Browsing by Author "Nakayaga Kalyango, Joan"
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Item Appointment keeping for medical review among patients with selected chronic diseases in an urban area of Uganda(The Pan African medical journal, 2014) Nakayaga Kalyango, Joan; Hall, Maurice; Karamagi, CharlesProper management of chronic diseases is important for prevention of disease complications and yet some patients miss appointments for medical review thereby missing the opportunity for proper monitoring of their disease conditions. There is limited information on missed appointments among chronic disease patients in resource limited settings. This study aimed to determine the prevalence of missed appointments for medical review and associated factors among chronic disease patients in an urban area of Uganda. Methods: patients or caregivers of children with chronic diseases were identified as they bought medicines from a community pharmacy. They were visited at home to access their medical documents and those whose chronic disease status was ascertained were enrolled. The data was collected using: questionnaires, review of medical documents, and in-depth interviews with chronic disease patients. Results: the prevalence of missed appointments was 42% (95%CI=35-49%). The factors associated with missed appointments were: monthly income ?30US Dollars (OR=2.56, CI=1.25–5.26), affording less than half of prescribed drugs (OR=3.92, CI=1.64–9.40), not experiencing adverse events (OR=2.66, CI=1.26–5.61), not sure if treatment helps (OR=2.84, CI=1.047.77), not having a medicines administration schedule (OR=6.77, CI=2.11–21.68), and increasing number of drugs (OR=0.72, CI=0.53–0.98). Conclusion: patients missed appointments mainly due to: financial and health system barriers, conflicting commitments with appointments, and perceptions of the disease condition. Patients should be supported with accessible and affordable health servicesItem 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 Assessment of the accuracy of malaria microscopy in private health facilities in Entebbe Municipality, Uganda: a cross‑sectional study(Malaria Journal, 2021) Mutabazi, Tobius; Sendaula, Emmanuel; Kakeeto, Alex; Okimat, Paul; Orishaba, Philip; Katongole, Simon Peter; Mpimbaza, Arthur; Byakika‑Kibwika, Pauline; Karamagi, Charles; Nakayaga Kalyango, Joan; Kamya, Moses R.; Dorsey, Grant; Nankabirwa, Joaniter I.Although microscopy remains the gold standard for malaria diagnosis, little is known about its accuracy in the private health facilities in Uganda. This study evaluated the accuracy of malaria microscopy, and factors associated with inaccurate smear results at private health facilities in Entebbe Municipality, Uganda. Methods: Between April and May 2018, all patients referred for a malaria smear in 16 private health facilities in Entebbe municipality were screened, and 321 patients were enrolled. A questionnaire was administered to collect demographic and clinical information, facility-based smear results were recorded from the participant’s consultation notes, and a research slide was obtained for expert microscopy during exit interview. A health facility assessment was conducted, and information on experience in performing malaria microscopy was collected from all facility personnel reading smears and the data was linked to the participant’s clinic visit.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 Concurrently wasted and stunted children 6-59 months in Karamoja, Uganda: prevalence and case detection(Maternal and Child Nutrition, 2020) Adobea Odei Obeng-Amoako, Gloria; Myatt, Mark; Conkle, Joel; Kaijuka Muwaga, Brenda; Aryeetey, Richmond; Okwi, Andrew Livex; Okullo, Isaac; Mupere, Ezekiel; Wamani, Henry; Briend, André; Karamagi, Charles Amnon Sunday; Nakayaga Kalyango, JoanWe assessed prevalence of concurrently wasted and stunted (WaSt) and explored the overlaps between wasted, stunted, underweight and low mid-upper arm circumference (MUAC) among children aged 6–59 months in Karamoja, Uganda. We also determined optimal weight-for-age (WAZ) and MUAC thresholds for detecting WaSt. We conducted secondary data analysis with 2015–2018 Food Security and Nutrition Assessment (FSNA) cross-sectional survey datasets from Karamoja. Wasting, stunting and underweight were defined as <−2.0 z-scores using WHO growth standards. Low MUAC was defined as <12.5 cm. We defined WaSt as concurrent wasting and stunting. Prevalence of WaSt was 4.96% (95% CI [4.64, 5.29]). WaSt was more prevalent in lean than harvest season (5.21% vs. 4.53%; p = .018). About half (53.92%) of WaSt children had low MUAC, and all were underweight. Younger children aged <36 months had more WaSt, particularly males. Males with WaSt had higher median MUAC than females (12.50 vs. 12.10 cm; p < .001). A WAZ <−2.60 threshold detected WaSt with excellent sensitivity (99.02%) and high specificity (90.71%). MUAC threshold <13.20 cm had good sensitivity (81.58%) and moderate specificity (76.15%) to detect WaSt. WaSt prevalence of 5% is a public health concern, given its high mortality risk. All children with WaSt were underweight and half had low MUAC. WAZ and MUAC could be useful tools for detecting WaSt. Prevalence monitoring and prospective studies on WAZ and MUAC cut-offs for WaSt detection are recommended. Future consideration to integrate WAZ into therapeutic feeding programmes is recommended to detect and treat WaSt children.Item Factors associated with concurrent wasting and stunting among children 6–59 months in Karamoja, Uganda(Maternal and Child Nutrition, 2021) Adobea Odei Obeng-Amoako, Gloria; Karamagi, Charles Amnon Sunday; Nangendo, Joanita; Okiring, Jaffer; Kiirya, Yerusa; Aryeetey, Richmond; Mupere, Ezekial; Myatt, Mark; Briend, André; Nakayaga Kalyango, Joan; Wamani, HenryChildren with concurrent wasting and stunting (WaSt) and children with severe wasting have a similar risk of death. Existing evidence shows that wasting and stunting share similar causal pathways, but evidence on correlates of WaSt remains limited. Research on correlates of WaSt is needed to inform prevention strategies. We investigated the factors associated with WaSt in children 6–59 months in Karamoja Region, Uganda. We examined data for 33,054 children aged 6–59 months using June 2015 to July 2018 Food Security and Nutrition Assessment in Karamoja. We defined WaSt as being concurrently wasted (weight-for-height z-scores <−2.0) and stunted (heightfor- age z-score <−2.0). We conducted multivariate mixed-effect logistic regression to assess factors associated with WaSt. Statistical significance was set at p < 0.05. In multivariate analysis, being male (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI] [1.60–2.00]), aged 12–23 months (aOR = 2.25; 95% CI [1.85–2.74]), 36–47 months (aOR = 0.65; 95% CI [0.50–0.84]) and 48–59 months (aOR = 0.71; 95% CI [0.54–0.93]) were associated with WaSt. In addition, acute respiratory infection (aOR = 1.30; 95% CI [1.15–1.48]), diarrhoea (aOR = 1.25; 95% CI [1.06–1.48]) and malaria/fever (aOR = 0.83; 95% CI [0.73–0.96]) episodes were associated with WaSt. WaSt was significantly associated with maternal underweight (body mass index <18.5 kg/m2), short stature (height <160 cm), low mid-upper arm circumference (MUAC <23 cm) and having ≥4 live-births. WaSt was prevalent in households without livestock (aOR = 1.30; 95% CI [1.13–1.59]). Preventing the occurrence of WaSt through pragmatic and joint approaches are recommended. Future prospective studies on risk factors of WaSt to inform effective prevention strategies are recommended.Item The impact of equity factors on receipt of timely appropriate care for children with suspected malaria in eastern Uganda(BMC Public Health, 2021) Humphreys, David; Nakayaga Kalyango, Joan; Alfvén, TobiasMalaria accounts for more than one-tenth of sub-Saharan Africa’s 2.8 million annual childhood deaths, and remains a leading cause of post-neonatal child mortality in Uganda. Despite increased communitybased treatment in Uganda, children continue to die because services fail to reach those most at risk. This study explores the influence of two key equity factors, socioeconomic position and rurality, on whether children with fever in eastern Uganda receive timely access to appropriate treatment for suspected malaria. Methods: This was a cross-sectional study in which data were collected from 1094 caregivers of children aged 6– 59 months on: illness and care-seeking during the previous two weeks, treatment received, and treatment dosing schedule. Additional data on rurality and household socioeconomic position were extracted from the Iganga- Mayuge Health and Demographic Surveillance Site (HDSS) database. A child was considered to have received prompt and appropriate care for symptoms of malaria if they received the recommended drug in the recommended dosing schedule on the day of symptom onset or the next day. Unadjusted and adjusted logistic regression models were developed to explore associations of the two equity factors with the outcome. The STROBE checklist for observational studies guided reporting. Results: Seventy-four percent of children had symptoms of illness in the preceding two weeks, of which fever was the most common. Children from rural households were statistically more likely to receive prompt and appropriate treatment with artemisinin-combination therapy than their semi-urban counterparts (OR 2.32, CI 1.17–4.59, p = 0.016). This association remained significant following application of an adjusted regression model that included the age of the child, caregiver relationship, and household wealth index (OR 2.4, p = 0.036). Wealth index in its own right did not exert a significant effect for children with reported fever (OR for wealthiest quintile = 1.02, CI 0.48–2.15, p = 0.958). Conclusions: The findings from this study help to identify the role and importance of two key equity determinants on care seeking and treatment receipt for fever in children. Whilst results should be interpreted within the limitations of data and context, further studies have the potential to assist policy makers to target inequitable social and spatial variations in health outcomes as a key strategy in ending preventable child morbidity and mortality.Item Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi‑experimental study(Malaria journal, 2017) Kitutu, Freddy Eric; Nakayaga Kalyango, Joan; Mayora, Chrispus; Ekholm Selling, Katarina; Peterson, Stefan; Wamani, HenryFever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda’s Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda. Methods: From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among careseeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller–care-seeker encounters in intervention drug shops. Results: The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2–107.2), 65.5% (95% CI 51.6–79.4) and 31.4% (95% CI 1.6–61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, − 0.009 p value < 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops. Conclusions: The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models.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 Policy Challenges Facing the Scale Up of Integrated Community Case Management (iCCM) in Uganda(International Journal of Health Policy and Management, 2021) Awor, Phyllis; Nakayaga Kalyango, Joan; Stålsby Lundborg, Cecilia; Ssengooba, Freddie; Eriksen, Jaran; Rutebemberwa, ElizeusIntegrated Community Case Management (iCCM) of malaria, pneumonia and diarrhoea is an equity focused strategy, to increase access to care for febrile illness in children under-5 years of age, in rural communities. Lay community members are trained to diagnose and treat malaria, pneumonia and diarrhoea in children, and to identify and refer very ill children. Today, many low-income countries including Uganda, have a policy for iCCM which is being rolled out through public sector community health workers (CHWs). Ten years after the introduction of the iCCM strategy in Uganda, it is important to take stock and understand the barriers and facilitators affecting implementation of the iCCM policy. Methods: We conducted an iCCM policy analysis in order to identify the challenges, enablers and priorities for scale-up of the iCCM strategy in Uganda. This was a qualitative case study research which included a document review (n = 52) and key informant interviews (n = 15) with Ugandan stakeholders. Interviews were conducted in 2017 and the desk review included literature up to 2019. Results: This paper highlights the iCCM policy trajectory since 2010 in Uganda and includes a policy timeline. The iCCM policy process was mainly led by international agencies from inception, with little ownership of the government. Many implementation challenges including low government funding, weak coordination and contradicting policies were identified, which could contribute to the slow scale up of the iCCM program. Despite the challenges, many enablers and opportunities also exist within the health system, which should be further harnessed to scale up iCCM in Uganda. These enabling factors include strong community commitment, existing policy instruments and the potential of utilizing also the private sector for iCCM implementation. Conclusion: The iCCM program in Uganda needs to be strengthen through increased domestic funding, strong coordination and a focus on monitoring, evaluation and operational research.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.