Newborn care knowledge and practices among care givers of newborns and young infants attending a regional referral hospital in Southwestern Uganda.

A child born in developing countries has a 10 times higher mortality risk compared to one born in developed countries. Uganda still struggles with a high neonatal mortality rate at 27/1000 live births. Majority of these death occur in the community when children are under the sole care of their parents and guardian. Lack of knowledge in new born care, inappropriate new born care practices are some of the contributors to neonatal mortality in Uganda. Little is known about parent/caregivers' knowledge, practices and what influences these practices while caring for the newborns. We systematically studied and documented newborn care knowledge, practices and associated factors among parents and care givers. To assess new born care knowledge, practices and associated factors among parents and care givers attending MRRH. We carried out a quantitative cross section methods study among caregivers of children from birth to six weeks of life attending a regional referral hospital in south western Uganda. Using pretested structured questionnaires, data was collected about care givers' new born care knowledge, practices and the associated factors. Data analysis was done using Stata version 17.0. We interviewed 370 caregivers, majority of whom were the biological mothers at 86%. Mean age was 26 years, 14% were unemployed and 74% had monthly earning below the poverty line. Mothers had a high antenatal care attendance of 97.6% and 96.2% of the deliveries were at a health facility Care givers had variant knowledge of essential newborn care with associated incorrect practices. Majority (84.6%) of the respondents reported obliviousness to putting anything in the babies' eyes at birth, however, breastmilk, water and saliva were reportedly put in the babies' eyes at birth by some caregivers. Hand washing was not practiced at all in 16.2% of the caregivers before handling the newborn. About 7.4% of the new borns received a bath within 24 hours of delivery and 19% reported use of herbs. Caregivers practiced adequate thermal care 87%. Cord care practices were inappropriate in 36.5%. Only 21% of the respondents reported initiation of breast feeding within 1 hour of birth, Prelacteal feeds were given by 37.6% of the care givers, water being the commonest prelacteal feed followed by cow's milk at 40.4 and 18.4% respectively. Majority of the respondents had below average knowledge about danger signs in the newborn where 63% and mean score for knowledge about danger signs was 44%. Caretaker's age and relationship with the newborn were found to have a statistically significant associated to knowledge of danger signs in the newborn baby. There are variable incorrect practices in the essential new born care and low knowledge and awareness of danger signs among caregivers of newborn babies. There is high health center deliveries and antenatal care attendance among the respondents could be used as an opportunity to increase caregiver awareness about the inappropriate practices in essential newborn care and the danger signs in a newborn.

Evaluating the Feasibility, Acceptability, and Preliminary Efficacy of SupportMoms-Uganda, an mHealth-Based Patient-Centered Social Support Intervention to Improve the Use of Maternity Services Among Pregnant Women in Rural Southwestern Uganda: Randomized Controlled Trial.

BACKGROUND: SMS text messaging and other mobile health (mHealth) interventions may improve knowledge transfer, strengthen access to social support (SS), and promote positive health behaviors among women in the perinatal period. However, few mHealth apps have been taken to scale in sub-Saharan Africa. OBJECTIVE: We evaluated the feasibility, acceptability, and preliminary efficacy of a novel, mHealth-based, and patient-centered messaging app designed using behavioral science frameworks to promote maternity service use among pregnant women in Uganda. METHODS: We performed a pilot randomized controlled trial between August 2020 and May 2021 at a referral hospital in Southwestern Uganda. We included 120 adult pregnant women enrolled in a 1:1:1 ratio to receive routine antenatal care (ANC; control), scheduled SMS text or audio messages from a novel messaging prototype (scheduled messaging [SM]), and SM plus SMS text messaging reminders to 2 participant-identified social supporters (SS). Participants completed face-to-face surveys at enrollment and in the postpartum period. The primary outcomes were feasibility and acceptability of the messaging prototype. Other outcomes included ANC attendance, skilled delivery, and SS. We conducted qualitative exit interviews with 15 women from each intervention arm to explore the intervention mechanisms. Quantitative and qualitative data were analyzed using STATA and NVivo, respectively. RESULTS: More than 85% and 75% of participants received ≥85% of the intended SMS text messages or voice calls, respectively. More than 85% of the intended messages were received within 1 hour of the expected time; 18% (7/40) of women experienced network issues for both intervention groups. Over 90% (36/40) of the intervention participants found this app useful, easy to use, engaging, and compatible and strongly recommended it to others; 70% (28/40), 78% (31/40), and 98% (39/40; P=.04) of women in the control, SM, and SS arms, respectively, had a skilled delivery. Half (20/40), 83% (33/40), and all (40/40; P=.001) of the women in the control, SM, and SS arms attended ≥4 ANC visits, respectively. Women in the SS arm reported the highest support (median 3.4, IQR 2.8-3.6; P=.02); <20% (8/40; P=.002) missed any scheduled ANC visit owing to lack of transportation. Qualitative data showed that women liked the app; they were able to comprehend ANC and skilled delivery benefits and easily share and discuss tailored information with their significant others, who in turn committed to providing them the needed support to prepare and seek help. CONCLUSIONS: We demonstrated that developing a novel patient-centered and tailored messaging app that leverages SS networks and relationships is a feasible, acceptable, and useful approach to communicate important targeted health-related information and support pregnant women in rural Southwestern Uganda to use available maternity care services. Further evaluation of maternal-fetal outcomes and integration of this intervention into routine care is needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT04313348; https://clinicaltrials.gov/ct2/show/NCT04313348.

Prevalence, correlates and treatment needs of dental caries among people on antiretroviral therapy in Uganda: a cross sectional study.

BACKGROUND: Oral diseases are estimated to affect half of people living with HIV in the western world, and are often marked by pain, discomfort, disfigurement and reduced quality of life. Both HIV-specific and antiretroviral therapy-associated oral diseases have been found in this population. However, the prevalence, correlates and treatment needs of dental caries among people on antiretroviral therapy has not been well studied in rural Africa where majority of people living with HIV reside. Moreover, health behaviors and access to dental care vary significantly from high-income countries in the global north. METHODS: A cross-sectional study was conducted among people living with HIV attending a high-volume HIV clinic with an enrollment of 10,000 patients in a regional referral hospital in Southwestern Uganda. The clinic is located in an urban setting with a large rural catchment area. Oral health data was collected using the modified World Health Organization oral health questionnaire for adults. Dental examinations were conducted to identify and classify dental caries using the decayed, missing, filled, teeth (DMFT) index and compute the treatment need. Logistic regression models were employed to identify correlate of dental caries. RESULTS: A total of 194 participants were included in the study. The majority were female (124/194, 63.9%) with a median age of 42 years (IQR 36-49). The prevalence of dental caries experience among study participants was 67%, (130/194, 95% CI 60-75%). The mean DMFT index score was 4 (IQR 2-6) and treatment need was 96% (192/200). A higher CD4 count was associated with the presence of dental caries (OR 0.403, 95% CI 0.175-0.932) although it was not significant in multivariate analysis. CONCLUSION: There is a high prevalence of dental caries among people living with HIV on ART in Uganda. Our data demonstrate a high oral treatment need among this population. We recommend inclusion of preventive and therapeutic oral care into HIV care in this region.

Understanding the Effect of a Healthcare Provider-Led Family Planning Support Intervention on Contraception use and Pregnancy Desires among Postpartum Women Living with HIV in Southwestern Uganda.

Modern contraceptive prevalence among women living with HIV (WLWH) in Uganda is still low at 45%, and up to a third of women are likely to discontinue the method within the first year of initiation. This increases risks of unplanned pregnancies, perinatal HIV transmission and pregnancy complications. We aim to explore and explain the mechanism of effect of a family planning support intervention investigated in a randomized controlled trial conducted between October 2016 and June 2018 among 320 postpartum WLWH at a referral hospital in Southwestern Uganda that led to improved uptake, decreased contraception discontinuation and lowered pregnancy rates. Thirty WLWH and 10 of their primary sexual partners who participated in this trial were purposively selected and interviewed in the local language; interviews were digitally recorded. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Up to 83% of women wanted to avoid pregnancy within the first year postpartum. Qualitative data showed that contraception uptake and use were influenced by: 1) Participant awareness and understanding of different methods available; 2) Participant perception of offered health services; 3) Healthcare provider (HCP) socio-cultural sensitivity to individual experiences and (mis)conceptions surrounding contraception; 4) Having tactile engagement, follow-up reminders and a reference to prompt action or discussions with partners. Supportive and culturally sensitive HCPs and systems facilitated information sharing leading to increased patient awareness and understanding of the contraceptive methods, and improved health user experience, care engagement, confidence and willingness to take up and continue using modern contraceptive methods.

Feasibility of an Interprofessional, Simulation-Based Curriculum to Improve Teamwork Skills, Clinical Skills, and Knowledge of Undergraduate Medical and Nursing Students in Uganda: A Cohort Study.

INTRODUCTION: Many deaths in Sub-Saharan Africa are preventable with provision of skilled healthcare. Unfortunately, skills decay after training. We determined the feasibility of implementing an interprofessional (IP) simulation-based educational curriculum in Uganda and evaluated the possible impact of this curriculum on teamwork, clinical skills (CSs), and knowledge among undergraduate medical and nursing students. METHODS: We conducted a prospective cohort study over 10 months. Students were divided into 4 cohorts based on clinical rotations and exposed to rotation-specific simulation scenarios at baseline, 1 month, and 10 months. We measured clinical teamwork scores (CTSs) at baseline and 10 months; CSs at baseline and 10 months, and knowledge scores (KSs) at baseline, 1 month, and 10 months. We used paired t tests to compare mean CTSs and KSs, as well as Wilcoxon rank sum test to compare group CS scores. RESULTS: One hundred five students (21 teams) participated in standardized simulation scenarios. We successfully implemented the IP, simulation-based curriculum. Teamwork skills improved from baseline to 10 months when participants were exposed to: (a) similar scenario to baseline {baseline mean CTS = 55.9% [standard deviation (SD) = 14.4]; 10-month mean CTS = 88.6%; SD = 8.5, P = 0.001}, and (b) a different scenario to baseline [baseline mean CTS = 55.9% (SD = 14.4); 10-month CTS = 77.8% (SD = 20.1), P = 0.01]. All scenario-specific CS scores showed no improvement at 10 months compared with baseline. Knowledge was retained in all scenarios at 10 months. CONCLUSIONS: An IP, simulation-based undergraduate curriculum is feasible to implement in a low-resource setting and may contribute to gains in knowledge and teamwork skills.

Healthcare provider perspectives regarding epilepsy care in Uganda.

OBJECTIVE: Epilepsy is the most common chronic neurological disorder in the world and imposes a large economic burden on global healthcare systems, especially in low-income settings and rural areas as is found in sub-Saharan Africa (SSA). Despite the high epilepsy prevalence, there are no systematic descriptions of healthcare provider (HCP) perceptions and needs in managing people with epilepsy (PWE) in Uganda. Identifying these perceptions and needs is crucial for understanding community priorities, thereby enhancing the development of culturally sensitive communications, interventions, and research approaches. METHODS: In this qualitative study, we used semistructured interview guides to conduct focus group discussions that explored the perspectives of 32 providers of epilepsy care from health facilities around Mbarara, Uganda. Our sample included nonspecialized general physicians (n = 3), medical residents (n = 8), medical clinical officers (n = 3), psychiatric clinical nurses (n = 6), medical nurses and nursing assistants (n = 9), and other providers (n = 3), who were loosely grouped into discussion groups based on level or type of training. Self-assessed proficiency ratings were also administered to gain a better understanding of participants' confidence in their training, preparedness, and capabilities regarding epilepsy care. Thematic analysis of the focus group transcripts was conducted to ascertain commonly occurring themes about perceptions and challenges in epilepsy care. RESULTS: Our analyses identified nine major themes that dominated the perspectives of the study participants: care management, medications, diagnostics, HCP training, human resources, location, patient education, social support, and community knowledge and beliefs. Proficiency ratings prioritized areas of confidence as knowledge related to referrals, psychosocial impacts, and seizure neurophysiology. Areas of need were revealed as knowledge of diagnostic tools and antiepileptic drug (AED) regimens. CONCLUSIONS: Our findings delineate the perspectives of providers caring for PWE, with consistent recognition of challenges centering around resource augmentation, infrastructure strengthening, and education. Participants emphasized the urgent need to augment these resources to address limitations in medication types and access, trained human resources, and diagnostic tools. They overwhelmingly recognized the need for infrastructure strengthening to address human, diagnostic, medicinal, and capital resource limitations that place undue burden on patients with epilepsy and physicians. Providers indicated a clear desire to learn more about different diagnostic tools and medical management practices, potentially through continuing education, specialized training, or more intentional in-school diagnostic preparation. They also advocated for the powerful influence of patient and family education and clearly articulated the need for community sensitization and support. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Sim for Life: Foundations-A Simulation Educator Training Course to Improve Debriefing Quality in a Low Resource Setting: A Pilot Study.

INTRODUCTION: Despite the importance of debriefing, little is known about the effectiveness of training programs designed to teach debriefing skills. In this study, we evaluated the effectiveness of a faculty development program for new simulation educators at Mbarara University of Science and Technology in Uganda, Africa. METHODS: Healthcare professionals were recruited to attend a 2-day simulation educator faculty development course (Sim for Life: Foundations), covering principles of scenario design, scenario execution, prebriefing, and debriefing. Debriefing strategies were contextualized to local culture and focused on debriefing structure, conversational strategies, and learner centeredness. A debriefing worksheet was used to support debriefing practice. Trained simulation educators taught simulation sessions for 12 months. Debriefings were videotaped before and after initial training and before and after 1-day refresher training at 12 months. The quality of debriefing was measured at each time point using the Objective Structured Assessment of Debriefing (OSAD) tool by trained, calibrated, and blinded raters. RESULTS: A total of 13 participants were recruited to the study. The mean (95% confidence interval) OSAD scores pretraining, posttraining, and at 12 months before and after refresher were 18.2 (14.3-22.1), 26.7 (22.8-30.6), 25.5 (21.2-29.9), and 27.0 (22.4-31.6), respectively. There was a significant improvement from pretraining to posttraining (P < 0.001), with no significant decay from posttraining to 12 months (P = 0.54). There was no significant difference in OSAD scores pre- versus post-refresher training at 12 months (P = 0.49). CONCLUSIONS: The Sim for Life Foundations program significantly improves debriefing skills with retention of debriefing skills at 12 months.

Women's Choice to Deliver at Home: Understanding the Psychosocial and Cultural Factors Influencing Birthing Choices for Unskilled Home Delivery among Women in Southwestern Uganda.

BACKGROUND: Utilization of perinatal services in Uganda remains low, with correspondingly high rates of unskilled home deliveries, which can be life-threatening. We explored psychosocial and cultural factors influencing birthing choices for unskilled home delivery among postpartum women in rural southwestern Uganda. METHODS: We conducted in-depth qualitative face-to-face interviews with 30 purposively selected women between December 2018 and March 2019 to include adult women who delivered from their homes and health facility within the past three months. Women were recruited from 10 villages within 20 km from a referral hospital. Using the constructs of the Health Utilization Model (HUM), interview topics were developed. Interviews were conducted and digitally recorded in a private setting by a native speaker to elicit choices and experiences during pregnancy and childbirth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive categories using inductive content analytic approach. RESULTS: Eighteen women (60%) preferred to deliver from home. Women's referent birth location was largely intentional. Overall, the data suggest women choose home delivery (1) because of their financial dependency and expectation for a "natural" and normal childbirth, affecting their ability and need to seek skilled facility delivery; (2) as a means of controlling their own birth processes; (3) out of dissatisfaction with facility-based care; (4) out of strong belief in fate regarding birth outcomes; (5) because they have access to alternative sources of birthing help within their communities, perceived as "affordable," "supportive," and "convenient"; and (6) as a result of existing gender and traditional norms that limit their ability and freedom to make family or health decisions as women. CONCLUSION: Women's psychosocial and cultural understandings of pregnancy and child birth, their established traditions, birth expectations, and perceptions of control, need, and quality of maternity care at a particular birthing location influenced their past and future decisions to pursue home delivery. Interventions to address barriers to healthcare utilization through a multipronged approach could help to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery.

When Women Deliver at Home Without a Skilled Birth Attendant: A Qualitative Study on the Role of Health Care Systems in the Increasing Home Births Among Rural Women in Southwestern Uganda.

BACKGROUND: Uganda's maternal mortality remains unacceptably high, with thousands of women and newborns still dying of preventable deaths from pregnancy and childbirth-related complications. Globally, Antenatal care (ANC) attendance has been associated with improved rates of skilled births. However, despite the fact that over 95% of women in Uganda attend at least one ANC, over 30% of women still deliver at home alone, or in the presence of an unskilled birth attendant, with many choosing to come to hospital after experiencing a complication. We explored barriers to women's decisions to deliver in a health care facility among postpartum women in rural southwestern Uganda, to ultimately inform interventions aimed at improving skilled facility births. METHODS: Between December 2018 and March 2019, we conducted in-depth qualitative face-to-face interviews with 30 post-partum women in rural southwestern Uganda. The purposeful sample was intended to represent women with differing experiences of pregnancy, delivery, and antenatal care. We included 15 adult women who had delivered from their homes and 15 who had delivered from a health facility in the previous 3 months. Women were recruited from 10 villages within 20 km of a regional referral hospital. Interviews were conducted and digitally recorded in a private setting by a trained native speaker to elicit experiences of pregnancy and birth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. RESULTS: Regardless of where they decided to give birth, women wished to deliver in a supportive, respectful, responsive and loving environment. The data revealed six key barriers to women's decisions to deliver from a health care facility: 1) Fear of unresponsive care, fueling a fear of being neglected or abandoned while at the facility; 2) fear of embarrassment and mistreatment by health care providers; 3) low perception of risk associated with pregnancy and childbirth; 4) preferences for particular birthing positions and their outcome expectations; 5) perceived lack of privacy in public facilities; and 6) perceived poor clinical and interpersonal skills of health providers to adequately explain birthing procedures or support expectant or laboring women and their newborn. CONCLUSION: Anticipation of unsupportive, unresponsive, disrespectful treatment, and a perceived lack of tolerance for simple, non-harmful traditions prevent women from delivering at health facilities. Building better interpersonal relationships between patients and providers within health systems could reinforce trust, improve patient-provider interaction, and facilitate useful information transfer during ANC and delivery visits. These expectations are important considerations in developing supportive health care systems that provide acceptable patient-friendly care. These findings are indicative of the vital need for midwives and other health care providers to have additional training in the role of communication and dignity in delivery of quality health care.

An Attitude Survey and Assessment of the Feasibility, Acceptability, and Usability of a Traumatic Brain Injury Decision Support Tool in Uganda.

BACKGROUND: Traumatic brain injury (TBI) prognostic models are potential solutions to severe human and technical shortages. Although numerous TBI prognostic models have been developed, none are widely used in clinical practice, largely because of a lack of feasibility research to inform implementation. We previously developed a prognostic model and Web-based application for in-hospital TBI care in low-resource settings. In this study, we tested the feasibility, acceptability, and usability of the application with potential end-users. METHODS: We performed our feasibility assessment with providers involved in TBI care at both a regional and national referral hospital in Uganda. We collected qualitative and quantitative data on decision support needs, application ease of use, and implementation design. RESULTS: We completed 25 questionnaires on potential uses of the app and 11 semistructured feasibility interviews. Top-cited uses were informing the decision to operate, informing the decision to send the patient to intensive care, and counseling patients and relatives. Participants affirmed the potential of the application to support difficult triage situations, particularly in the setting of limited access to diagnostics and interventions, but were hesitant to use this technology with end-of-life decisions. Although all participants were satisfied with the application and agreed that it was easy to use, several expressed a need for this technology to be accessible by smartphone and offline. CONCLUSIONS: We elucidated several potential uses for our app and important contextual factors that will support future implementation. This investigation helps address an unmet need to determine the feasibility of TBI clinical decision support systems in low-resource settings.

Trends in neurosurgical care in Western Uganda: an interrupted time series analysis.

OBJECTIVE: In addition to the rising burden of surgical disease globally, infrastructure and human resources for health remain a great challenge for low- and middle-income countries, especially in Uganda. In this study, the authors aim to explore the trends of neurosurgical care at a regional referral hospital in Uganda and assess the long-term impact of the institutional collaboration between Mulago National Referral Hospital and Duke University. METHODS: An interrupted time series is a quasi-experimental design used to evaluate the effects of an intervention on longitudinal data. The authors applied this design to evaluate the trends in monthly mortality rates for neurosurgery patients at Mbarara Regional Referral Hospital (MRRH) from March 2013 to October 2015. They used segmented regression and autoregressive integrated moving average models for the analysis. RESULTS: Over the study timeframe, MRRH experienced significant increases in referrals received (from 117 in 2013 to 211 in 2015), neurosurgery patients treated (from 337 in 2013 to 625 in 2015), and operations performed (from 61 in 2013 to 173 in 2015). Despite increasing patient volumes, the hospital achieved a significant reduction in hospital mortality during 2015 compared to prior years (p value = 0.0039). CONCLUSIONS: This interrupted time series analysis study showed improving trends of neurosurgical care in Western Uganda. There is a steady increase in volume accompanied by a sharp decrease in mortality through the years. Multiple factors are implicated in the significant increase in volume and decrease in mortality, including the addition of a part-time neurosurgeon, improvement in infrastructure, and increased experience. Further in-depth prospective studies exploring seasonality and long-term outcomes are warranted.

Mechanism of Pediatric Traumatic Brain Injury in Southwestern Uganda: A Prospective Cohort of 100 Patients.

BACKGROUND: Road traffic incidents (RTIs), falls, and violence contribute to more than two thirds of pediatric traumatic brain injuries in sub-Saharan Africa. In this study, we sought to assess mechanisms of pediatric traumatic brain injury in an effort to propose interventions for more effective pediatric head injury prevention. METHODS: A cohort of 100 patients who were <18 years treated at Mbarara Regional Referral Hospital between November 2016 and June 2017 were enrolled in the study. Information on etiology of injury was obtained via a questionnaire administered to patient caretakers at the time of admission. RESULTS: The mean age was found to be 7.5 years (standard deviation 5.2) and 38% were female. In our sample, 61% had computed tomography imaging done, of whom 88.5% had a positive finding. A majority of patients presented with a mild head injury (55%). RTIs were the predominant mechanism of injury across age groups (75%). Across all age groups, falls were responsible for a greater proportion of injuries in children aged 10-14 years (13.3%), whereas the greatest proportion of intentional injuries was reported in age group 10-14 and 15-17 years, 20% and 31.3%, respectively. Patients involved in pedestrian RTIs were significantly younger compared with those injured in nonpedestrian RTIs. Most parents (87.9%) were not with their children at the time of a pedestrian RTI. CONCLUSIONS: In Southwestern Uganda, the majority of pediatric neurotrauma patients are injured pedestrians, with no adult supervision at the time of the injury. Conducting a public awareness and education campaign on the necessity of child supervision is critical to decreasing pediatric head injuries in Uganda.