Browsing by Author "Mwanga-Amumpaire, Juliet"
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Item Appropriateness of Care for Common Childhood Infections at Low-Level Private Health Facilities in a Rural District in Western Uganda(International Journal of Environmental Research Public Health, 2021) Mwanga-Amumpaire, Juliet; Alfvén, Tobias; Obua, Celestino; Källander, Karin; Migisha, Richard; Stålsby Lundborg, Cecilia; Ndeezi, Grace; Nakayaga Kalyango, JoanIn Uganda, >50% of sick children receive treatment from primary level-private health facilities (HF). We assessed the appropriateness of care for common infections in under-five-year-old children and explored perspectives of healthcare workers (HCW) and policymakers on the quality of healthcare at low-level private health facilities (LLPHF) in western Uganda. This was a mixedmethods parallel convergent study. Employing multistage consecutive sampling, we selected 110 HF and observed HCW conduct 777 consultations of children with pneumonia, malaria, diarrhea or neonatal infections. We purposively selected 30 HCW and 8 policymakers for in-depth interviews. Care was considered appropriate if assessment, diagnosis, and treatment were correct. We used univariable and multivariable logistic regression analyses for quantitative data and deductive thematic analysis for qualitative data. The proportion of appropriate care was 11% for pneumonia, 14% for malaria, 8% for diarrhea, and 0% for neonatal infections. Children with danger signs were more likely to receive appropriate care. Children with diarrhea or ability to feed orally were likely to receive inappropriate care. Qualitative data confirmed care given as often inappropriate, due to failure to follow guidelines. Overall, sick children with common infections were inappropriately managed at LLPHF. Technical support and provision of clinical guidelines should be increased to LLPHF.Item Capacity to provide care for common childhood infections at low-level private health facilities in Western, Uganda(PLoS ONE, 2021) Mwanga-Amumpaire, Juliet; Ndeezi, Grace; Ka¨llander, Karin; Obua, Celestino; Migisha, Richard; Nkeramahame, Juvenal; Stålsby Lundborg, Cecilia; Nakayaga Kalyango, Joan; Alfv, TobiasLow-level private health facilities (LLPHFs) handle a considerable magnitude of sick children in low-resource countries. We assessed capacity of LLPHFs to manage malaria, pneumonia, diarrhea, and, possible severe bacterial infections (PSBIs) in under-five-year-olds. Methods We conducted a cross-sectional survey in 110 LLPHFs and 129 health workers in Mbarara District, Uganda between May and December 2019. Structured questionnaires and observation forms were used to collect data on availability of treatment guidelines, vital medicines, diagnostics, and equipment; health worker qualifications; and knowledge of management of common childhood infections. Results Amoxicillin was available in 97%, parental ampicillin and gentamicin in 77%, zinc tablets and oral rehydration salts in >90% while artemether-lumefantrine was available in 96% of LLPHF. About 66% of facilities stocked loperamide, a drug contraindicated in the management of diarrhoea in children. Malaria rapid diagnostic tests and microscopes were available in 86% of the facilities, timers/clocks in 57% but only 19% of the facilities had weighing scales and 6% stocked oxygen. Only 4% of the LLPHF had integrated management of childhood illness (IMCI) booklets and algorithm charts for management of common childhood illnesses. Of the 129 health workers, 52% were certificate nurses/midwives and (26% diploma nurses/clinical officers; 57% scored averagely for knowledge on management of common childhood illnesses. More than a quarter (38%) of nursing assistants had low knowledge scores. No notable significant differences existed between rural and urban LLPHFs in most parameters assessed. Conclusion Vital first-line medicines for treatment of common childhood illnesses were available in most of the LLPHFs but majority lacked clinical guidelines and very few had oxygen. Majority of health workers had low to average knowledge on management of the common childhood illnesses. There is need for innovative knowledge raising interventions in LLPHFs including refresher trainings, peer support supervision and provision of job aides.Item Inhaled Nitric Oxide and Cerebral Malaria: Basis of a Strategy for Buying Time for Pharmacotherapy(The Pediatric Infectious Disease Journal, 2012) Bergmark, Brian; Bergmark, Regan; Beaudrap, Pierre De; Boum, Yap; Mwanga-Amumpaire, Juliet; Carroll, Ryan; Zapol, WarrenThere are approximately 225–600 million new malaria infections worldwide annually, with severe and cerebral malaria representing major causes of death internationally. The role of nitric oxide (NO) in the host response in cerebral malaria continues to be elucidated, with numerous known functions relating to the cytokine, endovascular and cellular responses to infection with Plasmodium falciparum. Evidence from diverse modes of inquiry suggests NO to be critical in modulating the immune response and promoting survival in patients with cerebral malaria. This line of investigation has culminated in the approval of 2 phase II randomized prospective clinical trials in Uganda studying the use of inhaled NO as adjuvant therapy in children with severe malaria. The strategy underlying both trials is to use the sytemic antiinflammatory properties of inhaled NO to “buy time” for chemical antiparasite therapy to lower the parasite load. This article reviews the nexus of malaria and NO biology with a primary focus on cerebral malaria in humans.Item Inhaled Nitric Oxide as an Adjunctive Treatment for Cerebral Malaria in Children: A Phase II Randomized Open-Label Clinical Trial(Oxford University Press, 2015) Mwanga-Amumpaire, Juliet; Carroll, Ryan W.; Baudin, Elisabeth; Kemigisha, Elisabeth; Nampijja, Dorah; Mworozi, Kenneth; Santorino, Data; Nyehangane, Dan; Nathan, Daniel I.; De Beaudrap, Pierre; Etard, Jean-François; Feelisch, Martin; Fernandez, Bernadette O.; Berssenbrugge, Annie; Bangsberg, David; Bloch, Kenneth D.; Boum, Yap; Zapol, Warren M.Children with cerebral malaria (CM) have high rates of mortality and neurologic sequelae. Nitric oxide (NO) metabolite levels in plasma and urine are reduced in CM. Methods. This randomized trial assessed the efficacy of inhaled NO versus nitrogen (N2) as an adjunctive treatment for CM patients receiving intravenous artesunate.We hypothesized that patients treated with NO would have a greater increase of the malaria biomarker, plasma angiopoietin-1 (Ang-1) after 48 hours of treatment. Results. Ninety-two children with CM were randomized to receive either inhaled 80 part per million NO or N2 for 48 or more hours. Plasma Ang-1 levels increased in both treatment groups, but there was no difference between the groups at 48 hours (P = not significant [NS]). Plasma Ang-2 and cytokine levels (tumor necrosis factor-α, interferon- γ, interleukin [IL]-1β, IL-6, IL-10, and monocyte chemoattractant protein-1) decreased between inclusion and 48 hours in both treatment groups, but there was no difference between the groups (P = NS). Nitric oxide metabolite levels—blood methemoglobin and plasma nitrate—increased in patients treated with NO (both P < .05). Seven patients in the N2 group and 4 patients in the NO group died. Five patients in the N2 group and 6 in the NO group had neurological sequelae at hospital discharge. Conclusions. Breathing NO as an adjunctive treatment for CM for a minimum of 48 hours was safe, increased blood methemoglobin and plasma nitrate levels, but did not result in a greater increase of plasma Ang-1 levels at 48 hours.Item Perspectives on External Support to Low Level Private Health Facilities in Management of Childhood Infections in Mbarara District, Uganda: A Qualitative Study With Health Workers and Policy Makers(Research Square, 2020) Mwanga-Amumpaire, Juliet; Nakayaga Kalyango, Joan; Källander, Karin; Sundararajan, Radhika; Owokuhaisa, Judith; Obua, Celestino; Alfvén, Tobias; Ndeezi, GraceWith the under-five child mortality rate of 46.4 deaths per 1000 live births, Uganda needs to accelerate measures to reduce child deaths in order to achieve the Sustainable Development Goal 3. While 60-70 % of frontline health services are provided by the private sector, many low level private health facilities are unregistered, unregulated, and often miss out on innovative strategies rolled out by the Ministry of Health. Low level private health facilities need support in order to provide quality health care. We explored the perspectives of health workers and policy makers on external support given to low level private clinics providing health care for children. Methods: In-depth interviews were conducted from May to December 2019 with 43 purposively selected key informants. They included 30 health care professionals treating children in low level private clinics and 13 policy makers from Mbarara district and the Uganda Ministry of Health directly involved with ensuring quality of child health. The issues discussed included their views on the quantity, quality, factors determining support received and preferred modalities of support to low level private health facilities. Using an inductive approach, interview transcripts were coded to identify categories and themes. Results: We identified three themes which emerged from the data 1) External support is needed to address socio-economic, regulatory and knowledge gap issues, 2) Current support is not optimal, and, 3) Ideal support underscores working together. While the Ministry of Health recognises its’ responsibility to provide support and guidance to public and private health facilities, it acknowledges lack of support for low level private health facilities currently. Health providers emphasised technical capacity building and more supportive supervisory visits but not simply policing and apportioning blame. Conclusion: The current support being given to low level private health facilities (LLPHF) is inadequate. The support needs to be tailored to the needs of the facility and health facilities have to proactively ask for support. Capacity building with emphasis on training and supportive supervision are key strategies for providing external support to LLPHF.Item Point-of-Care Approaches for Meningitis Diagnosis in a Low-Resource Setting (Southwestern Uganda): Observational Cohort Study Protocol of the “PI-POC” Trial(JMIR research protocols, 2020) Gaudenzi, Giulia; Kumbakumba, Elias; Rasti, Reza; Nanjebe, Deborah; Réu, Pedro; Nyehangane, Dan; Mårtensson, Andreas; Nassejje, Milly; Karlsson, Jens; Mzee, John; Nilsson, Peter; Businge, Stephen; Loh, Edmund; Boum, Yap; Andersson-Svahn, Helene; Gantelius, Jesper; Mwanga-Amumpaire, Juliet; Alfvén, TobiasA timely differential diagnostic is essential to identify the etiology of central nervous system (CNS) infections in children, in order to facilitate targeted treatment, manage patients, and improve clinical outcome. Objective: The Pediatric Infection-Point-of-Care (PI-POC) trial is investigating novel methods to improve and strengthen the differential diagnostics of suspected childhood CNS infections in low-income health systems such as those in Southwestern Uganda. This will be achieved by evaluating (1) a novel DNA-based diagnostic assay for CNS infections, (2) a commercially available multiplex PCR-based meningitis/encephalitis (ME) panel for clinical use in a facility-limited laboratory setting, (3) proteomics profiling of blood from children with severe CNS infection as compared to outpatient controls with fever yet not severely ill, and (4) Myxovirus resistance protein A (MxA) as a biomarker in blood for viral CNS infection. Further changes in the etiology of childhood CNS infections after the introduction of the pneumococcal conjugate vaccine against Streptococcus pneumoniae will be investigated. In addition, the carriage and invasive rate of Neisseria meningitidis will be recorded and serotyped, and the expression of its major virulence factor (polysaccharide capsule) will be investigated. Methods: The PI-POC trial is a prospective observational study of children including newborns up to 12 years of age with clinical features of CNS infection, and age-/sex-matched outpatient controls with fever yet not severely ill. Participants are recruited at 2 Pediatric clinics in Mbarara, Uganda. Cerebrospinal fluid (for cases only), blood, and nasopharyngeal (NP) swabs (for both cases and controls) sampled at both clinics are analyzed at the Epicentre Research Laboratory through gold-standard methods for CNS infection diagnosis (microscopy, biochemistry, and culture) and a commercially available ME panel for multiplex PCR analyses of the cerebrospinal fluid. An additional blood sample from cases is collected on day 3 after admission. After initial clinical analyses in Mbarara, samples will be transported to Stockholm, Sweden for (1) validation analyses of a novel nucleic acid–based POC test, (2) biomarker research, and (3) serotyping and molecular characterization of S. pneumoniae and N. meningitidis. Results: A pilot study was performed from January to April 2019. The PI-POC trial enrollment of patients begun in April 2019 and will continue until September 2020, to include up to 300 cases and controls. Preliminary results from the PI-POC study are expected by the end of 2020. Conclusions: The findings from the PI-POC study can potentially facilitate rapid etiological diagnosis of CNS infections in low-resource settings and allow for novel methods for determination of the severity of CNS infection in such environment.Item A Qualitative Exploration of the Referral Process of Children with Common Infections from Private Low-Level Health Facilities in Western Uganda(Children, 2021) Mwanga-Amumpaire, Juliet; Nakayaga Kalyango, Joan; Ndeezi, Grace; Rujumba, Joseph; Owokuhaisa, Judith; Lundborg, Cecilia Stålsby; Alfvén, Tobias; Obua, Celestino; Källander, KarinOver 50% of sick children are treated by private primary-level facilities, but data on patient referral processes from such facilities are limited. We explored the perspectives of healthcare providers and child caretakers on the referral process of children with common childhood infections from private low-level health facilities in Mbarara District. We carried out 43 in-depth interviews with health workers and caretakers of sick children, purposively selected from 30 facilities, until data saturation was achieved. The issues discussed included the process of referral, challenges in referral completion and ways to improve the process. We used thematic analysis, using a combined deductive/inductive approach. The reasons for where and how to refer were shaped by the patients’ clinical characteristics, the caretakers’ ability to pay and health workers’ perceptions. Caretaker non-adherence to referral and inadequate communication between health facilities were the major challenges to the referral process. Suggestions for improving referrals were hinged on procedures to promote caretaker adherence to referral, including reducing waiting time and minimising the expenses incurred by caretakers. We recommend that triage at referral facilities should be improved and that health workers in low-level private health facilities (LLPHFs) should routinely be included in the capacity-building trainings organised by the Ministry of Health (MoH) and in workshops to disseminate health policies and national healthcare guidelines. Further research should be done on the effect of improving communication between LLPHFs and referral health facilities by affordable means, such as telephone, and the impact of community initiatives, such as transport vouchers, on promoting adherence to referral for sick children.Item A qualitative study of the perspectives of health workers and policy makers on external support provided to low-level private health facilities in a Ugandan rural district, in management of childhood infections(Global Health Action, 2021) Mwanga-Amumpaire, Juliet; Kalyango, Joan N.; Källander, Karin; Sundararajan, Radhika; Owokuhaisa, Judith; Rujumba, Joseph; Obua, Celestino; Alfvén, Tobias; Ndeezi, GraceWith the under-five child mortality rate of 46.4 deaths per 1000 live births, Uganda should accelerate measures to reduce child deaths to achieve the Sustainable Development Goal 3. While 60–70% of frontline health services are provided by the private sector, many low-level private health facilities (LLPHF) are unregistered, unregulated, and often miss innovative and quality improvement strategies rolled out by the Ministry of Health. LLPHF need support in order to provide quality health care. Objective: To explore the perspectives of health workers and policy makers on external support given to LLPHF providing health care for children in Mbarara District, Uganda. Methods: We carried out a qualitative study, in which 43 purposively selected health workers and policy makers were interviewed. The issues discussed included their views on the quantity, quality, factors determining support received and preferred modalities of support to LLPHF. We used thematic analysis, employing an inductive approach to code interview transcripts and to identify subthemes and themes. Results: The support currently provided to LLPHF to manage childhood illnesses is inadequate. Health providers emphasised a need for technical capacity building, provision of policies, guidelines and critical supplies as well as adopting a more supportive supervisory approach instead of the current supervision model characterised by policing, fault finding and apportioning blame. Registration of the health facilities and regular submission of reports as well as multi-stakeholder involvement are potential strategies to improve external support. Conclusion: The current support received by LLPHF is inadequate in quantity and quality. Capacity building with emphasis on training, provision of critical guidelines and supplies as well as and supportive supervision are key strategies for delivering appropriate external support to LLPHF.Item Sociocultural and Structural Factors Contributing to Delays in Treatment for Children with Severe Malaria: A Qualitative Study in Southwestern Uganda(The American journal of tropical medicine and hygiene, 2015) Sundararajan, Radhika; Mwanga-Amumpaire, Juliet; Adrama, Harriet; Tumuhairwe, Jackline; Mbabazi, Sheilla; Mworozi, Kenneth; Carroll, Ryan; Bangsberg, David; Boum II, Yap; Ware, Norma C.Malaria is a leading cause of pediatric mortality, and Uganda has among the highest incidences in the world. Increased morbidity and mortality are associated with delays to care. This qualitative study sought to characterize barriers to prompt allopathic care for children hospitalized with severe malaria in the endemic region of southwestern Uganda. Minimally structured, qualitative interviews were conducted with guardians of children admitted to a regional hospital with severe malaria. Using an inductive and content analytic approach, transcripts were analyzed to identify and define categories that explain delayed care. These categories represented two broad themes: sociocultural and structural factors. Sociocultural factors were 1) interviewee’s distinctions of “traditional” versus “hospital” illnesses, which were mutually exclusive and 2) generational conflict, where deference to one’s elders, who recommended traditional medicine, was expected. Structural factors were 1) inadequate distribution of health-care resources, 2) impoverishment limiting escalation of care, and 3) financial impact of illness on household economies. These factors perpetuate a cycle of illness, debt, and poverty consistent with a model of structural violence. Our findings inform a number of potential interventions that could alleviate the burden of this preventable, but often fatal, illness. Such interventions could be beneficial in similarly endemic, low-resource settings.Item Traditional healer support to improve HIV viral suppression in rural Uganda (Omuyambi): study protocol for a cluster randomized hybrid efectiveness-implementation trial(BioMed Central Ltd, 2024-07) Sundararajan, Radhika; Hooda, Misha; Lai, Yifan; Nansera, Denis; Audet, Carolyn; Downs, Jennifer; Lee, Myung Hee; McNairy, Margaret; Muyindike, Winnie; Mwanga-Amumpaire, JulietRural African people living with HIV face significant challenges in entering and remaining in HIV care. In rural Uganda, for example, there is a threefold higher prevalence of HIV compared to the national average and lower engagement throughout the HIV continuum of care. There is an urgent need for appropriate interventions to improve entry and retention in HIV care for rural Ugandans with HIV. Though many adults living with HIV in rural areas prioritize seeking care services from traditional healers over formal clinical services, healers have not been integrated into HIV care programs. The Omuyambi trial is investigating the effectiveness of psychosocial support delivered by traditional healers as an adjunct to standard HIV care versus standard clinic-based HIV care alone. Additionally, we are evaluating the implementation process and outcomes, following the Consolidated Framework for Implementation Research.BACKGROUNDRural African people living with HIV face significant challenges in entering and remaining in HIV care. In rural Uganda, for example, there is a threefold higher prevalence of HIV compared to the national average and lower engagement throughout the HIV continuum of care. There is an urgent need for appropriate interventions to improve entry and retention in HIV care for rural Ugandans with HIV. Though many adults living with HIV in rural areas prioritize seeking care services from traditional healers over formal clinical services, healers have not been integrated into HIV care programs. The Omuyambi trial is investigating the effectiveness of psychosocial support delivered by traditional healers as an adjunct to standard HIV care versus standard clinic-based HIV care alone. Additionally, we are evaluating the implementation process and outcomes, following the Consolidated Framework for Implementation Research.This cluster randomized hybrid type 1 effectiveness-implementation trial will be conducted among 44 traditional healers in two districts of southwestern Uganda. Healers were randomized 1:1 into study arms, where healers in the intervention arm will provide 12 months of psychosocial support to adults with unsuppressed HIV viral loads receiving care at their practices. A total of 650 adults with unsuppressed HIV viral loads will be recruited from healer clusters in the Mbarara and Rwampara districts. The primary study outcome is HIV viral load measured at 12 months after enrollment, which will be analyzed by intention-to-treat. Secondary clinical outcome measures include (re)initiation of HIV care, antiretroviral therapy adherence, and retention in care. The implementation outcomes of adoption, fidelity, appropriateness, and acceptability will be evaluated through key informant interviews and structured surveys at baseline, 3, 9, 12, and 24 months. Sustainability will be measured through HIV viral load measurements at 24 months following enrollment.METHODSThis cluster randomized hybrid type 1 effectiveness-implementation trial will be conducted among 44 traditional healers in two districts of southwestern Uganda. Healers were randomized 1:1 into study arms, where healers in the intervention arm will provide 12 months of psychosocial support to adults with unsuppressed HIV viral loads receiving care at their practices. A total of 650 adults with unsuppressed HIV viral loads will be recruited from healer clusters in the Mbarara and Rwampara districts. The primary study outcome is HIV viral load measured at 12 months after enrollment, which will be analyzed by intention-to-treat. Secondary clinical outcome measures include (re)initiation of HIV care, antiretroviral therapy adherence, and retention in care. The implementation outcomes of adoption, fidelity, appropriateness, and acceptability will be evaluated through key informant interviews and structured surveys at baseline, 3, 9, 12, and 24 months. Sustainability will be measured through HIV viral load measurements at 24 months following enrollment.The Omuyambi trial is evaluating an approach that could improve HIV outcomes by incorporating previously overlooked community lay supporters into the HIV cascade of care. These findings could provide effectiveness and implementation evidence to guide the development of policies and programs aimed at improving HIV outcomes in rural Uganda and other countries where healers play an essential role in community health.DISCUSSIONThe Omuyambi trial is evaluating an approach that could improve HIV outcomes by incorporating previously overlooked community lay supporters into the HIV cascade of care. These findings could provide effectiveness and implementation evidence to guide the development of policies and programs aimed at improving HIV outcomes in rural Uganda and other countries where healers play an essential role in community health.ClinicalTrials.gov NCT05943548. Registered on July 5, 2023. The current protocol version is 4.0 (September 29, 2023).TRIAL REGISTRATIONClinicalTrials.gov NCT05943548. Registered on July 5, 2023. The current protocol version is 4.0 (September 29, 2023). MEDLINE - Academic