Browsing by Author "Peterson, Stefan"
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Item ‘As soon as the umbilical cord gets off, the child ceases to be called a newborn’: sociocultural beliefs and newborn referral in rural Uganda(Global Health Action, 2015) Nalwadda, Christine K.; Waiswa, Peter; Guwatudde, David; Kerber, Kate; Peterson, Stefan; Kiguli, JulietThe first week of life is the time of greatest risk of death and disability, and is also associated with many traditional beliefs and practices. Identifying sick newborns in the community and referring them to health facilities is a key strategy to reduce deaths. Although a growing area of interest, there remains a lack of data on the role of sociocultural norms and practices on newborn healthcare-seeking in sub-Saharan Africa and the extent to which these norms can be modified. Objective: This study aimed to understand the community’s perspective of potential sociocultural barriers and facilitators to compliance with newborn referral. Method: In this qualitative study, focus group discussions (n12) were conducted with mothers and fathers of babies aged less than 3 months. In addition, in-depth interviews (n11) were also held with traditional birth attendants and mothers who had been referred by community health workers to seek health-facilitybased care. Participants were purposively selected from peri-urban and rural communities in two districts in eastern Uganda. Data were analysed using latent content analysis. Results: The community definition of a newborn varied, but this was most commonly defined by the period between birth and the umbilical cord stump falling off. During this period, newborns are perceived to be vulnerable to the environment and many mothers and their babies are kept in seclusion, although this practice may be changing. Sociocultural factors that influence compliance with newborn referrals to seek care emerged along three sub-themes: community understanding of the newborn period and cultural expectations; the role of community health actors; and caretaker knowledge, experience, and decision-making autonomy. Conclusion: In this setting, there is discrepancy between biomedical and community definitions of the newborn period. There were a number of sociocultural factors that could potentially affect compliance to newborn referral. The widely practised cultural seclusion period, knowledge about newborn sickness, individual experiences in households, perceived health system gaps, and decision-making processes were facilitators of or barriers to compliance with newborn referral. Designers of newborn interventions need to address locally existing cultural beliefs at the same time as they strengthen facility careItem Can malaria rapid diagnostic tests by drug sellers under field conditions classify children 5 years old or less with or without Plasmodium falciparum malaria? Comparison with nested PCR analysis(Malaria journal, 2018) Kitutu, Freddy Eric; Wamani, Henry; Selling, Katarina Ekholm; Ashaba Katabazi, Fred; Bisaso Kuteesa, Ronald; Peterson, StefanMalaria rapid diagnostic tests (RDTs) available as dipsticks or strips, are simple to perform, easily interpretable and do not require electricity nor infrastructural investment. Correct interpretation of and compliance with the RDT results is a challenge to drug sellers. Thus, drug seller interpretation of RDT strips was compared with laboratory scientist re-reading, and PCR analysis of Plasmodium DNA extracted from RDT nitrocellulose strips and fast transient analysis (FTA) cards. Malaria RDT cassettes were also assessed as a potential source of Plasmodium DNA. Methods: A total of 212 children aged between 2 and 60 months, 199 of whom had complete records at two study drug shops in south western Uganda participated in the study. Duplicate 5 μL samples of capillary blood were picked from the 212 children, dispensed onto the sample well of the CareStart™ Pf-HRP2 RDT cassette and a FTA, Whatman™ 3MM filter paper in parallel. The RDT strip was interpreted by the drug seller within 15–20 min, visually re-read centrally by laboratory scientist and from it; Plasmodium DNA was recovered and detected by PCR, and compared with FTA recovered P. falciparum DNA PCR detection. Results: Malaria positive samples were 62/199 (31.2%, 95% CI 24.9, 38.3) by drug seller interpretation of RDT strip, 59/212 (27.8%, 95% CI 22.2, 34.3) by laboratory scientist, 55/212 (25.9%, 95% CI 20.0, 32.6) by RDT nitrocellulose strip PCR and 64/212 (30.2%, 95% CI 24.4, 37.7). The overall agreement between the drug seller interpretation and laboratory scientist re-reading of the RDT strip was 93.0% with kappa value of 0.84 (95% CI 0.75, 0.92). The drug seller compliance with the reported RDT results was 92.5%. The performance of the three diagnostic strategies compared with FTA-PCR as the gold standard had sensitivity between 76.6 and 86.9%, specificity above 90%, positive predictive values ranging from 79.0 to 89.8% and negative predictive values above 90%. Conclusion: Drug sellers can use RDTs in field conditions and achieve acceptable accuracy for malaria diagnosis, and they comply with the RDT results. Plasmodium DNA can be recovered from RDT nitrocellulose strips even in the context of drug shops. Future malaria surveillance and diagnostic quality control studies with RDT cassette as a source of Plasmodium DNA are recommended.Item Cohort Profile: The Iganga-Mayuge Health and Demographic Surveillance Site, Uganda (IMHDSS, Uganda)(International journal of epidemiology, 2020) Kajungu, Dan; Hirose, Atsumi; Rutebemberwa, Elizeus; Pariyo, George W; Peterson, Stefan; Guwatudde, David; Galiwango, Edward; Tusubira, Valerie; Kaija, Judith; Nareeba, Tryphena; Hanson, ClaudiaThe Iganga Mayuge Health and Demographic Surveillance Site (IMHDSS) was set up in 2004 to provide a platform for community-based epidemiological research and research training. Seed funding was provided by the Swedish International Development Agency (SIDA) as part of the Karolinska Institutet, Sweden and Makerere University– Sweden bilateral research collaboration. The specific objectives at inception were to (i) register and monitor health and demographic events (births, deaths, migration) and dynamics in a population and serve as a resource of information for decision making, providing an environment for several community-based projects in single-/multi-disciplinary research and research training; (ii) provide unique, essential, household-level information individually tailored for policy, planning and research needs; (iii) provide a platform for training in applied field research and practical health, socioeconomic and demographic survey methods to students, staff and researchers; and (iv) provide a platform for high-quality household survey data for operational field trials that measures interventions including but not limited to, monitoring trends in communicable and noncommunicable diseases (NCDs), clinical and vaccine trials and other surveillance activities.Item Community effectiveness of malaria treatment in Uganda—a long way to Abuja targets(Annals of tropical paediatrics, 2005) Nsungwa-Sabiiti, Jesca; Tomson, Goran; Pariyo, George; Ogwal-Okeng, Jasper; Peterson, StefanAt the Roll Back Malaria summit for African countries in Abuja, the heads of state committed to ensure that by the year 2005 at least 60% of those suffering from malaria would have access to effective treatment within 24 hours of onset of symptoms. Aim: The aim of the study was to assess community effectiveness of malaria treatment in children. Method: A community-based survey of 500 households was undertaken in western Uganda. Results: A total of 260 (52%) children were reported to have had fever within the previous 2 weeks: 87% received some kind of treatment, 44% were said to have been treated within 24 hours of onset of symptoms, 47% received appropriate anti-malarials, 25% received the correct dosage, and 24% took the drug for the recommended period of time; altogether, only 7% received all the treatment steps. Conclusion: With drug efficacies of 50–90%, we estimate a community effectiveness of 4–6%, which is far from the 2005 Abuja target. The greatest need for improvement in the Home Based Fever Management strategy is in reducing delay in treatment and improving dosage and duration of treatment.Item Community health workers – a resource for identification and referral of sick newborns in rural Uganda(Tropical medicine & international health, 2013) Kayemba Nalwadda, Christine; Guwatudde, David; Waiswa, Peter; Kiguli, Juliet; Namazzi, Gertrude; Namutumba, Sarah; Tomson, Goran; Peterson, StefanTo determine community health workers’ (CHWs) competence in identifying and referring sick newborns in Uganda. methods Case-vignettes, observations of role-plays and interviews were employed to collect data using checklists and semistructured questionnaires, from 57 trained CHWs participating in a community health facility–linked cluster randomised trial. Competence to identify and refer sick newborns was measured by knowledge of newborn danger signs, skills to identify sick newborns and effective communication to mothers. Proportions and median scores were computed for each attribute with a pre-defined pass mark of 100% for knowledge and 90% for skill and communication. results For knowledge, 68% of the CHWs attained the pass mark. The median percentage score was 100 (IQR 94 100). 74% mentioned the required five newborn danger signs unprompted. ‘Red umbilicus/cord with pus’ was mentioned by all CHWs (100%), but none mentioned chest in-drawing and grunting as newborn danger signs. 63% attained the pass mark for both skill and communication. The median percentage scores were 91 (IQR 82 100) for skills and 94 (IQR 89, 94) for effective communication. 98% correctly identified the four case-vignettes as sick or not sick newborn. ‘Preterm birth’ was the least identified danger sign from the case-vignettes, by 51% of the CHWs. conclusion CHWs trained for a short period but effectively supervised are competent in identifying and referring sick newborns in a poor resource setting.Item Comparison of fasting plasma glucose and haemoglobin A1c point-of-care tests in screening for diabetes and abnormal glucose regulation in a rural low income setting(Diabetes Research and Clinical Practice, 2014) Mayega, Roy William; Guwatudde, David; Makumbi, Fredrick Edward; Nakwagala, Frederick Nelson; Peterson, Stefan; Tomson, Goran; Ostenson, Claes-GoranGlycated haemoglobin (HbA1C) has been suggested to replace glucose tests in identifying diabetes and pre-diabetes. We assessed agreement between fasting plasma glucose (FPG) and HbA1C rapid tests in classifying abnormal glucose regulation (AGR), and their utility for preventive screening in rural Africa. Methods: A population-based survey of 795 people aged 35–60 years was conducted in a mainly rural district in Uganda. FPG was measured using On-Call1 Plus glucometers, and classified using World Health Organization (WHO) and American Diabetes Association (ADA) criteria. HbA1C was measured using A1cNow1 kits and classified using ADA criteria. Body mass index and blood pressure were measured. Percentage agreement between the two tests was computed. Results: Using HbA1C, 11.3% of participants had diabetes compared with 4.8% for FPG. Prevalence of HbA1C-defined pre-diabetes (26.4%) was 1.2 times and 2.5 times higher than FPG-defined pre-diabetes using ADA (21.8%) and WHO (10.1%) criteria, respectively. With FPG as the reference, agreement between FPG and HbA1C in classifying diabetes status was moderate (Kappa = 22.9; Area Under the Curve (AUC) = 75%), while that for AGR was low (Kappa = 11.0; AUC = 59%). However, agreement was high (over 90%) among negative tests and among participants with risk factors for type 2 diabetes (obesity, overweight or hypertension). HbA1C had more procedural challenges than FPG.Item Coping with paediatric referral—Ugandan parents’ experience(The Lancet, 2004) Peterson, Stefan; Sabiiti, Jesca Nsungwa; Were, Wilson; Nsabagasani, Xavier; Magumba, Godfrey; Nambooze, Josephine; Mukasa, GelasiusReferral of severely ill children to hospital is key in the Integrated Management of Childhood Illness (IMCI). In rural Uganda, we documented the caretakers' ability to complete referral to hospital from 12 health facilities. Of 227 children, only 63 (28%) had completed referral after 2 weeks, at a median cost of US$8.85 (range 0.40–89.00). Failure to attend hospital resulted from lack of money (139 children, 90%), transport problems (39, 26%), and responsibilities at home (26, 17%). Children with incomplete referral continued treatment at referring health centres (87, 54%) or in the private sector (45, 28%). Our results show that cost of referral must decrease to make paediatric referral realistic. When referral is difficult, more specific IMCI referral criteria should be used and first-level health workers should be empowered to manage severely ill children.Item Diabetes and Pre-Diabetes among Persons Aged 35 to 60 Years in Eastern Uganda: Prevalence and Associated Factors(PLoS ONE, 2013) Mayega, Roy William; Guwatudde, David; Makumbi, Fredrick; Nakwagala, Frederick Nelson; Peterson, Stefan; Tomson, Goran; Ostenson, Claes-GoranOur aim was to estimate the prevalence of abnormal glucose regulation (AGR) (i.e. diabetes and prediabetes) and its associated factors among people aged 35-60 years so as to clarify the relevance of targeted screening in rural Africa. Methods: A population-based survey of 1,497 people (786 women and 711 men) aged 35-60 years was conducted in a predominantly rural Demographic Surveillance Site in eastern Uganda. Participants responded to a lifestyle questionnaire, following which their Body Mass Index (BMI) and Blood Pressure (BP) were measured. Fasting plasma glucose (FPG) was measured from capillary blood using On-Call® Plus (Acon) rapid glucose meters, following overnight fasting. AGR was defined as FPG ≥6.1mmol L-1 (World Health Organization (WHO) criteria or ≥5.6mmol L-1 (American Diabetes Association (ADA) criteria. Diabetes was defined as FPG >6.9mmol L-1, or being on diabetes treatment. Results: The mean age of participants was 45 years for men and 44 for women. Prevalence of diabetes was 7.4% (95%CI 6.1-8.8), while prevalence of pre-diabetes was 8.6% (95%CI 7.3-10.2) using WHO criteria and 20.2% (95%CI 17.5-22.9) with ADA criteria. Using WHO cut-offs, the prevalence of AGR was 2 times higher among obese persons compared with normal BMI persons (Adjusted Prevalence Rate Ratio (APRR) 1.9, 95%CI 1.3-2.8). Occupation as a mechanic, achieving the WHO recommended physical activity threshold, and higher dietary diversity were associated with lower likelihood of AGR (APRR 0.6, 95%CI 0.4-0.9; APRR 0.6, 95%CI 0.4-0.8; APRR 0.5, 95%CI 0.3-0.9 respectively). The direct medical cost of detecting one person with AGR was two US dollars with ADA and three point seven dollars with WHO cut-offs. Conclusions: There is a high prevalence of AGR among people aged 35-60 years in this setting. Screening for high risk persons and targeted health education to address obesity, insufficient physical activity and non-diverse diets are necessary.Item Effectiveness of Peer-supervision on Paediatric Fever Treatment among Registered Private Drug Sellers in East-Central Uganda: An Interrupted Time Series Analysis(Authorea Preprints, 2020) Bagonza, Arthur; Kitutu, Freddy; Peterson, Stefan; Martensson, Andreas; Mutto, Milton; Awor, Phyllis; Mukanga, David; Wamani, HenryRationale, aims and objectives: Appropriate treatment of paediatric fever in rural areas remains a challenge and may be partly due to inadequate supervision of licensed drug sellers. This study assessed the effectiveness of peer-supervision among drug sellers on appropriate treatment of pneumonia symptoms, uncomplicated malaria and non-bloody diarrhoea among children less than five years of age in the intervention (Luuka) and comparison (Buyende) districts, in East-Central Uganda. Methods: Data on pneumonia symptoms, uncomplicated malaria and non-bloody diarrhoea among children less than five years of age was abstracted from drug shop sick child registers over a 12-month period; six months before and six months after introduction of peer-supervision. Interrupted time series was applied to determine the effectiveness of the peer-supervision intervention on appropriate treatment of pneumonia, uncomplicated malaria and non-bloody diarrhoea among children less than five years of age attending drug shops in East Central Uganda. Results: The proportion of children treated appropriately for pneumonia symptoms was 10.84% (P<0.05, CI = [1.75, 19.9]) higher, for uncomplicated malaria was 1.46% (P = 0.79, CI = [-10.43, 13.36]) higher, and for non-bloody diarrhoea was 4.00% (p <0.05, CI = [-7.95, -0.13]) lower in the intervention district than the comparison district, respectively. Post-intervention trend results showed an increase of 1.21% (p =0.008, CI = [0.36, 2.05]) in the proportion appropriately treated for pneumonia symptoms, no difference in appropriate treatment for uncomplicated malaria, and a reduction of 1% (p <0.06, CI = [-1.95, 0.02]) in the proportion of children appropriately treated for nonbloody diarrhoea, respectively. Conclusions: Peer-supervision increased the proportion of children less than five years of age that received appropriate treatment for pneumonia symptoms but not for uncomplicated malaria and non-bloody diarrhoea. Implementation of community level interventions to improve paediatric fever management should consider including peersupervision among drug sellers.Item Health system effects of implementing integrated community case management (iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative study(BMJ Glob Health, 2017) Kitutu, Freddy Eric; Mayora, Chrispus; Johansson, Emily White; Peterson, Stefan; Wamani, Henry; Bigdeli, Maryam; Shroff, Zubin CyrusIntervening in private drug shops to improve quality of care and enhance regulatory oversight may have health system effects that need to be understood before scaling up any such interventions. We examine the processes through which a drug shop intervention culminated in positive unintended effects and other dynamic interactions within the underlying health system. Methods A multifaceted intervention consisting of drug seller training, supply of diagnostics and subsidised medicines, use of treatment algorithms, monthly supervision and community sensitisation was implemented in drug shops in South Western Uganda, to improve paediatric fever management. Focus group discussions and in-depth interviews were conducted with stakeholders (drug sellers, government officials and community health workers) at baseline, midpoint and end-line between September 2013 and September 2015. Using a health market and systems lens, transcripts from the interviews were analysed to identify health system effects associated with the apparent success of the intervention. Findings Stakeholders initially expressed caution and fears about the intervention's implications for quality, equity and interface with the regulatory framework. Over time, these stakeholders embraced the intervention. Most respondents noted that the intervention had improved drug shop standards, enabled drug shops to embrace patient record keeping, parasite-based treatment of malaria and appropriate medicine use. There was also improved supportive supervision, and better compliance to licensing and other regulatory requirements. Drug seller legitimacy was enhanced from the community and client perspective, leading to improved trust in drug shops. conclusion The study showed how effectively using health technologies and the perceived efficacy of medicines contributed to improved legitimacy and trust in drug shops among stakeholders. The study also demonstrated that using a combination of appropriate incentives and consumer empowerment strategies can help harmonise common practices with medicine regulations and safeguard public health, especially in mixed health market contexts.Item Health system preparedness for newborn care: a health facility assessment in rural Uganda(BMC Health Services Research, 2014) Kayemba, Christine; Peterson, Stefan; Tomson, Goran; Guwatudde, David; Kiguli, Juliet; Namazzibner Tagoola4, Gertrude Peter Waiswa1,2; Namutamba, Sarah; Namugaya, Faith; Nambuya, HarrietNewborn deaths must be reduced to achieve Millennium Development Goal four. Health facilities have a critical role to play in the fight to save the 2.9 million newborns that die in the world every year. It is not clear if health facilities in rural Uganda have the capacity to care for newborns. To assess the capacity of health facilities to care for newborns in Iganga and Mayuge districts in eastern Uganda for the three main mortality causes: preterm/ low birth weight, asphyxia and sepsis.Item High Adherence to Antimalarials and Antibiotics under Integrated Community Case Management of Illness in Children Less than Five Years in Eastern Uganda(PLoS ONE, 2013) Kalyango, Joan N.; Rutebemberwa, Elizeus; Karamagi, Charles; Mworozi, Edison; Ssali, Sarah; Alfven, Tobias; Peterson, StefanDevelopment of resistance to first line antimalarials led to recommendation of artemisinin based combination therapies (ACTs). High adherence to ACTs provided by community health workers (CHWs) gave reassurance that community based interventions did not increase the risk of drug resistance. Integrated community case management of illnesses (ICCM) is now recommended through which children will access both antibiotics and antimalarials from CHWs. Increased number of medicines has been shown to lower adherence.Item High Compliance with Newborn Community-to-Facility Referral in Eastern: An Opportunity to Improve Newborn Survival(PLoS ONE, 2013) Kayemba Nalwadda, Christine; Waiswa, Peter; Kiguli, Juliet; Namazzi, Gertrude; Namutamba, Sarah; Tomson, Göran; Peterson, Stefan; Guwatudde, DavidSeventy-five percent of newborn deaths happen in the first-week of life, with the highest risk of death in the first 24-hours after birth.WHO and UNICEF recommend home-visits for babies in the first-week of life to assess for danger-signs and counsel caretakers for immediate referral of sick newborns. We assessed timely compliance with newborn referrals made by community-health workers (CHWs), and its determinants in Iganga and Mayuge Districts in rural eastern Uganda. Methods: A historical cohort study design was used to retrospectively follow up newborns referred to health facilities between September 2009 and August 2011. Timely compliance was defined as caretakers of newborns complying with CHWs’ referral advice within 24-hours. Results: A total of 724 newborns were referred by CHWs of whom 700 were successfully traced. Of the 700 newborns, 373 (53%) were referred for immunization and postnatal-care, and 327 (47%) because of a danger-sign. Overall, 439 (63%) complied, and of the 327 sick newborns, 243 (74%) caretakers complied with the referrals. Predictors of referral compliance were; the newborn being sick at the time of referral- Adjusted Odds Ratio (AOR) = 2.3, and 95% Confidence-Interval (CI) of [1.6 - 3.5]), the CHW making a reminder visit to the referred newborn shortly after referral (AOR =1.7; 95% CI: [1.2 -2.7]); and age of mother (25-29) and (30-34) years, (AOR =0.4; 95% CI: [0.2 - 0.8]) and (AOR = 0.4; 95% CI: [0.2 - 0.8]) respectively. Conclusion: Caretakers’ newborn referral compliance was high in this setting. The newborn being sick, being born to a younger mother and a reminder visit by the CHW to a referred newborn were predictors of newborn referral compliance. Integration of CHWs into maternal and newborn care programs has the potential to increase care seeking for newborns, which may contribute to reduction of newborn mortality.Item ‘I know those people will be approachable and not mistreat us’: a qualitative study of inspectors and private drug sellers’ views on peer supervision in rural Uganda(Globalization and Health, 2020) Bagonza, Arthur; Peterson, Stefan; Mårtensson, Andreas; Mutto, Milton; Awor , Phllis; Kitutu, Freddy Eric; Linda, Gibson; Wamani, HenryPeer supervision improves health care delivery by health workers. However, in rural Uganda, self supervision is what is prescribed for licensed private drug sellers by statutory guidelines. Evidence shows that self-supervision encourages inappropriate treatment of children less than ve years of age by private drug sellers. This study constructed a model for an appropriate peer supervisor to augment the self supervision currently practiced by drug sellers at district level in rural Uganda. In this qualitative study, six Key informant interviews were held with inspectors while ten focus group discussions were conducted with one hundred and thirty drug sellers. Data analysis was informed by the Kathy Charmaz constructive approach to grounded theory. Atlas ti.7 software package was used for data management.Item ‘I never thought that this baby would survive; I thought that it would die any time’: perceptions and care for preterm babies in eastern Uganda(Tropical medicine & international health, 2010) Waiswa, Peter; Nyanzi, Stella; Namusoko-Kalungi, Sarah; Peterson, Stefan; Tomson, Goran; Pariyo, George W.To explore the current care for and perceptions about preterm babies among community members in eastern Uganda. methods A neonatal midwife observed care of preterm babies in one general hospital and 15 health centres using a checklist and a field diary. In-depth interviews were conducted with 11 community health workers (CHWs) and also with 10 mothers, six fathers and three grandmothers of preterm babies. Three focus group discussions were conducted with midwives and women and men in the community. Content analysis of data was performed. results Community members mentioned many features which may correctly be used to identify preterm babies. Care practices for preterm babies at health facilities and community level were inadequate and potentially harmful. Health facilities lacked capacity for care of preterm babies in terms of protocols, health workers’ skills, basic equipment, drugs and other supplies. However, community members and CHWs stated that they accepted the introduction of preterm care practices such as skinto- skin and kangaroo mother care. conclusion In this setting, care for preterm babies is inadequate at both health facility and community level. However, acceptance of the recommended newborn care practices indicated by the community is a window of opportunity for introducing programmes for preterm babies. In doing so, consideration needs to be given to the care provided at health facilities as well as to the gaps in community care that are largely influenced by beliefs, perceptions and lack of awareness.Item Inclusion of private sector in district health systems; case study of private drug shops implementing modified Integrated Community Case Management (iCCM) strategy in Rural Uganda(BMC Health Services Research, 2014) Kitutu, Freddy; Mayora, Chrispus; Awor, Phyllis; Birger, Forsberg; Peterson, Stefan; Wamani, HenryUganda Ministry of Health passed the Public Private Partnership for Health (PPPH) policy to strengthen the health system by leveraging strategic advantages of private healthcare providers [1]. The National Malaria program has gone further to develop a malaria case management strategy through a multi-stakeholder consultative process [2]. Makerere University School of Public Health (MakSPH) partnered with Mbarara district to implement the iCCM strategy in private licensed drug shops in rural areas. The partnership aimed to increase access to quality medicines and point of care diagnostics for child febrile illnesses, minimize excess use of antimalarials and antibiotics, share information of cases diagnosed and treated at the drug shops and promote child survival.Item Increased Use of Community Medicine Distributors and Rational Use of Drugs in Children Less than Five Years of Age in Uganda Caused by Integrated Community Case Management of Fever(The American journal of tropical medicine and hygiene, 2012) Kalyango, Joan N.; Lindstrand, Ann; Rutebemberwa, Elizeus; Ssali, Sarah; Kadobera, Daniel; Karamagi, Charles; Peterson, Stefan; Alfven, TobiasWe compared use of community medicine distributors (CMDs) and drug use under integrated community case management and home-based management strategies in children 6–59 months of age in eastern Uganda. A crosssectional study with 1,095 children was nested in a cluster randomized trial with integrated community case management (CMDs treating malaria and pneumonia) as the intervention and home-based management (CMDs treating only malaria) as the control. Care-seeking from CMDs was higher in intervention areas (31%) than in control areas (22%; P = 0.01). Prompt and appropriate treatment of malaria was higher in intervention areas (18%) than in control areas (12%; P = 0.03) and among CMD users (37%) than other health providers (9%). The mean number of drugs among CMD users compared with other health providers was 1.6 versus 2.4 in intervention areas and 1.4 versus 2.3 in control areas. Use of CMDs was low. However, integrated community case management of childhood illnesses increased use of CMDs and rational drug use.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 Integrated community case management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms in children under five years in Eastern Uganda(Malaria Journal, 2013) Kalyango, Joan N.; Alfven, Tobias; Peterson, Stefan; Mugenyi, Kevin; Karamagi, Charles; Rutebemberwa, ElizeusEfforts to improve access to treatment for common illnesses in children less than five years initially targeted malaria alone under the home management of malaria strategy. However under this strategy, children with other illnesses were often wrongly treated with anti-malarials. Integrated community case management of common childhood illnesses is now recommended but its effect on promptness of appropriate pneumonia treatment is unclear. Objectives: To determine the effect of integrated malaria and pneumonia management on receiving prompt and appropriate antibiotics for pneumonia symptoms and treatment outcomes as well as determine associated factors. Methods: A follow-up study was nested within a cluster-randomized trial that compared under-five mortality in areas where community health workers (CHWs) treated children with malaria and pneumonia (intervention areas) and where they treated children with malaria only (control areas). Children treated by CHWs were enrolled on the day of seeking treatment from CHWs (609 intervention, 667 control) and demographic, illness, and treatment seeking information was collected. Further information on illness and treatment outcomes was collected on day four. The primary outcome was prompt and appropriate antibiotics for pneumonia symptoms and the secondary outcome was treatment outcomes on day four. Results: Children in the intervention areas were more likely to receive prompt and appropriate antibiotics for pneumonia symptoms compared to children in the control areas (RR = 3.51, 95%CI = 1.75-7.03). Children in the intervention areas were also less likely to have temperature ≥37.5°C on day four (RR = 0.29, 95%CI = 0.11-0.78). The decrease in fast breathing between day one and four was greater in the intervention (9.2%) compared to the control areas (4.2%, p-value = 0.01). Conclusions: Integrated community management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms and improves treatment outcomes.Item Modifiable Socio-Behavioural Factors Associated with Overweight and Hypertension among Persons Aged 35 to 60 Years in Eastern Uganda(PLoS ONE, 2012) Mayega, Roy William; Makumbi, Fredrick; Rutebemberwa, Elizeus; Peterson, Stefan; O¨stenson, Claes- Goran; Tomson, Goran; Guwatudde, DavidFew studies have examined the behavioural correlates of non-communicable, chronic disease risk in lowincome countries. The objective of this study was to identify socio-behavioural characteristics associated with being overweight or being hypertensive in a low-income setting, so as to highlight possible interventions and target groups. Methods: A population based survey was conducted in a Health and Demographic Surveillance Site (HDSS) in eastern Uganda. 1656 individuals aged 35 to 60 years had their Body Mass Index (BMI) and blood pressure (BP) assessed. Seven lifestyle factors were also assessed, using a validated questionnaire. Logistic regression was used to identify sociobehavioural factors associated with being overweight or being hypertensive. Results: Prevalence of overweight was found to be 18% (25.2% of women; 9.7% of men; p,0.001) while prevalence of obesity was 5.3% (8.3% of women; 2.2% of men). The prevalence of hypertension was 20.5%. Factors associated with being overweight included being female (OR 3.7; 95% CI 2.69–5.08), peri-urban residence (OR 2.5; 95% CI 1.46–3.01), higher socioeconomic status (OR 4.1; 95% CI 2.40–6.98), and increasing age (OR 1.8; 95% CI 1.12–2.79). Those who met the recommended minimum physical activity level, and those with moderate dietary diversity were less likely to be overweight (OR 0.5; 95% CI 0.35–0.65 and OR 0.7; 95% CI 0.49–3.01). Factors associated with being hypertensive included peri-urban residence (OR 2.4; 95%CI 1.60–3.66), increasing age (OR 4.5; 95% CI 2.94–6.96) and being over-weight (OR 2.8; 95% CI 1.98– 3.98). Overweight persons in rural areas were significantly more likely to be hypertensive than those in peri-urban areas (p = 0.013). Conclusions: Being overweight in low-income settings is associated with sex, physical activity and dietary diversity and being hypertensive is associated with being overweight; these factors are modifiable. There is need for context-specific health education addressing disparities in lifestyles at community levels in rural Africa.