Plain and Mud/Wattle wall substrates, respectively. This study has shown that vector behavior, biology and physiology need consistent monitoring and surveillance for further entomological characterization and the need for coming up with new vector control interventions.

BackgroundInfants born to HIV-infected mothers are at a high risk of acquiring the infection. The World Health Organization (WHO) recommends early diagnosis of HIV-exposed infants (HEIs) through deoxyribonucleic acid polymerase chain reaction (DNA PCR) and rapid HIV testing. Early detection of paediatric HIV is critical for access to antiretroviral therapy treatment (ART) and child survival. There’s, however, limited evidence of the adherence to early infant diagnosis (EID) of HIV testing protocol among HEIs in fishing communities in Uganda. This study assessed adherence to EID of HIV testing protocol among HIV-exposed infants in a hard-to-reach fishing community in Uganda.MethodsWe conducted a cross-sectional study employing quantitative data collection methods among HEIs in selected healthcare facilities in Buvuma islands, Buvuma district. We obtained secondary data from mother-infant pair files enrolled on the EID program using a data extraction tool. Data were analysed using STATA Version 14. Modified poisson regression analysis was used to determine the factors associated with non-adherence to the 1st DNA PCR test among HIV-exposed infants enrolled into care.ResultsNone of the HIV-exposed infants had done all the EID tests prescribed by the HIV testing protocol within the recommended time frame for the period of January 2014-December 2016. Adherence to the 1st and 2nd DNA PCR, and rapid HIV tests was 39.5%, 6.1% and 81.0% respectively. Being under the care of single mothers (PR=1.11, 95% CI: 1.01-1.23, p=0.023) and cessation of breast feeding (PR=0.90, 95% CI: 0.83-0.98, p=0.025) were significantly associated with non-adherence to the 1st DNA PCR.ConclusionNone of the HIV-exposed infants adhered to all the EID tests of HIV testing protocol. Adherence to the 1st DNA PCR was positively associated with being a single mother and exclusive breast feeding. Therefore, single mothers and those who stop breastfeeding should be supported to ensure timely EID.

Supplemental material, sj-pdf-2-imr-10.1177_03000605221138491 for Sickle cell trait screening in students in a Ugandan university: a cross-sectional study by Erina Kisakye, Yahaya Gavamukulya and Banson John Barugahare in Journal of International Medical Research

Supplemental material, sj-pdf-1-imr-10.1177_03000605221138491 for Sickle cell trait screening in students in a Ugandan university: a cross-sectional study by Erina Kisakye, Yahaya Gavamukulya and Banson John Barugahare in Journal of International Medical Research

Additional file 1: Table S1. ParentCorps implementation models and impact evidence. Table S2. Power estimation for child and teacher effectiveness outcomes.

Introduction: Intensified Case Finding (ICF) is a cost-effective strategy for tuberculosis (TB) control and improving quality of life however, its implementation by health workers is generally reported as low in Uganda. There is limited information on the level of ICF implementation and the barriers or facilitators to its implementation among public health facilities in Kampala Capital City Authority (KCCA). In this study we determined the level of ICF implementation, facilitators and its barriers in KCCA public health facilities. Methods: We conducted a cross-sectional study between May-July 2015. We purposively selected six KCCA public health facilities and conducted exit interviews with patients attending Anti-Retroviral Therapy (ART) clinics to assess whether they were screened for TB. In-depth and key informant interviews with health workers were conducted to explore their experiences in implementing ICF. Results: Overall, ICF implementation was sub optimal. Less than 10% (30/321) clients reported being screened for current cough, fever, weight loss or night sweats. Conversely, 90.0% (289/321) clients screened for at least one TB symptom with cough being the most frequently asked symptom 87.5% (281/321). Of 131 clients who were screened and reported having at least one TB symptom, 36.6% (48/131) were sent to the laboratory, 2.3% (3/131) for X-Ray and 61.1% (80/131) to pharmacy. Training, support supervision, proper coordination, and support from implementing partners were facilitators of ICF implementation. Poor staff attitude, irregular supply of ICF related inputs/materials, high workload, transport and stigma were key barriers to ICF policy implementation. Conclusion: ICF implementation at ART clinics in KCCA public health facilities was sub optimal. Health workers’ attitude, training, support supervision and stigma of TB clients should be addressed for better ICF implementation.

Introduction: The surge in COVID-19 cases triggered a need for surveillance systems to implement new strategies that augment and accelerate manual contact tracing. In Uganda, COVID-19 cases increased exponentially following the relaxation of the national lockdown. However, little is known about how the surveillance system mitigated COVID-19 transmission during this period. We sought to understand how contact tracing was being conducted in Kampala district following relaxation of the national lockdown. Methods: We conducted a cross-sectional qualitative study, between November and December 2020, among surveillance response officials in the five Divisions of Kampala-Uganda. We purposively selected and interviewed 14 key informants from the Division health offices who included five Division surveillance focal persons, four data analysts and five laboratory personnel. Interviews were audio recorded and transcribed verbatim. We used a conventional approach for content analysis to identify emergent themes. Results: We found that adjustments were made in the contact tracing system to cope with the increasing number of COVID-19 cases. Online and mobile application technology systems including Go-data, WhatsApp, Open Data Kit and City Health Information System were adopted for collection, storage, analysis and reporting of contact tracing data. In one Division, community health workers were trained and engaged. Phone calls were adopted to supplement physical follow-up of contacts. We found managerial barriers such as delays in communication, limited skilled-workforce and insufficient laboratory supplies. Behavioral barriers including lack of cooperation from cases and contacts triggered by perceived stigma affected effective implementation and sustainability of the adjustments in contact tracing. Conclusion: Online systems and engagement of community health workers were adopted to optimize contact tracing coverage in Kampala. There is need to assess the effectiveness and outcomes of digital solutions to contact tracing in resource-limited settings. Besides, clear strategies should be designed to ensure the attainment of gains from community health workers when engaged in surveillance response activities.

Background Clinical laboratory services are a critical component of the health system for effective disease diagnosis, treatment, control and prevention. However, many laboratories in Sub Saharan Africa remain dysfunctional. The high costs of tests in the private sector also remain a hindrance to accessing testing services. This study aimed at assessing the functionality of laboratories based on test menus and the associated constraints in Uganda. Methods This cross sectional quantitative study involved an assessment of 100 laboratories randomly selected in 20 districts from four regions of the country. Sixteen percent of the studied laboratories were regional hub laboratories. Laboratory in charges and managers in each of the selected laboratories were interviewed. A checklist for laboratory supplies adapted from the Essential Medicines and Health supplies list for Uganda, (2012) was used to assess availability of testing supplies. Data was analyzed using excel and STATA 14. Results At the point of assessment, generally, all laboratories were able to perform malaria tests and HIV tests. All the hub laboratories conducted malaria tests and TB screening. Less than half had electrolytes tests due to lack of equipment, nonfunctioning equipment and lack of reagents. Full blood count tests were missing in 25% of the hub laboratories mainly due to lack of equipment. The lack of reagents (66.7%) and the lack of equipment (58.3%) caused the majority 10/16 of the hubs to routinely referred specimens for tests that are supposed to be carried out in these laboratories due to lack of reagents (66.7%) and non-functional equipment (58.3%). Although officially recognized as an operational structure, Hub laboratories lacked a list of essential and vital supplies. Conclusions Most laboratories performed well for the common tests. However, many laboratories did not meet testing requirements especially for the advanced tests according to standard testing menus for Uganda due to non-functioning equipment, lack of equipment and reagents. Hubs lack list of essential supplies. Therefore, there is need to provide equipment to laboratories, repair the non-functional ones and develop an essential list of supplies for the hub laboratories.

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

Background Safe, high-quality surgical care in many African countries is a critical need. Challenges include availability of surgical providers, improving quality of care, and building workforce capacity. Despite growing evidence that mentoring is effective in African healthcare settings, less is known about its role in surgery. We examined a multimodal approach to mentorship as part of a safe surgery intervention (Safe Surgery 2020) to improve surgical quality. Our goal was to distill lessons for policy makers, intervention designers, and practitioners on key elements of a successful surgical mentorship program. Methods We used a convergent, mixed-methods design to examine the experiences of mentees, mentors, and facility leaders with mentorship at 10 health facilities in Tanzania’s Lake Zone. A multidisciplinary team of mentors worked with surgical providers over 17 months using in-person mentorship, telementoring, and WhatsApp. We conducted surveys, in-depth interviews, and focus groups to capture data in four categories: (1) satisfaction with mentorship; (2) perceived impact; (3) elements of a successful mentoring program; and (4) challenges to implementing mentorship. We analyzed quantitative data using frequency analysis and qualitative data using the constant comparison method. Recurrent and unifying concepts were identified through merging the qualitative and quantitative data. Results Overall, 96% of mentees experienced the intervention as positive, 88% were satisfied, and 100% supported continuing the intervention in the future. Mentees, mentors, and facility leaders perceived improvements in surgical practice, the surgical ecosystem, and in reducing postsurgical infections. Several themes related to the intervention’s success emerged: (1) the intervention’s design, including its multimodality, side-by-side mentorship, and standardization of practices; (2) the mentee–mentor relationship, including a friendly, safe, non-hierarchical, team relationship, as well as mentors’ understanding of the local context; and (3) mentorship characteristics, including non-judgmental feedback, experience, and accessibility. Challenges included resistance to change, shortage of providers, mentorship dose, and logistics. Conclusions Our study suggests a multimodal mentorship approach is promising in building the capacity of surgical providers. By distilling the experiences of the mentees, mentors, and facility leaders, our lessons provide a foundation for future efforts to establish effective surgical mentorship programs that build provider capacity and ultimately improve surgical quality.

Background and Aims: There is a high burden of vaccine-preventable diseases in the children under five years of age, particularly pneumonia diarrhea and which is greatly affected by low immunization coverage despite the existing efforts and policies. This study was carried out in Butaleja district and was aimed at establishing the socio-demographic determinants of vaccine coverage for pneumococcus and rotavirus among under five children (U5C) in the district. Study Design: This was a mixed methods cross-sectional study. Place and Duration of Study: Busolwe Town Council, Butaleja District, Eastern Uganda. Methodology: Structured researcher administered questionnaires were administered to 434 caregivers of U5C in different parts of Butaleja district. In-depth interviews with key informants and focused group discussions with Village Health Teams and community members were conducted. Review of Health Management Information Systems records was done. STATA 15 was used to analyze the data. Results: The study found that there is a declining trend in completion of the doses of Pneumococcal vaccine (PCV) and Rotavirus vaccine. For example, in quarter 1 of 2019, out of the 312 children who started immunization, only 2 completed Rota virus immunization and only 117 completed PCV vaccinations a trend that has been observed since 2016. The factors that showed a significant association with the the fact that they gave their child at least one dose of the vaccine were having been sensitized on the current immunisation schedule(P-value =

Background Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority. Objective To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection. Methods We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania’s Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact. Results Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2–33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7–60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1–1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4–56.1%; P Conclusion Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.

Background Children in low-and-middle-income countries (LMICs) are facing tremendous mental health challenges. Numerous evidence-based interventions (EBIs) have been adapted to LMICs and shown effectiveness in addressing the needs, but most EBIs have not been adopted widely using scalable and sustainable implementation models that leverage and strengthen existing structures. There is a need to apply implementation science methodology to study strategies to effectively scale-up EBIs and sustain the practices in LMICs. Through a cross-sector collaboration, we are carrying out a second-generation investigation of implementation and effectiveness of a school-based mental health EBI, ParentCorps Professional Development (PD), to scale-up and sustain the EBI in Uganda to promote early childhood students’ mental health. Our previous studies in Uganda supported that culturally adapted PD resulted in short-term benefits for classrooms, children, and families. However, our previous implementation of PD was relied on mental health professionals (MHPs) to provide PD to teachers. Because of the shortage of MHPs in Uganda, a new scalable implementation model is needed to provide PD at scale. Objectives This study tests a new scalable and sustainable PD implementation model and simultaneously studies the effectiveness. This paper describes use of collaboration, task-shifting, and Train-the-Trainer strategies for scaling-up PD, and protocol for studying the effectiveness-implementation of ParentCorps-PD for teachers in urban and rural Ugandan schools. We will examine whether the new scale-up implementation approach will yield anticipated impacts and investigate the underlying effectiveness-implementation mechanisms that contribute to success. In addition, considering the effects of PD on teachers and students will influence by teacher wellness. This study also examines the added value (i.e. impact and costs) of a brief wellness intervention for teachers and students. Methods Using a hybrid-type II effectiveness-implementation cluster randomized controlled trial (cRCT), we will randomize 36 schools (18 urban and 18 rural) with 540 teachers and nearly 2000 families to one of three conditions: PD + Teacher-Wellness (PDT), PD alone (PD), and Control. Primary effectiveness outcomes are teachers’ use of mental health promoting strategies, teacher stress management, and child mental health. The implementation fidelity/quality for the scale-up model will be monitored. Mixed methods will be employed to examine underlying mechanisms of implementation and impact as well as cost-effectiveness. Discussion This research will generate important knowledge regarding the value of an EBI in urban and rural communities in a LMIC, and efforts toward supporting teachers to prevent and manage early signs of children’s mental health issues as a potentially cost-effective strategy to promote child population mental health in low resource settings. Trial Registration: This trial was registered with ClinicalTrials.gov (registration number: NCT04383327; https://clinicaltrials.gov/ct2/show/NCT04383327) on May13, 2020.

Introduction: In Uganda, 300,000 children under 5 years are acutely malnourished with 1.3% suffering from Severe Acute Malnutrition (SAM). Mbale Regional Referral hospital (MRRH) nutrition unit admits SAM children with comorbidities into inpatient care striving to ensure recovery, reduce morbidity and mortality. We assessed the incidence and predictors of time to recovery among SAM children admitted as inpatients in MRRH nutrition unit. Methods: We reviewed records of children 6-59 months old managed at the inpatient unit for SAM at MRRH from 2013 to 2016. Data on patient demographics, comorbidities, medications administered, and treatment outcomes were collected from the integrated nutrition register and patient charts. Recovery incidence was determined using Kaplan Meier survival analysis. Cox proportional hazards regression competing risks model with death, default and transfer as competing risks was fit to identify predictors of time to recovery. Results: Overall, 322 patient records were reviewed of which 183 (56.8%) were males with median age of 19 months (IQR; 14-26 months). Of these, 246 (76.4%) recovered with recovery incidence of 31.3 per 1000 person days and a median recovery time of 27 days (IQR; 16-38 days). Children with SAM who were dewormed during treatment were 33% more likely to recover faster compared to their counterparts who were not dewormed (AHR= 1.33; C.I = 1.01-1.74). Conclusion: Recovery was in acceptable range of Sphere standards and deworming was a predictor of time to recovery. The Uganda Ministry of health should ensure nutritional rehabilitation units follow the stipulated guidelines for management of SAM. Findings were limited by missing data.

Background Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment Framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality. Methods We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania’s Lake Zone. We used documentation analysis with confirmatory key informant interviews (n=6) to describe the Exploration and Preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n=101) post-initiation to characterize the Implementation phase. Data were analyzed using the constant comparison method. Results In the Exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the Preparation phase, onsite visits identified priorities and barriers to implementation in order to adapt the intervention components and curriculum. In the Active Implementation phase, four themes related to the inner organizational context – vision for safe surgery, existing surgical practices, leadership support, and resilience – and three themes related to the intervention – innovation-value fit, holistic approach, and buy-in – facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their needs to deliver safe surgery evolved over the implementation period. Conclusion Examining implementation through the Exploration, Preparation, Implementation and Sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.