Improving alcohol and substance use screening in school-age children: translation, adaptation and psychometric evaluation of the CRAFFT tool for Lumasaaba, Uganda.

BACKGROUND: Children at risk of substance use disorders (SUD) should be detected using brief structured tools for early intervention. This study sought to translate and adapt the Car, Relax, Alone, Forget, Family/Friends, Trouble (CRAFFT) tool to determine its diagnostic accuracy, and the optimum cut-point to identify substance use disorders (SUD) risk in Ugandan children aged 6 to 13 years. METHODS: This was a sequential mixed-methods study conducted in two phases. In the first qualitative phase, in Kampala and Mbale, the clinician-administered CRAFFT tool version 2.1 was translated into the local Lumasaaba dialect and culturally adapted through focus group discussions (FGDs) and in-depth interviews, in collaboration with the tool's authors. Expert reviews and translations by bilingual experts provided insights on linguistic comprehensibility and cultural appropriateness, while pilot testing with the target population evaluated the tool's preliminary effectiveness. In the second phase, the CRAFFT tool, adapted to Lumasaaba, was quantitatively validated against the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) for diagnosing SUD in Mbale district, through a survey. Participants, chosen randomly from schools stratified according to ownership, location, and school size, were assessed for the tool's reliability and validity, including comparisons to the MINI KID as the Gold Standard for diagnosing SUD. Data were analyzed using STATA-15. Receiver-operating-characteristic analysis was performed to determine the sensitivity, specificity, and criterion validity of the CRAFFT with the MINI-KID. RESULTS: Of the 470 children enrolled, 2.1% (n = 10) had missing data on key variables, leaving 460 for analysis. The median age and interquartile range (IQR) was 11 (9-12) years and 56.6% were girls. A total of 116 (25.2%) children had consumed alcohol in the last twelve-month period and 7 (1.5%) had used other substances. The mean CRAFFT score for all the children (n = 460) was 0.32 (SD 0.95). The prevalence of any alcohol use disorder (2 or more positive answers on the MINI KID) in the last 12 months was 7.2% (n = 32). The Lumasaaba version of the CRAFFT tool demonstrated good internal consistency (Cronbach's α = 0.86) and inter-item correlation (Spearman correlation coefficient of 0.84 (p < 0.001). At a cut-off score of 1.00, the CRAFFT had optimal sensitivity (91%) and specificity (92%) (Area Under the Curve (AUC) 0.91; 95% CI 0.86-0.97) to screen for SUD. A total of 62 (13.5%) had CRAFFT scores of > 1. CONCLUSION: The Lumasaaba version of the CRAFFT tool has sufficient sensitivity and specificity to identify school-age children at risk of SUD.

"She gives it to her child who doesn't even talk": a qualitative exploration of alcohol and drug use among primary school-age children in Uganda.

BACKGROUND: There is little research on alcohol and other drugs (AOD) use by school-age children in low-resource settings like Uganda. Including the voices of children in research can inform prevention and early intervention efforts for those at risk of AOD use. The aim of this study was to understand the perspectives of children aged 6 to 13 years regarding AOD in Uganda. METHODS: This qualitative study was conducted in Mbale district, Uganda from February to March 2020. Eight focus group discussions (FGDs) were conducted with 56 primary school-age children, stratified by age (6-9 and 10-13 years), sex (male and female), and school status (in school and out of school). All FGDs were conducted in either Lumasaaba or Luganda. The FGDs were audio-recorded, transcribed verbatim, and translated into English. Data were coded, and overarching themes were identified using thematic framework analysis. RESULTS: Two themes identified were (1) Children's perceptions and experiences with AODs. The participants understood alcohol by its consistency, colour, odour, and by brand/logo. They described the types and quantities of AOD consumed by school-age children, brewing processes for homemade alcoholic drinks, and short and long-term consequences of the use of alcohol. (2) Contributing factors to childhood drinking included: Stress relief for children who experienced multiple adversities (orphaned, poverty-stricken, and hailing from broken homes), fitting in with friends, influence from families, and media exposure that made alcohol look cool. Children would start drinking at an early age) or were given alcohol by their parents, sometimes before they could start talking. In the community, alcohol and other drugs were cheap and available and children could drink from anywhere, including in the classroom. CONCLUSIONS: Children eligible for primary education in Uganda can easily access and use AOD. Several factors were identified as contributing to alcohol and other drug use among children, including availability and accessibility, advertising, lack of parental awareness and supervision, peer influence, adverse childhood experiences, socioeconomic factors, and cultural norms. There is a need for multi-sectoral action for awareness of childhood AOD use and deliberate consideration of children in the planning, design, and implementation of research, policies, and programs for prevention and early intervention.

Child and adolescent mental health services in Uganda.

INTRODUCTION: Worldwide, one in five children and adolescents suffer from mental health disorders, while facing limited opportunities for treatment and recovery. Growing up, they face multiple challenges that might contribute to the development of mental disorders. Uganda is a developing country with a history of prolonged civil and regional wars associated with child soldiers, large numbers of refugees and internally displaced people due to natural disasters and unrests, and a large infectious disease burden mainly due to acute respiratory tract infections, malaria and HIV/AIDS. OBJECTIVE: This paper aims to examine the current status of child and adolescent mental health services in Uganda. METHODOLOGY: A scoping review approach was used to select studies on child and adolescent mental health services (CAMHS) in Uganda. A search of MEDLINE, Wiley and PubMed databases was conducted using eligibility criteria. The papers were summarized in tables and then synthesized using the Frameworks for monitoring health systems performance designed by the World Health Organisation (WHO). This was done according to the Preferred Reporting Items for Systematic Review and M-Analyses Extension for Scoping Review (PRISMA-ScR) guidelines. RESULTS: Twelve studies were identified; five of them used qualitative methods and focused mostly on the current limitations and strengths of CAMHS in Uganda, while six quantitative studies investigated the effects of new interventions. One study used a mixed-methods approach. In summary, the papers outlined a need for collaboration with the primary health sector and traditional healers to ensure additional human resources, as well as the need to focus on groups such as orphans, HIV/AIDS-affected youth, former child soldiers and refugees. CONCLUSION: Relatively few studies have been conducted on CAMHS in Uganda, and most of those that exist are part of larger studies involving multiple countries. CAMHS in Uganda require improvement and needs to focus especially on vulnerable groups such as orphans, HIV/AIDS-affected youth and former child soldiers.

"I feel good when I drink"-detecting childhood-onset alcohol abuse and dependence in a Ugandan community trial cohort.

BACKGROUND: Alcohol, substance use, and mental health disorders constitute major public health issues worldwide, including in low income and lower middle-income countries, and early initiation of use is an important predictor for developing substance use disorders in later life. This study reports on the existence of childhood alcohol abuse and dependence in a sub-study of a trial cohort in Eastern Uganda. METHODS: The project SeeTheChild-Mental Child Health in Uganda (STC) included a sub-study of the Ugandan site of the study PROMISE SB: Saving Brains in Uganda and Burkina Faso. PROMISE SB was a follow-up study of a trial birth cohort (PROMISE EBF) that estimated the effect that peer counselling for exclusive breast-feeding had on the children's cognitive functioning and mental health once they reached 5-8 years of age. The STC sub-study (N = 148) used the diagnostic tool MINI-KID to assess mental health conditions in children who scored medium and high (≥ 14) on the Strengths and Difficulties Questionnaire (SDQ) in the PROMISE SB cohort N = (119/148; 80.4%). Another 29/148 (19.6%) were recruited from the PROMISE SB cohort as a comparator with low SDQ scores (< 14). Additionally, the open-ended questions in the diagnostic history were analysed. The MINI-KID comprised diagnostic questions on alcohol abuse and dependence, and descriptive data from the sub-study are presented in this paper. RESULTS: A total of 11/148 (7.4%) children scored positive for alcohol abuse and dependence in this study, 10 of whom had high SDQ scores (≥ 14). The 10 children with SDQ-scores ≥ 14 had a variety of mental health comorbidities of which suicidality 3/10 (30.0%) and separation anxiety disorder 5/10 (50.0%) were the most common. The one child with an SDQ score below 14 did not have any comorbidities. Access to homemade brew, carer's knowledge of the drinking, and difficult household circumstances were issues expressed in the children's diagnostic histories. CONCLUSIONS: The discovery of alcohol abuse and dependence among 5-8 year olds in clinical interviews from a community based trial cohort was unexpected, and we recommend continued research and increased awareness of these conditions in this age group.Trial registration Trial registration for PROMISE SB: Saving Brains in Uganda and Burkina Faso: Clinicaltrials.gov (NCT01882335), 20 June 2013. Regrettably, there was a 1 month delay in the registration compared to the commenced re-inclusion in the follow-up study: https://clinicaltrials.gov/ct2/show/NCT01882335?term=saving+brains&draw=2&rank=1.

Correction to: Health system factors influencing uptake of human papilloma virus (HPV) vaccine among adolescent girls 9-15 years in Mbale District, Uganda.

In the original article [1] the first paragraph of the Background section was omitted due to a discrepancy between the metadata of the article and the PDF version.

Health system factors influencing uptake of Human Papilloma Virus (HPV) vaccine among adolescent girls 9-15 years in Mbale District, Uganda.

BACKGROUND: Globally, cervical cancer is the fourth most common cancer in women with more than 85% of the burden in developing countries. In Uganda, cervical cancer has shown an increase of 1.8% per annum over the last 20 years. The availability of the Human Papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. Understanding how the health system influences uptake of the vaccine is critical to improve it. This study aimed to assess how the health systems is influencing uptake of HPV vaccine so as to inform policy for vaccine implementation and uptake in Mbale district, Eastern Uganda. METHODS: We conducted a cross sectional study of 407 respondents, selected from 56 villages. Six key informant interviews were conducted with District Health Officials involved in implementation of the HPV vaccine. Quantitative data was analyzed using Stata V.13. Prevalence ratios with their confidence intervals were reported. Qualitative data was audio recorded, transcribed verbatim and analyzed using MAXQDA V.12, using the six steps of thematic analysis developed by Braun and Clarke. RESULTS: Fifty six (14%) of 407 adolescents self-reported vaccine uptake. 182 (52.3%) of 348 reported lack of awareness about the HPV vaccine as the major reason for not having received it. Receiving vaccines from outreach clinics (p = 0.02), having many options from which to receive the vaccine (p = 0.02), getting an explanation on possible side-effects (p = 0.024), and receiving the vaccine alongside other services (p = 0.024) were positively associated with uptake. Key informants reported inconsistency in vaccine supply, inadequate training on HPV vaccine, and the lack of a clear target for HPV vaccine coverage as the factors that contribute to low uptake. CONCLUSION: We recommend training of health workers to provide adequate information on HPV vaccine, raising awareness of the vaccine in markets, schools, and radio talk shows, and communicating the target to health workers. Uptake of the HPV vaccine was lower than the Ministry of Health target of 80%. We recommend training of health workers to clearly provide adequate information on HPV vaccine, increasing awareness about the vaccine to the adolescents and increasing access for girls in and out of school.

"We are like co-wives": Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda.

BACKGROUND: Early identification and management of mental illness in childhood and adolescence helps to avert debilitating mental illness in adulthood but the attention given to Child and Adolescent Mental Health (CAMH) has until recently been low. Traditional healers are often consulted by patients with mental illness and in Uganda, up to 60% of patients attending traditional healers have moderate to severe mental illness. Poor access to CAMH care in Uganda creates a treatment gap that could be met through enhanced collaboration between traditional healers and biomedical health systems. The aim of this study was to explore traditional healers' views on their collaboration with biomedical health systems so as to inform the implementation of strategies to improve access to CAMH services in Uganda. METHODS: In-depth interviews with 20 purposively selected traditional healers were conducted in November 2015. A semi-structured interview guide was used to explore: 1) The experiences of traditional healers with mental ill-health in children and adolescents; 2) their willingness to collaborate with the formal health system; and 3) their perception of clinicians' willingness to collaborate with them. Interviews were conducted in local languages and tape recorded. Data were analysed using thematic analysis. RESULTS: Traditional healers described several experiences managing children and adolescents with mental illness, which they ascribed to spiritual and physical causes. The spiritual explanations were a consequence of unhappy ancestral spirits, modern religions and witchcraft, while physical causes mentioned included substance abuse and fevers. No traditional healer had received a patient referred to them from a medical clinic although all had referred patients to clinics for non-mental health reasons. Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies in alleviating mental suffering. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them. CONCLUSION: Potential for collaboration between traditional healers and biomedical health systems for improving access to CAMH services in Uganda exists, but is undermined by mutual mistrust and competition between traditional healers and clinicians.

Does child and adolescent mental health in-service training result in equivalent knowledge gain among cadres of non-specialist health workers in Uganda? A pre-test post-test study.

BACKGROUND: Early identification and management of child and adolescent mental health (CAMH) disorders helps to avert mental illness in adulthood but a CAMH treatment gap exists in Uganda. CAMH integration into primary health care (PHC) through in-service training of non-specialist health workers (NSHW) using the World Health Organisation (WHO) Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) is a strategy to address this gap. However, results of such training are not supported by information on training development or delivery; and are undifferentiated by NSHW cadre. We aim to describe an in-service CAMH training for NSHW in Uganda and assess cadre-differentiated learning outcomes. METHODS: Thirty-six clinical officers, nurses and midwives from 18 randomly selected PHC clinics in eastern Uganda were trained for 5 days on CAMH screening and referral using a curriculum based on the mhGAP-IG version 1.0 and PowerPoint slides from the International Association of Child and Adolescent Psychiatry and Allied Professions (IACAPAP). The residential training was evaluated through pre- and post- training tests of CAMH knowledge and attitudes using the participants' post-test scores; and the difference between pre-test and post-test scores. Two-tailed t-tests assessed differences in mean pre-test and post-test scores between the cadres; hierarchical linear regression tested the association between cadre and post test scores; and logistic regression evaluated the relationship between cadre and knowledge gain at three pre-determined cut off points. RESULTS: Thirty-three participants completed both pre-and post-tests. Improved mean scores from pre- to post-test were observed for both clinical officers (20% change) and nurse/midwives (18% change). Clinical officers had significantly higher mean test scores than nurses and midwives (p < 0.05) but cadre was not significantly associated with improvement in CAMH knowledge at the 10% (AOR 0.08; 95 CI [0.01, 1.19]; p = 0.066), 15% (AOR 0.16; 95% CI [0.01, 2.21]; p = 0.170), or 25% (AOR 0.13; 95% CI [0.01, 1.74]; p = 0.122) levels. CONCLUSION: We aimed to examine CAMH learning outcomes by NSHW cadre. NSHW cadre does not influence knowledge gain from in-service CAMH training. Thus, an option for integrating CAMH into PHC in Uganda using the mhGAP-IG and IACAPAP PowerPoint slides is to proceed without cadre differentiation.

Utilization of outreach immunization services among children in Hoima District, Uganda: a cluster survey.

BACKGROUND: The global vaccine action plan 2011-2020 was endorsed by 194 states to equitably extend the benefits of immunization to all people. However, gaps in vaccination coverage remain in developing countries such as Uganda. One of the strategies used to tackle existing inequities is implementation of outreach immunization services to deliver services to those with poor geographical access. However, reports of inconsistent use of these services prevail; therefore understanding the factors associated with use of these services is critical for improving service delivery. This study examined the factors associated with utilization of outreach immunization services among children aged 10-23 months in Hoima District, Uganda. RESULTS: Overall, 87.4% (416/476) of the children had ever utilized outreach immunization services. Of these, 3.6% (15/416) had completed their entire immunization schedules from outreach immunization sessions. Use of outreach services was associated with reports that the time of outreach sessions was convenient [adjusted odds ratio (AOR) 2.9, 95% confidence interval (CI) 1.32-6.51], community mobilization was done prior to outreach sessions (AOR 4.9, 95% CI 1.94-12.61), the caretaker knew the benefits of childhood immunizations (AOR 2.1, 95% CI 1.30-4.42), and the caretaker was able to name at least four vaccine preventable diseases (AOR 3.0, 95% CI 1.13-7.88). CONCLUSIONS: Utilization of outreach immunization services in Hoima District was high but reduced with subsequent vaccine doses. Therefore, strategies targeted at retaining service users for the entire immunization schedule need to be developed and implemented. Such strategies could include health education emphasizing the benefits of childhood immunization.

Urban settings do not ensure access to services: findings from the immunisation programme in Kampala Uganda.

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.

Community knowledge and perceptions about indoor residual spraying for malaria prevention in Soroti district, Uganda: a cross-sectional study.

BACKGROUND: Malaria is the leading cause of morbidity and mortality in Uganda. The Ministry of Health (MoH) plans to scale up indoor residual spraying (IRS) for malaria vector control. However, there is limited information on community knowledge and perceptions towards IRS. This study assessed community knowledge and perceptions about IRS in Soroti district, eastern Uganda. METHODS: The study was cross-sectional and it covered 770 randomly selected households in urban and rural settings in Soroti district, Eastern Uganda. The respondents were heads of household and or their proxies. The data were collected on the sociodemographic characteristics, knowledge of the insecticides that could be used for IRS, parts of the houses that would be sprayed, importance of IRS, role of household heads in IRS programme, frequency and the time of spraying. Responses to the questions on these areas were used to create a composite dependent variable categorized as knowledgeable if they had responded correctly to at least three questions or not knowledgeable about IRS if they responded correctly to less than three questions. In addition, respondents were asked if they thought the IRS programme would be beneficial or not. Bivariate and multivariate logistic regression analyses were carried out using SPSS version 17. RESULTS: Less than half, (48.6%, 374/770) of the respondents were knowledgeable about IRS. Urban residents (AOR 1.92, 95% CI 1.04-3.56) and those with secondary education or higher (AOR 4.81, 95% CI 2.72-8.52) were knowledgeable about IRS. Three-quarters, (74.4%, 354/473) of respondents who had ever heard of IRS, perceived it as beneficial. Two-thirds, (66.4%, 314/473) reported that IRS would have negative effects. Respondents who reported that, IRS programme is beneficial were: 23 years or older (AOR 2.17, 95% CI 1.07-4.38), had attained secondary education or higher (AOR 2.16, 95% CI 1.22-3.83) and were knowledgeable about IRS (AOR 2.21, 95% CI 1.17-4.17). CONCLUSIONS: Knowledge about IRS is inadequate and negative perceptions about its use are prominent especially among the rural and less educated individuals. To ensure householders' cooperation and participation in the IRS programme, adequate community mobilization and sensitization is needed prior to use of IRS for effective malaria control.

Timeliness of childhood vaccinations in Kampala Uganda: a community-based cross-sectional study.

BACKGROUND: Child survival is dependent on several factors including high vaccination coverage. Timely receipt of vaccines ensures optimal immune response to the vaccines. Yet timeliness is not usually emphasized in estimating population immunity. In addition to examining timeliness of the recommended Expanded Programme for Immunisation (EPI) vaccines, this paper identifies predictors of untimely vaccination among children aged 10 to 23 months in Kampala. METHODS: In addition to the household survey interview questions, additional data sources for variables included data collection of child's weight and length. Vaccination dates were obtained from child health cards. Timeliness of vaccinations were assessed with Kaplan-Meier time-to-event analysis for each vaccine based on the following time ranges (lowest-highest target age): BCG (birth-8 weeks), polio 0 (birth-4 weeks), three polio and three pentavalent vaccines (4 weeks-2 months; 8 weeks-4 months; 12 weeks-6 months) and measles vaccine (38 weeks-12 months). Cox regression analysis was used to identify factors associated with vaccination timeliness. RESULTS: About half of 821 children received all vaccines within the recommended time ranges (45.6%; 95% CI 39.8-51.2). Timely receipt of vaccinations was lowest for measles (67.5%; 95% CI 60.5-73.8) and highest for BCG vaccine (92.7%: 95% CI 88.1-95.6). For measles, 10.7% (95% CI 6.8-16.4) of the vaccinations were administered earlier than the recommended time. Vaccinations that were not received within the recommended age ranges were associated with increasing number of children per woman (adjusted hazard ratio (AHR); 1.84, 95% CI 1.29-2.64), non-delivery at health facilities (AHR 1.58, 95% CI 1.02-2.46), being unmarried (AHR 1.49, 95% CI 1.15-1.94) or being in the lowest wealth quintile (AHR 1.38, 95% CI 1.11-1.72). CONCLUSIONS: Strategies to improve vaccination practices among the poorest, single, multiparous women and among mothers who do not deliver at health facilities are necessary to improve timeliness of vaccinations.

More support for mothers: a qualitative study on factors affecting immunisation behaviour in Kampala, Uganda.

BACKGROUND: The proportion of Ugandan children who are fully vaccinated has varied over the years. Understanding vaccination behaviour is important for the success of the immunisation programme. This study examined influences on immunisation behaviour using the attitude-social influence-self efficacy model. METHODS: We conducted nine focus group discussions (FGDs) with mothers and fathers. Eight key informant interviews (KIIs) were held with those in charge of community mobilisation for immunisation, fathers and mothers. Data was analysed using content analysis. RESULTS: Influences on the mother's immunisation behaviour ranged from the non-supportive role of male partners sometimes resulting into intimate partner violence, lack of presentable clothing which made mothers vulnerable to bullying, inconvenient schedules and time constraints, to suspicion against immunisation such as vaccines cause physical disability and/or death. CONCLUSIONS: Immunisation programmes should position themselves to address social contexts. A community programme that empowers women economically and helps men recognise the role of women in decision making for child health is needed. Increasing male involvement and knowledge of immunisation concepts among caretakers could improve immunisation.