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Simon Peter Katongole,1 Patricia Akweongo,2 Robert Anguyo,3 Daniel Evans Kasozi,4 Augustine Adomah-Afari2 1Simon Peter Katongole, School of Public Health, Gudie University Project, Kampala, Uganda; 2Department of Health Policy, Planning and Management, University of Ghana, Accra, Ghana; 3Monitoring, Evaluation, Technical Assistance and Research (METRe) Group; Department of International Public Health, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK; 4The United States Agency for International Development, US Embassy Kampala, Kampala, UgandaCorrespondence: Simon Peter Katongole, Gudie University Project, P.O. Box 27450, Kampala, Uganda, Tel +256 702 830 019, Email spkatongole@gmail.comPurpose: This study sought to determine the magnitude of patients’ misdiagnosis, classify the extent to which patients were misdiagnosed, determine the major diagnostic groupings and the topmost misdiagnosed diseases 11th version of the International Classification of Diseases (ICD-11).Methods: We conducted a retrospective review of 2431 patients’ records. A patient was adjudged to have been misdiagnosed if there was a difference between the initial diagnosis and the final diagnoses which had been collectively and collaboratively agreed upon review on admission. Misdiagnosis was classified as Class I, Class II, Class III and Class IV. The Pareto analysis was used to determine the topmost misdiagnosed diseases and ICD-11 major diagnostic groupings. We established the three leading misdiagnosed diseases for each of the topmost ICD-11 major diagnostic groupings.Results: The results indicate that 9.2% (223/2341) of the inpatients were initially misdiagnosed. There were 303 conditions involved in the misdiagnosis. The majority, 70.9% (158/223) of the misdiagnosed patients were classified as Class I. The ICD-11 major diagnostic groupings accounted for at least 80% of the misdiagnosis were certain infectious or parasitic diseases (32%), diseases of the digestive system (12%), diseases of the circulatory system (11%), endocrine, nutritional or metabolic disorders (9%), diseases of the respiratory system (7%), diseases of the genitourinary system 20/303 (7%), and diseases of blood and blood forming organs (5%). The 19 topmost misdiagnosed diseases or conditions included; peptic ulcer disease, severe malaria, hypertension, gastroenteritis, pneumonia, urinary tract infection, enteric fever, tuberculosis, septicemia, bacteremia, anaemia, congestive cardiac failure, diabetes mellitus, stroke, chronic obstructive pulmonary disease, respiratory tract infection, cystitis, cryptococcal meningitis, epilepsy and gastritis.Conclusion: Efforts to improve patient diagnosis should focus on the “vital few” topmost misdiagnosed conditions and ICD-11 major diagnostic groupings that account for at least 80% of the burden of the misdiagnosis.Keywords: prevalence, classification, misdiagnosis, general hospitals

Introduction: Inpatient misdiagnosis is a major public health problem in sub-Saharan Africa, the scope and causes of which are unknown. The purpose of this cross-sectional study, conducted in five hospitals in central Uganda, was to identify the factors associated with inpatient misdiagnosis in general hospitals in central Uganda. Methodology: An explanatory mixed methods cross-sectional study was used. A retrospective review of 2,431 patient records was performed using explicit review methods to determine the extent of patient misdiagnosis and other variables thought to be related to patient misdiagnosis. Any discrepancy between the admission diagnosis made in the emergency room or outpatient clinic and the patient's discharge diagnosis made upon discharge was defined as a misdiagnosis. The diagnoses were classified using the World Health Organization ICD-11. Six clinical staff and six medical staff were interviewed using in-depth interviews (IDIs) in a phenomenological approach to obtain their explanatory account of factors associated with misdiagnosis. A logistic regression and a deductive thematic analysis were carried out on quantitative and qualitative data analyses. The quantitative and qualitative findings of the study were mixed in interpretation. Results: Misdiagnosis was discovered in 223/2431 (9.2%) of the admitted patients' records. Misdiagnosis was associated with the following factors: a patient admitted to Nakaseke hospital [aOR = 1.95, 95% CI = 1.17–3.25, p = 0.01], admission at night [aOR = 3, 95% CI = 1.81–5.02, p0.01], male patient [aOR = 1.89, 95% CI = 1.35–2.64, p0.01], patient's age groups 10–19 [AOR = 2.3, 95% CI = 2.3-9. Misdiagnosis was also linked to multimorbidity (aOR = 4.71, 95% CI = 1.91–11.65, p0.01) and patients with rare diseases (aOR = 2.57, 95% CI = 1.28–5.18, p0.01). Patients with no underlying diseases [aOR = 0.63; 95% CI = 0.43–0.91, p = 0.015] and those who were not referred [aOR = 0.51; 95% CI = 0.31–0.86, p = 0.011] had a lower risk of misdiagnosis. The quantitative findings of significant (p 0.05) and non-significant patient, contextual, disease, and health system factors associated with misdiagnosis were validated by the qualitative findings. Conclusion: To improve diagnostic accuracy, hospitals should reorganize patient admission processes, provide targeted training, create policies or guidelines targeting risk factors for misdiagnosis, and implement a diagnostic error prevention culture that addresses factors related to misdiagnosis in the respective hospitals oriented.

Misdiagnosis of inpatients is a major public health issue whose scope and causes are unknown in Sub-Saharan African countries. The purpose of this cross-sectional study, which was conducted in five hospitals in central Uganda, was to identify the factors associated with inpatient misdiagnosis in general hospitals in Central Uganda. Records of 2,431 patients admitted between July 1st, 2019 and June 30th, 2020 were specifically reviewed to obtain data on variables thought to be associated with misdiagnosis. The admission diagnosis assigned at the emergency or outpatient department was compared to the discharge diagnosis assigned immediately after the patient’s admission, with any difference considered a misdiagnosis. The disease, patient, health system, and environmental factors associated with misdiagnosis were identified using multivariable logistic regression analysis.Misdiagnosis was found in the records of 223/2431 (9.2%) of the admitted patients. A patient admitted to Nakaseke hospital [aOR=1.95, 95% CI=1.17-3.25, p=0.01], being admitted at night [aOR=3, 95% CI=1.81-5.02, p0.01], male patient [aOR=1.89, 95% CI=1.35-2.64, p0.01], patient’s age groups 10-19 [AOR=2.3, 95% CI=2.3-9.25, p0.01]; 20-29 [AOR=8.15, 95% CI=4.18-15.89], pTo improve diagnostic accuracy, hospitals should reorganize patient admission processes, conducted targeted training, develop policy or guidelines targeting factors predisposing to misdiagnosis, and the adopt a diagnostic error prevention culture.

Background Although microscopy remains the gold standard for malaria diagnosis, little is known about its accuracy in the private health facilities in Uganda. This study evaluated the accuracy of malaria microscopy, and factors associated with inaccurate smear results at private health facilities in Entebbe Municipality, Uganda. Methods Between April and May 2018, all patients referred for a malaria smear in 16 private health facilities in Entebbe municipality were screened, and 321 patients were enrolled. A questionnaire was administered to collect demographic and clinical information, facility-based smear results were recorded from the participant’s consultation notes, and a research slide was obtained for expert microscopy during exit interview. A health facility assessment was conducted, and information on experience in performing malaria microscopy was collected from all facility personnel reading smears and the data was linked to the participant’s clinic visit. Results The test positivity rate of malaria parasitaemia was 15.0% by expert microscopy. The sensitivity, specificity and negative predictive value of the facility-based microscopy were high (95.8%, 90.1 and 99.2%, respectively). However; the positive predictive value (PPV) was low with 27/73 (63%) patients diagnosed with malaria not having the disease. Majority of the inaccurate results were from 2 of the 23 laboratory personnel reading the smears. The factors associated with inaccurate smear readings included being read by a technician; (1) who had less than 5 years’ experience in reading malaria smears (adjusted Odds Ratio [aOR] = 9.74, 95% confidence interval [CI] (1.06–89.5), p-value = 0.04), and (2) who was examining less than 5 smears a day (aOR = 38.8, 95% CI 9.65–156, p-value Conclusions The accuracy of malaria microscopy in this setting was high, although one third of the patients diagnosed with malaria did not have the disease. Majority of the errors in smear readings were made by two laboratory personnel, with the main factor associated with inaccurate smear results being low experience in malaria microscopy. In-service training may be sufficient to eliminate inaccurate smear results in this setting, and these private facilities would be ideal model facilities to improve the quality of malaria microscopy in Uganda especially in the public sector where accuracy is still poor.

David Kavuma,1,2 Juliet Ndibazza,1 Venantius Bbaale Kirwana,3 Hussein Mukasa Kafeero,1 Simon Peter Katongole,1 Joseph Baruch Baluku2 1Faculty of Health Sciences, Uganda Martyrs University-Nkozi, Kampala, Uganda; 2Directorate of Medical Services, Mildmay Uganda, Kampala, Uganda; 3Monitoring, Evaluation and Learning, Sexual Reproductive Health and Rights Alliance, Kampala, UgandaCorrespondence: David Kavuma, Tel +2560772839416, Email davikavu@gmail.comIntroduction: Evidence is lacking about condom use among out-of-school young people (OS-YP) on anti-retroviral therapy (ART). This study aimed to understand the factors associated with consistent condom use among OS-YP aged 15– 24 years old on ART in Central Uganda.Methods: This was a quantitative descriptive cross-sectional study conducted among 357 OS-YP on ART from seven districts of Central Uganda. Interviewer-administered questionnaire was used to collect data on consistent condom use in the past 12 months from OS-YP, aged 15– 24 years, who did not intend to have children in that period. Consistent condom use by participants was considered to be the routine (always) use of condoms during sexual intercourse in the past 12 months. Frequencies and percentages were used for univariate analysis, while Pearson’s Chi-square was used to determine bivariate association and logistic regression analysis for multivariable association with consistent condom use, at 95% confidence level.Results: Of the 357 sexually active OS-YP on ART, 73% were females. The age range of study participants was between 15 and 24 years old (with a mean ± standard deviation of 20± 3 years) where 55% were aged 20 to 24 years, while their sexual partners were aged ≥ 25 years, and 49% of respondents did not use condoms. Primary school education level, being employed, rural residence, and receiving ART from health facilities with a perceived adequate number of health workers were strongly associated with consistent condom use with the adjusted odds ratio (AOR) of 0.2 (95% CI 0.07– 0.69) level of education; 2.12 (95% CI 1.06– 4.26) employment status; 2.46 (95% CI 1.19– 5.10) residence and 6.08 (95% CI 1.05– 35.22) perceived level of staffing at the health facility, respectively.Conclusion: Efforts to increase consistent condom use should focus on recruiting more providers in health facilities to intensify condom use sensitization among sexually active young people on ART in the context of HIV epidemic control.Keywords: out-of-school young people, antiretroviral therapy, consistent condom use

BackgroundTuberculosis (TB) remains a significant public health concern, and a leading cause of ill-health and death globally. More so, People living with HIV have been shown to carry an increased risk of developing TB with an estimated one-third of deaths in this population. The World Health Organization recommends systematic and routine screening of PLHIV for TB on every clinic visit and further testing using sputum for those with a positive TB screen test. Not all PLHIV with a positive TB screen test in Ghana are further tested for TB using sputum and the factors for this are not well understood. This study assessed factors associated with sputum ordering for TB diagnosis in PLHIV who were screened positive for TB in three hospitals providing HIV care and treatment services in the Greater Accra region of Ghana.MethodsMixed method study performed at three purposively selected hospitals providing HIV care and treatment services in the Greater Accra region. The study involved a cross sectional review of patients’ charts and in-depth interviews with health workers involved in the care and treatment of PLHIV. Quantitative data was analyzed using STATA version 15. Chi square test was used for bivariate analysis. Logistic regression was used for multivariate analysis. P≤ 0.05 was considered statistically significant. Inductive thematic analysis was used to determine emerging themes from the interviews. The major themes were represented with representative quotations.ResultsFour hundred (400) patient charts were reviewed of which 67.7% were female with median age of 39 (IQR 31-49). TB screening was recorded in 78% (95% CI 73.6, 82.0) of the patients of whom ninety-two (92) patients had a positive TB screen test. Only 53 (57.6%) who had a positive screen test had sputum ordered for further TB testing. In the multivariate analysis, patient general appearance described as abnormal (OR=3.05, p=0.036), having more than one TB symptom (OR=3.42, p=0.028) and presence of an alternative presumptive diagnosis (OR=0.34, p=0.023) were associated with having a sputum test ordered. High patient numbers, inability to produce sputum, unwillingness of the not so sick patients to provide sputum and the costs associated with chest X-ray were perceived as the challenges to further testing for TB.ConclusionTB screening in PLHIV is still lower than recommended and almost half of PLHIV with a positive TB screen test did not have a sputum test documented. Sputum testing was likely to be done in patients with an abnormal general appearance and more than one TB symptom and unlikely in those with an alternative presumptive diagnosis. High workload, costs of TB tests, lack of training for health workers and inability to produce sputum by patients were the barriers to sputum testing highlighted by the health workers.

The COVID-19 pandemic has had devastating effects on health systems at global, national, and subnational levels. During disease outbreaks, the human resources for health are among the most affected building blocks of the healthcare system. However, there is limited data on the experiences of frontline health workers during the COVID-19 pandemic and their implications for their psychosocial wellbeing. We conducted in-depth interviews with health workers in two hospitals in Uganda and Ghana that have been at the helm of treating people who are being treated for COVID-19. This chapter discusses how COVID-19 has impacted the mental health and psychosocial wellbeing of health workers in two African countries, Uganda and Ghana. It also discusses the mechanisms employed by health workers to cope with COVID-19 and its consequences. In addition, we also discuss existing strategies the health systems of these countries have developed and implemented to promote the mental health and psychosocial wellbeing of health workers managing the COVID-19 pandemic in hospitals in Uganda and Ghana. We conclude by calling upon governments and the international community to invest in promoting the mental and psychosocial wellbeing of health workers as well as people who are being treated for COVID-19 affected by outbreaks particularly COVID-19.

PurposeThe study drew on capacity framework around the individual, organisational, health system and wider context to explore gaps in health supply chain (HSC) workers capacity and competency to perform supply chain (SC) functions and the lessons for workforce development.Design/methodology/approachA mixed-method study was conducted across the Northern Region of Ghana. Qualitative data were collected from in-depth interviews with 34 key SC managers at the regional, district and facility levels. A semi-structured questionnaire was administered through the RedCap mobile app to 233 core HSC workers and non-core workers (clinicians with additional responsibilities in SC). Data were managed and analysed inductively and deductively for themes.FindingsWeak knowledge and competency in SC functions attributed to poor training exposure and organisational support for capacity building, undermined the capacity to perform basic SC functions, especially by the non-core category. The policy and regulatory environment of the HSC marketplace were described as fluid and with complexity of demands. Both worker categories, therefore, requested functional, technical, managerial and customer care competencies to anticipate and manage complexities. Structural characteristics of the health system giving narrow decision space to HSC workers cascaded the capacity for innovation and initiative and promoted frustrations among mid-level managers. Infrastructural deficits and shortfalls in operational resources scaled back the capacity to efficiently manage inventory and ensure that commodities reach clients in good quality.Originality/valueFinding suggest that capacity building of HSC workers, strengthening of health institutions structural and resource capacity, and leveraging on technology will enable optimal performance of HSC functions.

BackgroundEffective implementation of Tuberculosis infection control (TB IC) measures in health facilities delivering TB care services is very critical in controlling nosocomial transmission of TB infections among health workers, patients and their attendants. The aim of the study was to assess and document the implementation of TB IC practices in TB diagnostic and treatment health facilities in Kampala District, which accounts for 15-20% of the total TB burden in Uganda.MethodsIn August 2015, we conducted a cross-sectional study in 25 health facilities including 07 Public and 18 Private healthcare facilities in Kampala. We used a modified checklist adopted from the national manual for implementing TB control measures in health care facilities. We reviewed health facility records and where necessary observed TB IC practices to triangulate our findings. We conducted univariate analysis and generated proportions in order to describe the extent of implementation of TB IC measures.ResultsOn average, 73% of both administrative and managerial, 65% environmental, and 56% personal protective TB IC measures were complied with at the health facilities visited. Private health facilities implemented 71% of both administrative and managerial TBIC measures compared to public health facilities (31%). Thirty Six percent of health facilities reported that they were regularly screening health care workers for TB. By Observation, 28% had TB IC guideline, 36% had TB IC plan, 12% had a designated area for sputum collection, 56% were regularly opening windows, 40% had fans installed in the waiting areas and/or consultation rooms and 24% had bio-safety cabinets fitted with UV light. In addition, 60% had N95 respirators but only 32% of the facilities reported that their health workers routinely wore them.ConclusionImplementation of WHO recommended TB IC measures in health facilities delivering TB care services in Kampala was sub optimal. Routine involvement of health facility management as well as increasing human resources for health is critical in implementing easy to do TBIC measures like triaging, patients’ educating on coughing etiquette and respiratory hygiene and daily window opening particularly in public health care settings where implementation of administrative TB IC measures is wanting

Considering the COVID-19 global public health crisis, this paper examines the socio-cultural, economic and psychosocial impact of the pandemic on urban refugees in Uganda. We analyse the living conditions of urban refugees that make it problematic for them to adhere to public health measures. Since COVID-19 is perceived as “imported”, refugees are assumed as its potential transmitters, consequently experiencing heightened stigma and isolation. Lack of culturally and linguistically accessible information and services excludes them from on-going efforts to prevent the pandemic. The lockdown has affected refugee livelihoods and increased income insecurity, sexual and gender-based violence and anxiety. Given the paucity of government-led services to contain the epidemic, we argue that contingency planning must involve refugees and their communities to access accurate and relevant information in appropriate languages. It is also important to build the capacity of frontline workers to understand the specific needs of refugees to deliver appropriate protection in the context of the pandemic.