HIV prevalence among children admitted with severe acute malnutrition and associated factors with mother-to-child HIV transmission at Mulago Hospital, Uganda: A mixed methods study.

BACKGROUND: Despite global efforts to eliminate mother-to-child-transmission of HIV (MTCT), many children continue to become infected. We determined the prevalence of HIV among children with severe acute malnutrition (SAM) and that of their mothers, at admission to Mwanamugimu Nutrition Unit, Mulago Hospital, Uganda. We also assessed child factors associated with HIV-infection, and explored factors leading to HIV-infection among a subset of the mother-child dyads that tested positive. METHODOLOGY: We conducted a cross-sectional evaluation within the REDMOTHIV (Reduce mortality in HIV) clinical trial that investigated strategies to reduce mortality among HIV-infected and HIV-exposed children admitted with SAM at the Nutrition Unit. From June 2021 to December 2022, we consecutively tested children aged 1 month to 5 years with SAM for HIV, and the mothers who were available, using rapid antibody testing upon admission to the unit. HIV-antibody positive children under 18 months of age had a confirmatory HIV-DNA PCR test done. In-depth interviews (IDIs) were conducted with mothers of HIV positive dyads, to explore the individual, relationship, social and structural factors associated with MTCT, until data saturation. Quantitative data was analyzed using descriptive statistics and logistic regression in STATAv14, while a content thematic approach was used to analyze qualitative data. RESULTS: Of 797 children tested, 463(58.1%) were male and 630(79.1%) were ≤18months of age; 76 (9.5%) tested positive. Of 709 mothers, median (IQR) age 26 (22, 30) years, 188(26.5%) were HIV positive. Sixty six of the 188 mother-infant pairs with HIV exposure tested positive for HIV, an MTCT rate of 35.1% (66/188). Child age >18 months was marginally associated with HIV-infection (crude OR = 1.87,95% CI: 1.11-3.12, p-value = 0.02; adjusted OR = 1.72, 95% CI: 0.96, 3.09, p-value = 0.068). The IDIs from 16 mothers revealed associated factors with HIV transmission at multiple levels. Individual level factors: inadequate information regarding prevention of MTCT(PMTCT), limited perception of HIV risk, and fear of antiretroviral drugs (ARVs). Relationship level factors: lack of family support and unfaithfulness (infidelity) among sexual partners. Health facility level factors: negative attitude of health workers and missed opportunities for HIV testing. Community level factors: poverty and health service disruptions due to the COVID-19 pandemic. CONCLUSION: In this era of universal antiretroviral therapy for PMTCT, a 10% HIV prevalence among severely malnourished children is substantially high. To eliminate vertical HIV transmission, more efforts are needed to address challenges mothers living with HIV face intrinsically and within their families, communities and at health facilities.

Implementation challenges in preeclampsia care: perspectives from health care professionals in urban Uganda.

BACKGROUND: Sub-Saharan Africa bears the burden of 70% of maternal deaths worldwide, of which ∼10% are attributable to hypertensive disorders of pregnancy, primarily complications of preeclampsia. In other global settings, outcomes of pregnancies affected by preeclampsia are improved with timely and effective medical care. OBJECTIVE: This study aimed to explore the perspectives of local health care professionals on how preeclampsia care is currently delivered in the study setting and what challenges they experience in providing prompt and safe care. We identified specific objectives of exploring stakeholder perceptions of (1) recognizing preeclampsia and (2) timely intervention when preeclampsia is diagnosed. We also explored the wider system factors (eg, cultural, financial, and logistic challenges) that health care professionals perceived as affecting their ability to deliver optimal preeclampsia care. STUDY DESIGN: Individual semistructured interviews were conducted with health care professionals and stakeholders. The findings were analyzed using thematic analysis. RESULTS: Thirty-three participants contributed to the study, including doctors and midwives with varying degrees of clinical experience and external stakeholders. The following 5 key themes emerged: delayed patient presentation, recognizing the unwell patient with preeclampsia, the challenges of the existing triage system, stakeholder disconnect, and ways of learning from each other. Health care professionals referenced an important psychosocial perspective associated with preeclampsia in the study setting, which may influence the likelihood of seeking care through traditional healers rather than hospital-based routes. CONCLUSION: We identify the key barriers to improving maternal and neonatal outcomes of preeclampsia, described at both the institutional level and within the wider setting. The study provides invaluable contextual information that suggests that a systems-based approach to health care quality improvement may be effective in reducing rates of maternal and neonatal morbidity and mortality.

Acceptability to donate human milk among postnatal mothers at St. Francis hospital Nsambya, Uganda: a mixed method study.

BACKGROUND: The World Health Organization recommends the use of donated human milk (HM) as the second-best option for mothers who are temporarily unable to provide sufficient breast milk to meet the needs of their infants. However, HM donation is yet to become an accepted practice in Uganda. We assessed the level of, and factors associated with acceptability to donate HM among postnatal mothers at St. Francis Hospital Nsambya (SFHN). METHODS: A cross-sectional sequential explanatory mixed method study was conducted between October 2018 and March 2019. A questionnaire on sociodemography, awareness and likely acceptability to donate HM was administered to 410 postnatal mothers at SFHN. Multivariate logistic regression analysis was undertaken to determine factors associated with acceptance of HM donation. Focus Group Discussions (4) and Key Informants Interviews (4) were used to explore factors influencing behaviours to donate human milk. Qualitative data were analysed using a content thematic approach. RESULTS: Overall acceptance of donating the HM was 77.6%, and the significant factors were: willingness to express the HM (AOR 7.5; 95% CI 3.01, 18.68); wet-nursing knowledge (AOR 2.3; 95% CI 1.1, 5.0) and visit to under-5 years' clinic (AOR 21.3; 95% CI 2.3, 196.9). The major themes in relation to accepting to donate HM were wet nursing experience, and confidence in donating the HM, and its perceived effectiveness. There were concerns about the safety and adequacy of HM and fear of transmitting criminal behaviours and mental illness through human milk. CONCLUSIONS: Acceptance to donate HM among postnatal mothers at St. Francis Hospital Nsambya was very high. Willingness to express and store human milk, prior knowledge about wet nursing and a visit to an under-five outpatient clinic were associated with acceptance. Thus, establishing a human milk bank is feasible in the study setting.

Hypothyroidism among children and adolescents with nephrotic syndrome in Mulago National Referral Hospital, Kampala, Uganda; a cross-sectional study.

BACKGROUND: Nephrotic syndrome (NS) is the commonest glomerular disease among children. It is characterized by heavy proteinuria and is a risk factor for hypothyroidism in the affected children. Hypothyroidism is of concern because it affects the physical and intellectual development of children and adolescents. This study sought to establish the prevalence and factors associated with hypothyroidism among children and adolescents with NS. METHODS: A cross-sectional design was used to study 70 children and adolescents aged 1-19 years diagnosed with nephrotic syndrome and being followed up in the kidney clinic in Mulago National Referral Hospital. Questionnaires were used to collect patients' socio-demographics and clinical information. A blood sample was taken for analysis for thyroid stimulating hormone (TSH) and free thyroxine (FT4), renal function tests and serum albumin. Hypothyroidism included both overt and subclinical forms. Overt hypothyroidism was defined as TSH level > 10 mU/L and FT4 < 10pmol/L, or FT4 < 10pmol/l with normal TSH, or TSH < 0.5mU/l. Sub-clinical hypothyroidism was defined as TSH ranging between 5 and10 mU/L with normal age appropriate FT4 levels. Urine samples were collected and taken for a dipstick examination. The data was analyzed using STATA version 14. The Bayesian Logistic regression analysis approach was used to estimate odds ratios (OR) and their associated 95% credible intervals. All predictor variables with p value < 0.05 at frequentist statistical analysis were considered significant. RESULTS: The mean age (standard deviation) of participants was 9 years (3.8). There were more males; 36 of 70 (51.4%). The prevalence of hypothyroidism was 23% (16/70 participants). Of the 16 children with hypothyroidism, 3 (18.7%) had overt hypothyroidism while 13 had subclinical hypothyroidism. Only low serum albumin was found to be strongly associated with hypothyroidism; Bayesian OR 132.57 (CI 9.13-567.10) with a frequentist OR of 37 and a p value of 0.001. CONCLUSION: The prevalence of hypothyroidism among children and adolescent with nephrotic syndrome attending Mulago Hospital paediatric kidney clinic was 23%. Hypoalbuminemia was found to be associated with hypothyroidism. Therefore, children and adolescents that have severely low levels of serum albumin should be screened for hypothyroidism and linked to endocrinologists for care.

"I thought I was going to die": Experiences of COVID-19 patients managed at home in Uganda.

BACKGROUND: In Uganda, approximately 170,000 confirmed COVID-19 cases and 3,630 deaths have been reported as of January 2023. At the start of the second COVID-19 wave, the Ugandan health system was overwhelmed with a sudden increase in the number of COVID-19 patients who needed care, and the Ministry of Health resorted to home-based isolation and care for patients with mild to moderate disease. Before its rollout, the COVID-19 home-based care strategy had neither been piloted nor tested in Uganda. OBJECTIVE: To explore the experiences of COVID-19 patients managed at home in Uganda. METHODS: This was a qualitative study that was conducted to explore the lived experiences of COVID-19 patients managed at home. The study was carried out among patients who presented to three hospitals that were designated for treating COVID-19 patients in Uganda. COVID-19 patients diagnosed at these hospitals and managed at home were followed up and contacted for in-depth telephone interviews. The data were analysed using thematic content analysis with the aid of NVIVO 12.0.0 (QRS International, Cambridge, MA). RESULTS: Participants experienced feelings of fear and anxiety: fear of death, fear of losing jobs, fear of infecting loved ones and fear of adverse events such as loss of libido. Participants also reported feelings of loneliness, hopelessness and depression on top of the debilitating and sometimes worsening symptoms. In addition to conventional medicines, participants took various kinds of home remedies and herbal concoctions to alleviate their symptoms. Furthermore, COVID-19 care resulted in a high economic burden, which persisted after the COVID-19 illness. Stigma was a major theme reported by participants. Participants recommended that COVID-19 care should include counselling before testing and during and after the illness to combat the fear and stigma associated with the diagnosis. Another recommendation was that health workers should carry out home visits to patients undergoing home-based care and that COVID-19 treatment should be free of charge. CONCLUSION: COVID-19 home-based care was associated with fear, anxiety, loneliness, depression, economic loss and stigma. Policymakers should consider various home-based follow-up strategies and strengthen counselling of COVID-19 patients at all stages of care.

"Here, your only relative is money " why slum social networks do not facilitate neighborhood community development: insights through a sanitation lens.

INTRODUCTION: Though social networks which are deemed vehicles of community development exist in slum areas, underdevelopment still persists in these areas. We explored the nature and role of social networks in facilitating community development in the slums of Kampala through a sanitation lens. METHODS: Qualitative Social Network Analysis (SNA) was done to understand the nature of slum social networks primarily through the analysis of sanitation behavior. Data were collected through six Focus Group Discussions (FGD), six In-depth Interviews (IDIs), and 18 Key Informant Interviews (KII) with Government, civil society and private stakeholders. We used both inductive and deductive thematic analysis. RESULTS: Four themes emerged in our analysis; i); Unsupportive environments, uncooperative neighbours and uncertainty of tenure: participants reported slums as unsupportive of community development due to a shortage of space, poverty and unplanned services. Tenants perceived landlords as exploitative and predatory and wished the tables are turned. This notion of cyclic exploitation did not encourage collective action for community good. Short-term economic survival trumped long-term community interests ii) Patronage and poor service delivery: varying degrees of patronage led to multiple forms of illegalities and violations such as tax evasion. Due to vested interests and corruption among public officials, the slum population was lethargic. iii) Intersecting realities of poverty and unemployment: slum dwellers lived on the margins daily. Hence, poor living conditions were a secondary concern. iv) Social relations for personal development: Slum social networks were driven by individual interests rather than community good. Slum dwellers prioritized connections with people of common socio-economic interests. As such social networks were instrumental only if they 'added value'. CONCLUSION: Social networks in slums are only concerned about survival needs. Slums require responses that address the complexity of slum formation and broader livelihood challenges, as well as re-assessing the meaning of community. We posit that more needs to be done in understanding the meaning and workings of a sociology beyond physical societies. Poverty is a modifier of social systems and processes and should be a concern for all stakeholders involved in slum development.

'When I receive ARVs through my group, my heart settles': Participants' perceptions and experiences of Friends for Life Circles for Option B+ in Kampala and Mityana Districts, Uganda.

The Friends for Life Circles (FLC) was a parallel randomized controlled trial testing the efficacy of a group peer support intervention to support long-term adherence to Option B+ in Kampala and Mityana districts in Uganda. We explored FLC participants' experiences and perceptions of the intervention on adherence to Option B+ for PMTCT and potential implications for strengthening the PMTCT program. We collected data from six focus group discussions with lactating women enrolled in the FLC intervention, and from 14 key informant interviews with health workers, district and national level stakeholders, as well as male partners of FLC participants. Data were analysed using a content thematic approach in a continuous and iterative process. Women described the FLC intervention as acceptable and beneficial in enhancing their understanding of HIV and the need for ART. The FLC helped women, especially those newly diagnosed with HIV infection to come to terms with their diagnosis and overcome the fear of death linked to testing HIV positive, and provided opportunities to enhance ART initiation, resumption and adherence. The FLC provided safe spaces for women, to learn about ART, and to receive support from peers including adherence reminders through home visits and 'coded' reminder messages. Receiving ART from support groups protected members from stigma and long lines at health facilities. Fear of stigma, health system challenges, the high cost of caring for animals and lack of money to save in groups were key challenges noted. The FLC support groups were crucial in providing needed support for women to initiate, resume and adhere to lifelong ART for Option B+. It is important that women who test HIV positive and start ART for life receive psychosocial support from peers and health workers to improve chances of preventing HIV transmission from mothers to children.

Delay in healthcare seeking for young children with severe pneumonia at Mulago National Referral Hospital, Uganda: A mixed methods cross-sectional study.

BACKGROUND: Globally, pneumonia is the leading infectious cause of under-five mortality, and this can be reduced by prompt healthcare seeking. Data on factors associated with delays in seeking care for children with pneumonia in Uganda is scarce. OBJECTIVES: The study aimed to determine the prevalence, factors associated with delay, barriers, and facilitators of prompt healthcare seeking for children under five years of age with severe pneumonia attending Mulago National Referral Hospital (MNRH) Uganda. METHODS: A mixed methods cross-sectional study was conducted among 384 caregivers of children with severe pneumonia at MNRH. Quantitative data was collected using interviewer-administered structured questionnaires and qualitative data through focus group discussions with caregivers. Descriptive statistics were used to determine the prevalence of delay in care seeking. Logistic regression analysis was used to determine the factors that were independently associated with delay in seeking healthcare. Content thematic analysis was used to analyze for barriers and facilitators of prompt healthcare seeking. RESULTS: The prevalence of delay in seeking healthcare was 53.6% (95% CI: 48.6-58.6). Long distance to a hospital (AOR = 1.94, 95% CI 1.22-3.01, p value = 0.003), first seeking care elsewhere (AOR = 3.33, 95% CI 1.85-6.01, p value = 0.001), and monthly income ≤100,000 UGX (28 USD) (AOR = 2.27,95% CI 1.33-3.86, p value = 0.003) were independently associated with delay in seeking healthcare. Limited knowledge of symptoms, delayed referrals, self-medication, and low level of education were barriers to prompt healthcare seeking while recognition of symptoms of severe illness in the child, support from spouses, and availability of money for transport were key facilitators of early healthcare seeking. CONCLUSION: This study showed that more than half of the caregivers delayed seeking healthcare for their children with pneumonia symptoms. Caregivers who first sought care elsewhere, lived more than 5 km from the hospital, and earned less than 28 USD per month were more likely to delay seeking healthcare for their children with severe pneumonia. Limited knowledge of symptoms of pneumonia, self-medication, and delayed referral hindered prompt care-seeking. Key facilitators of prompt care-seeking were accessibility to health workers, support from spouses, and recognition of symptoms of severe illness in children. There is a need for programs that educate caregivers about pneumonia symptoms, in children less than five years.

Nutritional status of young children born with low birthweight in a low resource setting: an observational study.

OBJECTIVE: Every year, an estimated 20 million babies are born with low birthweight and this number is increasing globally. Survivors are at risk of lifelong morbidities like undernutrition. We assessed the growth and nutritional status for children born with low birthweight at Mulago Hospital, Uganda. METHODS: We conducted a cross sectional study to describe the nutritional status of children aged between 22 and 38 months and born weighing ≤ 2000 g. Anthropometric measurements; weight for height, height for age and weight for age z-scores were generated based on the World Health Organization standards to define wasting, stunting and underweight respectively. Data was collected using a structured questionnaire and analysis was done using STATA version 14. RESULTS: Of the 251 children, 129 (51.4%) were male, mean age was 29.7 months SD 4.5) and maternal mean age was 29.9 (SD 5.3). A total of 101(40.2%) had normal nutritional status. The prevalence of wasting, underweight and stunting were: 8 (3.2%), 36 (14.4%) and 106 (42.2%) respectively. CONCLUSION: Six of ten children born with low birthweight were at risk of undernutrition in early childhood: underweight and stunting were higher than the national prevalence. Targeted interventions are needed for children with very low birth weight.

Hypothyroidism Among Children and Adolescents With Nephrotic Syndrome in Mulago National Referral Hospital, Kampala, Uganda; a Cross-sectional Study.

Background: Nephrotic syndrome (NS) is the commonest glomerular disease among children. It is characterized by heavy proteinuria and is a risk factor for hypothyroidism in the affected children. Hypothyroidism is of concern because it affects the physical and intellectual development of children and adolescents. This study sought to establish the prevalence and factors associated with hypothyroidism among children and adolescents with NS. Methods: A cross-sectional design was used to study 70 children and adolescents aged 1-19 years diagnosed with nephrotic syndrome and being followed up in the kidney clinic in Mulago National Referral Hospital. Questionnaires were used to collect patients' socio-demographics and clinical information. A blood sample was taken for analysis for thyroid stimulating hormone (TSH) and free thyroxine (FT4), renal function tests and serum albumin. Hypothyroidism included both overt and subclinical forms. Overt hypothyroidism was defined as TSH level > 10 mU/L and FT4 < 10pmol/L, or FT4 < 10pmol/l with normal TSH, or TSH < 0.5mU/l. Sub-clinical hypothyroidism was defined as TSH ranging between 5 and10 mU/L with normal age appropriate FT4 levels. Urine samples were collected and taken for a dipstick examination. The data was analyzed using STATA version 14 and a p-value < 0.05 was considered as significant. Results: The mean age (standard deviation) of participants was 9 years (3.8). There were more males; 36 of 70 (51.4%). The prevalence of hypothyroidism was 23% (16/70 participants). Of the 16 children with hypothyroidism, 3 (18.7%) had overt hypothyroidism while 13 had subclinical hypothyroidism. Only low serum albumin, aOR 35.80 (confidence interval 5.97-214.69 and a p value of < 0.001) was associated with hypothyroidism. Conclusion: The prevalence of hypothyroidism among children and adolescent with nephrotic syndrome attending Mulago Hospital paediatric kidney clinic was 23%. Hypolbuminemia was found to be associated with hypothyroidism. Therefore, children and adolescents that have severely low levels of serum albumin should be screened for hypothyroidism and linked to endocrinologists for care.

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll.

BACKGROUND: Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017. METHODS: We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers. RESULTS: At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future. CONCLUSIONS: Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.

"Prevalence, outcome and factors associated with dysglycemia among critically ill children presenting to Fort Portal Regional Referral Hospital: A cross sectional study".

Introduction: Dysglycemia has been shown to influence outcome among critically ill children. We aimed to determine the prevalence, outcome and factors associated with dysglycemia among critically ill children aged one month to 12 years presenting to Fort Portal regional referral hospital. Methods: The study employed a descriptive, cross-sectional design for prevalence and factors associated, and longitudinal observational study design to determine the immediate outcome. Critically ill children aged one month to 12 years were systematically sampled and triaged at outpatient department using World Health Organization emergency signs. The random blood glucose was evaluated on admission and at 24 hours. Verbal and written informed consent/assent were obtained after stabilization of the study participants. Those that had hypoglycemia were given Dextrose 10% and those with hyperglycemia had no intervention. Results: Of the 384 critically ill children, dysglycemia was present in 21.7% (n = 83), of those 78.3% (n = 65) had hypoglycemia and 21.7% (n = 18) had hyperglycemia. The proportion of dysglycemia at 24 hours was 2.4% (n = 2). None of the study participants had persistent hypoglycemia at 24 hours. The cumulative mortality at 48hours was 3.6% (n = 3). At 48 hours 33.2% (n = 27) had stable blood glucose levels and were discharged from the hospital. After multiple logistic regression, obstructed breathing (AOR 0.07(0.02-0.23), inability to breastfeed/drink (AOR 2.40 (1.17-4.92) and active convulsions (AOR 0.21 (0.06-0.74), were the factors that were significantly associated with dysglycemia among critically ill children. The results will guide in the revision of policies and treatment protocols to facilitate better management of children at risk of dysglycemia nationally. Conclusions: Dysglycemia was found to affect one in five critically ill children aged one month to 12 years presenting to Fort Portal Regional Referral Hospital. Dysglycemia outcomes are good with early intervention.

Cultural beliefs and practices on perinatal death: a qualitative study among the Lango community in Northern Uganda.

BACKGROUND: Perinatal death has profound psychosocial effects on women and their families. Sociocultural contexts influence the burden, rituals and bereaved's support. Little is known about cultural beliefs and practices related to perinatal death. This study explored the cultural perspectives of the Lango community on perinatal death. METHODS: This study utilised a focused ethnographic design anchored on a symbolic interactionist framework to understand the meanings attached to beliefs and practices on stillbirth or neonatal death among the Lango community in Lira District, Northern Uganda. Participants were sampled purposively for FGD while key informants were identified through snowballing technique. Data were audio recorded in Lango, transcribed, and later translated, a codebook was developed and data entered into Atlas. ti version 8.4.26 and then coded. It was analysed both deductively and inductively into themes. RESULTS: Stillbirth and early neonatal death both attract similar rituals as would an older child. Burial is not rushed and is attended by family members and close friends. Stillbirths and children that die before naming are buried without names. Bereaved families are comforted and encouraged about future pregnancies. Currently, Lango associates the deaths to biomedical explanations such as teenage pregnancies, inadequate pregnancy care, health system challenges and poor health-seeking behaviour, unlike previously when they were attributed to consequences of unacceptable social behaviours, superstitious beliefs and witchcraft. Antenatal care and health facility childbirths are currently preferred over traditional practices for good pregnancy outcomes. CONCLUSION: Stillbirth or early neonatal death is viewed as the death of a child, different from other settings. Thus, rituals are performed to honour, create memory, and maintain the connection with deceased babies. Bereaved parents are supported. Health care workers need to provide culturally sensitive support to parents after perinatal loss. The prevailing beliefs of perinatal death cause in terms of biomedical explanations consistent with known determinants and preference for health facility care for prevention creates an opportunity for improving perinatal health.

Dihydroartemisinin-piperaquine or sulphadoxine-pyrimethamine for the chemoprevention of malaria in children with sickle cell anaemia in eastern and southern Africa (CHEMCHA): a protocol for a multi-centre, two-arm, double-blind, randomised, placebo-controlled superiority trial.

BACKGROUND: An estimated 300,000 babies are born with sickle cell anaemia (SCA) annually. Affected children have chronic ill health and suffer premature death. Febrile illnesses such as malaria commonly precipitate acute crises in children with SCA. Thus, chemoprophylaxis for malaria is an important preventive strategy, but current regimes are either sub-optimally effective (e.g. monthly sulphadoxine-pyrimethamine, SP) or difficult to adhere to (e.g. daily proguanil). We propose dihydroartemisinin-piperaquine (DP) as the agent with the most potential to be used across Africa. METHODS: This will be a randomised, double-blind, parallel-group superiority trial of weekly single-day courses of DP compared to monthly single-day courses of SP in children with SCA. The study will be conducted in eastern (Uganda) and southern (Malawi) Africa using randomisation stratified by body weight and study centre. Participants will be randomised using an allocation of 1:1 to DP or SP. We will investigate the efficacy, safety, acceptability and uptake and cost-effectiveness of malaria chemoprevention with weekly courses of DP vs monthly SP in 548 to 824 children with SCA followed up for 12-18 months. We will also assess toxicity from cumulative DP dosing and the development of resistance. Participant recruitment commenced on 30 April 2021; follow-up is ongoing. DISCUSSION: At the end of this study, findings will be used to inform regional health policy. This manuscript is prepared from protocol version 2.1 dated 1 January 2022. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov, NCT04844099 . Registered on 08 April 2021.

"My baby is fine, no need for more clinic visits." Facilitators and barriers for utilisation of follow-up services for children born preterm in low-resource setting: Parents' perceptions.

OBJECTIVES: We sought to understand the facilitators and barriers impacting utilisation of follow-up services for children born preterm as perceived by parents in a low-resource setting. METHODS: We conducted a qualitative study at Mulago Hospital, Uganda, with parents of children born preterm and aged 22-38 months at the time of the study. We collected data using five in-depth interviews and four focus group discussions. Data were analysed using thematic analysis informed by the social-ecological model. RESULTS: Ten subthemes emerged that could be grouped into three main themes: (1) Individual: parents' knowledge, parenting skills, perception of follow-up and infant's condition; (2) Relationship: support for the mother and information sharing; (3) Institution: facility setup, cost of care, available personnel and distance from the facility. Parents of preterm infants perceived receiving timely information, better understanding of prematurity and its complications, support from spouses, availability of free services and encouragement from health workers as facilitators for utilisation of follow-up services. Limited male involvement, parents' negative perception of follow-up, stable condition of infant, health facility challenges especially congestion at the hospital, distance and care costs were key barriers. CONCLUSION: An interplay of facilitators and barriers at individual, interpersonal and health system levels encourage or deter parents from taking their preterm children for follow-up services. Improving utilisation of services will require educating parents on the importance of follow-up even when children are not sick, eliciting maternal support from spouses and peers and addressing health system gaps that make follow-up unattractive and costly.

Health-related quality of life of patients with sickle cell disease aged 8-17 years at Kamuzu Central Hospital, Malawi.

BACKGROUND: Sickle cell disease (SCD) is characterized by both acute and chronic complications that affect the daily lives of patients and lower their quality of life. OBJECTIVE: To describe the health-related quality of life (HRQoL) and the associated factors in children aged 8-17 years with SCD attending the pediatric hematology clinic at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. METHODS: A mixed-methods cross-sectional study was conducted at KCH. Patient data were collected with the aid of a standardized case report form. HRQoL was assessed using PedsQL™ Sickle Cell Disease Module by the child's report. Associations between HRQoL scores and independent variables were evaluated by a linear regression model. In-depth interviews were then carried out and the qualitative data were analyzed using content thematic analysis. RESULTS: A hundred and sixty-three children with SCD were enrolled and 52.1% were females. Their median age was 11.2 ± 2.7 years. The mean global HRQoL score of the children was 62 ± 17.3. The highest scores were in the treatment domain (72.5 ± 15.1) while the lowest scores were in the emotions domain (55.2 ± 28.7). The mean pain score was 58.8 ± 16.3. The factors associated with low HRQoL scores were pain (ß-coefficient -6.97 CI (-3.07,-15.58); p value .034) and low hemoglobin levels (ß-coefficient 2.29 CI (.65-3.91); p value .006). CONCLUSION: The HRQoL of this population is low. Pain and low hemoglobin were significantly associated with low HRQoL scores. Adequate treatment to control pain and increase the steady-state hemoglobin may improve the HRQoL of children with SCD. Interventions to address low emotional scores are recommended.

"Your heart keeps bleeding": lived experiences of parents with a perinatal death in Northern Uganda.

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

Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda.

INTRODUCTION: WHO recommends vaccination against HPV for girls before sexual debut. Uganda started HPV vaccination in 2008 as pilot programs in 2 districts, followed by national roll out in 2015. Despite the availability of vaccines against human papillomavirus (HPV) in Uganda in the period covered by the study, there was reported low HPV vaccine uptake and completion especially of the second dose in Uganda; with little information available on timely completion of HPV vaccine and the associated factors in Uganda. This study was therefore done to determine the HPV vaccine dose 2 completion and describe the possible factors associated with timely HPV vaccine completion and non-completion among girls of age 9-14 years attending the adolescent clinic at Mulago hospital. METHODS: A retrospective mixed methods study was conducted in Mulago National Referral hospital adolescent clinic. Data were mainly collected through review of charts and folders for clinic attendance by eligible girls and focus group discussions with eligible girls that completed the 2 doses of HPV vaccine on recommended/scheduled time. RESULTS: Out of the 201 girls studied, 87 girls (43.3%) had timely completion of the HPV vaccination. Knowledge about HPV infection and HPV vaccine benefits, positive peer influence and healthcare worker recommendation to get vaccinated at health facility level positively influenced timely completion of HPV vaccine. Among barriers to completion of HPV vaccine identified were: inadequate information about HPV infection and HPV vaccine, concerns about HPV vaccine efficacy and safety, unclear communication with adolescents/caregivers from healthcare workers and -stock out of the HPV vaccine. CONCLUSION: Timely completion of the second dose of HPV vaccine among girls attending the adolescent clinic of Mulago hospital was low (at 43.3%) but higher when compared to earlier published reports. Interventions around improved social mobilization, enhanced outreach and static vaccination approach and education of eligible girls on HPV vaccination can help increase vaccine uptake.

'There Were Moments We Wished She Could Just Die': The Highly Gendered Burden of Nodding Syndrome in Northern Uganda.

Nodding Syndrome (NS) occurs within a wide spectrum of epilepsies seen in onchocerciasis endemic areas of sub-Saharan Africa. It has debilitating consequences on affected individuals and increases the socio-economic, physical and psychological burden on care-givers and their households, diminishing their standing within the community. Social science research on the disproportionate burden of the disease on females is limited. Based on ethnographic research over 3 years in northern Uganda, we explored the burden of being ill and care-giving for persons with NS from a gendered perspective. We found that NS-affected females were at greater risk of physical and psychological abuse, sexual violence, unwanted pregnancies, sexually transmitted infections and stigma, in a context of deteriorating socio-economic conditions. Primary care-givers of the NS-affected, mostly women, struggled to make ends meet and were subjected to stigma and abandonment. Targeted interventions, including legal protection for affected females, stigma reduction, and psycho-social and financial support are needed.