Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic.

The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities.

An educational intervention in rural Uganda: Risk-targeted home talks by village health workers.

OBJECTIVE: Evaluate the effectiveness of home talks (HTs), a novel model of health education delivered by village health workers (VHWs) with primary-level education to rural African mothers. Talk recipients were assessed by health census to be at risk for ill-health in one of 5 ways: malnutrition, diarrhea, respiratory disease, HIV, and poverty due to family size. METHODS: Each participant received a pre-test, immediate post-test and delayed post-test on their assigned HT topic and a pre-test and delayed post-test on a randomly assigned control topic. Differences in scoring were examined against controls and over time using paired t-tests and general linear regression analysis, respectively. RESULTS: Subjects lost knowledge gained from the HTs over time, but what they retained at 3 months was far greater than what they learned about the control topics (p-values <0.0001), independent of subjects' educational level. CONCLUSION: Targeted HTs to people with health census-identified risk factors resulted in learning and significant retention of knowledge. PRACTICE IMPLICATIONS: Positive behavioral change resulting from health education has been shown in diverse contexts. This personal model of home talk education by VHWs targeting vulnerable families is flexible and effective and may be used to improve community health in other impoverished settings worldwide.

Unilateral Complete Agenesis of Mesonephric Duct Derivatives in an 82-year-Old Male Cadaver: Embryology, Anatomy and Clinical Considerations.

Development of urogenital anatomy in the human fetus is the result of a complex interplay between multiple different tissues. The time course of development is well documented and the morphologic outcomes of insults at various time points during development are predictable. We present a cadaveric case of unilateral agenesis of the left kidney, ureter, bladder hemitrigone, ureteric opening, seminal vesicle, vas deferens, and epididymis. Failure of development of the mesonephric duct early during embryogenesis, likely between the third and fifth week, caused ipsilateral urogenital organ agenesis.

Crude tonsillectomy and local concepts of illness in Kisoro, Uganda: community perception of gapfura and its treatment.

The practice of crude tonsillectomy (CT), performed by traditional healers for a locally defined illness known as gapfura, has become increasingly common in south-western Uganda. This study describes perceptions of gapfura and examines the intersection of locally defined and biomedical illness. Kisoro District Hospital (KDH) staff (n=55) were surveyed, with 95% reporting that CT caused death, and 60% estimating that recipients died as a result of the procedure. Surveys of community members (n=737) revealed that 95% were familiar with gapfura as a common illness with variable symptoms; syndrome classification categorised 58% of descriptive responses as 'upper respiratory infection', while 42% suggested more severe diseases. Although only 26% of community respondents told the interviewer that CT was the best treatment, 47% believed the majority of community members use CT and 43% of those treated for gapfura within the past year received CT. The divergent perceptions of community members and allopathic health providers may be rooted in the use of gapfura as an idiom reflecting larger social stressors and CT as a response to this distress. Interventions to curb the practice of CT need to be multifaceted and will involve further anthropologic investigation, public health involvement, and education that encompasses the social context of disease.