Browsing by Author "Sundararajan, Radhika"
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Item Caregivers’ and nurses’ perceptions of the Smart Discharges Program for children with sepsis in Uganda: A qualitative study(Public Library of Science, 2024-10) Behan, Justine; Kabajaasi, Olive; Derksen, Brooklyn; Sendegye, George; Kugumikiriza, Brenda; Komugisha, Clare; Sundararajan, Radhika; Jacob, Shevin T; Kenya-Mugisha, Nathan; Wiens, Matthew OSepsis arises when the body's response to an infection injures its own tissues and organs. Among children hospitalized with suspected sepsis in low-income country settings, mortality rates following discharge are high, similar to mortality rates in hospital. The Smart Discharges Program uses a mobile health (mHealth) platform to identify children at high risk of post-discharge mortality to receive enhanced post-discharge care. This study sought to explore the perceptions and experiences of the caregivers and nurses of children enrolled into the Smart Discharges Program and the program's effect on post-discharge care. We conducted an exploratory qualitative study, which included in-person focus group discussions (FGDs) with 30 caregivers of pediatric patients enrolled in the Smart Discharges Program and individual, semi-structured interviews with eight Smart Discharges Program nurses. The study was carried out at four hospitals in Uganda in 2019. Following thematic analysis, three key themes pertaining to the Smart Discharges program were identified: (1) Facilitators and barriers to follow-up care after discharge; (2) Changed caregiver behavior following discharge; and (3) Increased involvement of male caregivers. Facilitators included telephone/text message reminders, positive nurse-patient relationship, and the complementary aspects of the program. Barriers included resource constraints and negative experiences during post-discharge care seeking. With regards to behavior, when provided with relevant and well-timed information, caregivers reported increased knowledge about post-discharge care and improvements in their ability to care for their child. Enrolment in the Smart Discharges Program also increased male caregiver involvement, increased provision of resources and improved communication within the family and with the healthcare system. The Smart Discharges approach is an impactful strategy to improve pediatric post-discharge care, and similar approaches should be considered to improve the hospital to home transition in similar low-income country settings.Sepsis arises when the body's response to an infection injures its own tissues and organs. Among children hospitalized with suspected sepsis in low-income country settings, mortality rates following discharge are high, similar to mortality rates in hospital. The Smart Discharges Program uses a mobile health (mHealth) platform to identify children at high risk of post-discharge mortality to receive enhanced post-discharge care. This study sought to explore the perceptions and experiences of the caregivers and nurses of children enrolled into the Smart Discharges Program and the program's effect on post-discharge care. We conducted an exploratory qualitative study, which included in-person focus group discussions (FGDs) with 30 caregivers of pediatric patients enrolled in the Smart Discharges Program and individual, semi-structured interviews with eight Smart Discharges Program nurses. The study was carried out at four hospitals in Uganda in 2019. Following thematic analysis, three key themes pertaining to the Smart Discharges program were identified: (1) Facilitators and barriers to follow-up care after discharge; (2) Changed caregiver behavior following discharge; and (3) Increased involvement of male caregivers. Facilitators included telephone/text message reminders, positive nurse-patient relationship, and the complementary aspects of the program. Barriers included resource constraints and negative experiences during post-discharge care seeking. With regards to behavior, when provided with relevant and well-timed information, caregivers reported increased knowledge about post-discharge care and improvements in their ability to care for their child. Enrolment in the Smart Discharges Program also increased male caregiver involvement, increased provision of resources and improved communication within the family and with the healthcare system. The Smart Discharges approach is an impactful strategy to improve pediatric post-discharge care, and similar approaches should be considered to improve the hospital to home transition in similar low-income country settings. MEDLINE - AcademicItem Community health workers trained to conduct verbal autopsies provide better mortality measures than existing surveillance: Results from a cross-sectional study in rural western Uganda(PLoS ONE, 2019) Nabukalu, Doreen; Ntaro, Moses; Seviiri, Mathias; Reyes, Raquel; Wiens, Matthew; Sundararajan, Radhika; Mulogo, Edgar; Boyce, Ross M.In much of sub-Saharan Africa, health facilities serve as the primary source of routine vital statistics. These passive surveillance systems, however, are plagued by infrequent and unreliable reporting and do not capture events that occur outside of the formal health sector. Verbal autopsies (VA) have been utilized to estimate the burden and causes of mortality where civil registration and vital statistics systems are weak, but VAs have not been widely employed in national surveillance systems. In response, we trained lay community health workers (CHW) in a rural sub-county of western Uganda to conduct VA interviews in order to assess the feasibility of leveraging CHW to measure the burden of disease in resource limited settings. Methods and findings Trained CHWs conducted a cross-sectional survey of the 36 villages comprising the Bugoye sub-county to identify all deaths occurring in the prior year. The sub county has an estimated population of 50,249, approximately one-quarter of whom are children under 5 years of age (25.3%). When an eligible death was reported, CHWs administered a WHO 2014 VA questionnaire, the results of which were analyzed using the InterVA-4 tool. To compare the findings of the CHW survey to existing surveillance systems, study staff reviewed inpatient registers from neighboring referral health facilities in an attempt to match recorded deaths to those identified by the survey. Overall, CHWs conducted high quality VA interviews on direct observation, identifying 230 deaths that occurred within the sub-county, including 77 (33.5%) among children under five years of age. More than half of the deaths (123 of 230, 53.5%) were reported to have occurred outside a health facility and thus would not be captured by passive surveillance. More than two-thirds (73 of 107, 68.2%) of facility deaths took place in one of three nearby hospitals, yet only 35 (47.9%) were identified on our review of inpatient registers. Consistent with previous VA studies, the leading causes of death among children under five years of age were malaria (19.5%), prematurity (19.5%), and neonatal pneumonia (15.6%). while among adults, HIV/AIDS-related deaths illness (13.6%), pulmonary tuberculosis (11.4%) and malaria (8.6%) were the leading causes of death. No child deaths identified from inpatient registers listed HIV/AIDS as a cause of death despite 8 deaths (10.4%) attributed to HIV/AIDS as determined by VA. Conclusions Lay CHWs are able to conduct high quality VA interviews to capture critical information that can be analyzed using standard methodologies to provide a more complete estimate of the burden and causes of mortality. Similar approaches can be scaled to improve the measurement of vital statistics in order to facilitate appropriate public health interventions in rural areas of sub-Saharan Africa.Item Factors Motivating Traditional Healer versus Biomedical Facility Use for Treatment of Pediatric Febrile Illness: Results from a Qualitative Study in Southwestern Uganda(The American journal of tropical medicine and hygiene, 2020) Hooft, Anneka; Nabukalu, Doreen; Mwanga-Amumpaire, Juliet; Gardiner, Michael A.; Sundararajan, RadhikaFebrile illnesses, such as malaria and pneumonia, are among the most common causes of mortality in children younger than 5 years in Uganda outside of the neonatal period. Their impact could be mitigated through earlier diagnosis and treatment at biomedical facilities; however, it is estimated that a large percentage of Ugandans (70–80%) seek traditional healers for their first line of medical care. This study sought to characterize individual and structural influences on health care–seeking behaviors for febrile children. Minimally structured, qualitative interviews were conducted for 34 caregivers of children presenting to biomedical and traditional healer sites, respectively. We identified six themes that shape the pathway of care for febrile children: 1) peer recommendations, 2) trust in biomedicine, 3) trust in traditional medicine, 4) mistrust in providers and therapies, 5) economic resources and access to health care, and 6) perceptions of child health. Biomedical providers are preferred by those who value laboratory testing and formal medical training, whereas traditional healer preference is heavily influenced by convenience, peer recommendations, and firm beliefs in traditional causes of illness. However, most caregivers concurrently use both biomedical and traditional therapies for their child during the same illness cycle. The biomedical system is often considered as a backup when traditional healing “fails.” Initiatives seeking to encourage earlier presentation to biomedical facilities must consider the individual and structural forces that motivate seeking traditional healers. Educational programs and cooperation with traditional healers may increase biomedical referrals and decrease time to appropriate care and treatment for vulnerable/susceptible children.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 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 Shortening ‘‘the Road’’ to Improve Engagement with HIV Testing Resources: A Qualitative Study Among Stakeholders in Rural Uganda(AIDS Patient Care and STDs, 2021) Broderick, Kathryn; Ponticiello, Matthew; Nabukalu, Doreen; Tushemereirwe, Patricia; Nuwagaba, Gabriel; King, Rachel; Mwanga-Amumpaire, Juliet; Sundararajan, RadhikaIn HIV-endemic areas, traditional healers are frequently used with, or instead of, biomedical resources for health care needs. Studies show healers are interested in and capable of supporting patients in the HIV care cascade. However, adults who receive care from healers have low engagement with HIV services. To achieve epidemic control, we must understand gaps between the needs of HIV-endemic communities and the potential for healers to improve HIV service uptake. This study's objective was to characterize stakeholder perspectives on barriers to HIV testing and approaches to mitigate barriers in a medically pluralistic, HIV-endemic region. This study was conducted in Mbarara District, a rural area of southwestern Uganda with high HIV prevalence. Participants included HIV clinical staff, traditional healers, and adults receiving care from healers. Fifty-six participants [N = 30 females (52%), median age 40 years (interquartile range, 32–51.5)] were recruited across three stakeholder groups for minimally structured interviews. Themes were identified using an inductive, grounded theory approach and linked together to create a framework explaining stakeholder perspectives on HIV testing. Stakeholders described the “road” to HIV testing as time-consuming, expensive, and stigmatizing. All agreed healers could mitigate barriers by delivering HIV testing at their practices. Collaborations between biomedical and traditional providers were considered essential to a successful healer-delivered HIV testing program. This work describes a novel approach to “shorten the road” to HIV testing, suggesting that traditional healer-delivered HIV testing holds promise to expand uptake of testing among communities with limited access to existing programs.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 - AcademicItem Understanding PrEP Acceptability Among Priority Populations: Results from a Qualitative Study of Potential Users in Central Uganda(AIDS and Behavior, 2022) Sundararajan, Radhika; Wyatt, Monique A.; Muwonge, Timothy R.; Pisarski, Emily E.; Mujugira, Andrew; Haberer, Jessica E.; Ware, Norma C.Daily oral pre-exposure prophylaxis (PrEP) can safely and effectively prevent HIV acquisition in HIV-negative individuals. However, uptake of PrEP has been suboptimal in sub-Saharan Africa. The goal of this qualitative study was to identify facilitators of and barriers to PrEP acceptability among target users not taking PrEP. Fifty-nine individuals belonging to Ugandan priority populations participated in a single in-depth interview. Participants perceived themselves as being at high risk for HIV acquisition, and expressed interest in PrEP as an HIV prevention strategy. Two forms of stigma emerged as potential barriers to PrEP use: (1) misidentification as living with HIV; and (2) disclosure of membership in a priority population. Acceptability of PrEP was dampened for this sample of potential PrEP users due to anticipated stigmatization. Mitigating stigma should be a key component of effective PrEP delivery to reach UNAIDS goal of ending the AIDS epidemic by 2030.Item Using verbal autopsies to estimate under-5 mortality at household level in a rural area of southwestern Uganda: a cross-sectional study(The Lancet Global Health, 2018) Nabukalu, Doreen; Ntaro, Moses; Seviiri, Mathias; Sundararajan, Radhika; Reyes, Raquel; Boyce, Ross; Mulogo, EdgarIn rural Uganda, paediatric deaths that occur outside of health facilities often go unnoticed by the health system, and information on their magnitude and causes remains limited. We aimed to assess the causes of mortality of children younger than 5 years at household level in Bugoye subcounty, Uganda. Methods This cross-sectional study was done in all 35 villages of Bugoye subcounty in March and April, 2017. Community health workers collected data on all deaths in all households of the subcounty that occurred between Jan 1, 2016, and Jan 1, 2017, using 2014 WHO standardised verbal autopsy (VA) questionnaires. Causes of death were determined using the InterVA-4 algorithm and cause-specific mortality proportions were calculated using STATA. Findings The VA survey identified 77 deaths among children younger than 5 years that occurred during the study period. Nearly half of these deaths occurred among neonates (n=38 [49%]), followed by ages 1–11 months (n=21 [27%]), and 1–4 years (n=18 [23%]). Among neonates, mortality most commonly occurred in the first 24 h (n=17 [22%]), followed by 8–28 days (n=10 [13%]). The five leading causes of death for all ages were malaria (19%), prematurity (19%), neonatal pneumonia (16%), HIV/AIDS-related illnesses (10%), and acute respiratory tract infections including pneumonia (9%). Malaria was the dominant cause of death for those aged 1–11 months and 1–4 years, accounting for 44% and 33%, respectively. Prematurity and neonatal pneumonia were the leading causes of death among neonates. Most deaths (81%) captured from the VAs could not be traced from the records of the reported health facilities in the district. Interpretation There is a considerable discrepancy between mortality captured by the district and mortality in the communities. Interventions that address common causes of mortality for children younger than 5 years need to be strengthened and extended to rural health facilities. Community death registration systems are lacking and in need of revitalisation. VA surveys could be conducted by district health authorities periodically to collect mortality data in the rural and hard-to-reach areas. Funding Joint AFRO/TDR Small Grants Scheme for implementation research in infectious diseases of poverty.