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  • 1. Alfvén, Tobias
    et al.
    Axelson, Henrik
    Lindstrand, Ann
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Persson, Lars-Ake
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Dödligheten minskar, men fortfarande dör 7 miljoner barn varje år2013In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 110, no 1-2, p. 28-30Article in journal (Other academic)
    Abstract [sv]

    Millenniemål 4 lyder: »Barnadödligheten under de fem första levnadsåren ska minska med två tredjedelar till 2015 jämfört med år 1990«.

    Barnadödligheten minskar i ­stora delar av världen, men inte i tillräckligt snabb takt för att uppnå målet. Den skiljer sig också kraftigt mellan länder och mellan olika grupper inom länderna.

    Sex dödsorsaker står för mer än 90 procent av alla dödsfall före 5 års ålder: neonatal mortalitet, lunginflammation, diarré, ­malaria, mässling och HIV/aids. ­Undernäring beräknas vara ­delorsak till cirka en tredjedel av dessa dödsfall.

    Vi har kunskap och metoder att med kostnadseffektiva lösningar reducera barnadödligheten med två tredjedelar. Fortsatt inter­nationellt samarbete, utökade ­resurser samt lokal, nationell po­litisk vilja krävs för att lyckas.

  • 2.
    Aweko, Juliet
    et al.
    Karolinska Inst, Dept Publ Hlth Sci, Stockholm, Sweden.
    De Man, Jeroen
    Inst Trop Med, Dept Publ Hlth, Antwerp, Belgium.
    Absetz, Pilvikki
    Univ Eastern Finland, Inst Publ Hlth & Clin Nutr, Joensuu, Finland.
    Östenson, Claes-Göran
    Karolinska Univ Hosp, Dept Mol Med & Surg, Stockholm, Sweden.
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mölsted Alvesson, Helle
    Karolinska Inst, Dept Publ Hlth Sci, Stockholm, Sweden.
    Daivadanam, Meena
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics. Karolinska Inst, Dept Publ Hlth Sci, Stockholm, Sweden.
    Patient and Provider Dilemmas of Type 2 Diabetes Self-Management: A Qualitative Study in Socioeconomically Disadvantaged Communities in Stockholm2018In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 15, no 9, article id 1810Article in journal (Refereed)
    Abstract [en]

    Studies comparing provider and patient views and experiences of self-management within primary healthcare are particularly scarce in disadvantaged settings. In this qualitative study, patient and provider perceptions of self-management were investigated in five socio-economically disadvantaged communities in Stockholm. Twelve individual interviews and four group interviews were conducted. Semi-structured interview guides included questions on perceptions of diabetes diagnosis, diabetes care services available at primary health care centers, patient and provider interactions, and self-management support. Data was analyzed using thematic analysis. Two overarching themes were identified: adopting and maintaining new routines through practical and appropriate lifestyle choices (patients), and balancing expectations and pre-conceptions of self-management (providers). The themes were characterized by inherent dilemmas representing confusions and conflicts that patients and providers experienced in their daily life or practice. Patients found it difficult to tailor information and lifestyle advice to fit their daily life. Healthcare providers recognized that patients needed support to change behavior, but saw themselves as inadequately equipped to deal with the different cultural and social aspects of self-management. This study highlights patient and provider dilemmas that influence the interaction and collaboration between patients and providers and hinder uptake of self-management advice.

  • 3.
    Awor, Phyllis
    et al.
    School of Public Health, College of Health Sciences, Makarere University, Kampala, Uganda.
    Miller, Jane
    Malaria and Child Survival Department, Population Services International, Nairobi, Kenya.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Systematic literature review of integrated community case management and the private sector in Africa: Relevant experiences and potential next step2014In: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 4, no 2Article in journal (Refereed)
  • 4.
    Awor, Phyllis
    et al.
    Makerere Univ, Sch Publ Hlth, Kampala, Uganda.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Makerere Univ, Sch Publ Hlth, Kampala, Uganda;Unicef, New York, NY USA.
    Gautham, Meenakshi
    London Sch Hyg & Trop Med, London, England.
    Delivering child health interventions through the private sector in low and middle income countries: challenges, opportunities, and potential next steps2018In: BMJ. British Medical Journal, E-ISSN 1756-1833, Vol. 362, article id k2950Article, review/survey (Refereed)
  • 5. Awor, Phyllis
    et al.
    Wamani, Henry
    Bwire, Godfrey
    Jagoe, George
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Private sector drug shops in integrated community case management of malaria, pneumonia, and diarrhea in children in Uganda2012In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 87, no 5 Suppl, p. 92-96Article in journal (Refereed)
    Abstract [en]

    We conducted a survey involving 1,604 households to determine community care-seeking patterns and 163 exit interviews to determine appropriateness of treatment of common childhood illnesses at private sector drug shops in two rural districts of Uganda. Of children sick within the last 2 weeks, 496 (53.1%) children first sought treatment in the private sector versus 154 (16.5%) children first sought treatment in a government health facility. Only 15 (10.3%) febrile children treated at drug shops received appropriate treatment for malaria. Five (15.6%) children with both cough and fast breathing received amoxicillin, although no children received treatment for 5-7 days. Similarly, only 8 (14.3%) children with diarrhea received oral rehydration salts, but none received zinc tablets. Management of common childhood illness at private sector drug shops in rural Uganda is largely inappropriate. There is urgent need to improve the standard of care at drug shops for common childhood illness through public-private partnerships.

  • 6.
    Awor, Phyllis
    et al.
    Centre for International Health, Department of Global Public Health and Primary Health Care, University of Bergen, Norway.
    Wamani, Henry
    School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
    Tylleskar, Thorkild
    Centre for International Health, Department of Global Public Health and Primary Health Care, University of Bergen, Norway.
    Jagoe, George
    Medicines for Malaria Venture, Geneva, Switzerland.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Increased access to care and appropriateness of treatment at private sector drug shops with integrated management of malaria, pneumonia and diarrhoea: a quasi-experimental study in Uganda2014In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 12, p. e115440-Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION:

    Drug shops are a major source of care for children in low income countries but they provide sub-standard care. We assessed the feasibility and effect on quality of care of introducing diagnostics and pre-packaged paediatric-dosage drugs for malaria, pneumonia and diarrhoea at drug shops in Uganda.

    METHODS:

    We adopted and implemented the integrated community case management (iCCM) intervention within registered drug shops. Attendants were trained to perform malaria rapid diagnostic tests (RDTs) in each fever case and count respiratory rate in each case of cough with fast/difficult breathing, before dispensing recommended treatment. Using a quasi-experimental design in one intervention and one non-intervention district, we conducted before and after exit interviews for drug seller practices and household surveys for treatment-seeking practices in May-June 2011 and May-June 2012. Survey adjusted generalized linear models and difference-in-difference analysis was used.

    RESULTS:

    3759 (1604 before/2155 after) household interviews and 943 (163 before/780 after) exit interviews were conducted with caretakers of children under-5. At baseline, no child at a drug shop received any diagnostic testing before treatment in both districts. After the intervention, while no child in the non-intervention district received a diagnostic test, 87.7% (95% CI 79.0-96.4) of children with fever at the intervention district drug shops had a parasitological diagnosis of malaria, prior to treatment. The prevalence ratios of the effect of the intervention on treatment of cough and fast breathing with amoxicillin and diarrhoea with ORS/zinc at the drug shop were 2.8 (2.0-3.9), and 12.8 (4.2-38.6) respectively. From the household survey, the prevalence ratio of the intervention effect on use of RDTs was 3.2 (1.9-5.4); Artemisinin Combination Therapy for malaria was 0.74 (0.65-0.84), and ORS/zinc for diarrhoea was 2.3 (1.2-4.7).

    CONCLUSION:

    iCCM can be utilized to improve access and appropriateness of care for children at drug shops.

  • 7. Awor, Phyllis
    et al.
    Wamani, Henry
    Tylleskar, Thorkild
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Drug seller adherence to clinical protocols with integrated management of malaria, pneumonia and diarrhoea at drug shops in Uganda2015In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 14, article id 277Article in journal (Refereed)
    Abstract [en]

    Background: Drug shops are usually the first source of care for febrile children in Uganda although the quality of care they provide is known to be poor. Within a larger quasi-experimental study introducing the WHO/UNICEF recommended integrated community case management (iCCM) of malaria, pneumonia and diarrhoea intervention for community health workers in registered drug shops, the level of adherence to clinical protocols by drug sellers was determined. Methods: All drug shops (N = 44) in the intervention area were included and all child visits (N = 7,667) from October 2011-June 2012 to the participating drug shops were analysed. Drug shops maintained a standard iCCM register where they recorded the children seen, their symptoms, diagnostic test performed, treatments given and actions taken. The proportion of children correctly assessed and treated was determined from the registers. Results: Malaria management: 6,140 of 7,667 (80.1%) total visits to drug shops were of children with fever. 5986 (97.5%) children with fever received a malaria rapid diagnostic test (RDT) and the RDT positivity rate was 78% (95% CI 77-79). 4,961/5,307 (93.4%) children with a positive RDT received artemisinin combination therapy. Pneumonia management: after respiratory rate assessment of children with cough and fast/difficult breathing, 3,437 (44.8%) were categorized as "pneumonia", 3,126 (91.0%) of whom received the recommended drug-amoxicillin. Diarrhoea management: 2,335 (30.5%) child visits were for diarrhoea with 2,068 (88.6%) correctly treated with oral rehydration salts and zinc sulphate. Dual/Triple classification: 2,387 (31.1%) children had both malaria and pneumonia and 664 (8.7%) were classified as having three illnesses. Over 90% of the children with dual or triple classification were treated appropriately. Meanwhile, 381 children were categorized as severely sick (with a danger sign) with 309 (81.1%) of them referred for appropriate management. Conclusion: With the introduction of the iCCM intervention at drug shops in Eastern Uganda, it was possible to achieve high adherence to the treatment protocols, which is likely compatible with increased quality of care.

  • 8.
    Baker, Ulrika
    et al.
    Karolinska Inst, Widerstromska Huset, Dept Publ Hlth Sci Global Hlth Hlth Syst & Policy, Tomtebodavagen 18 A, S-17177 Stockholm, Sweden.;Karolinska Inst, Div Family Med, Dept Neurobiol Care Sci & Soc, Nobels Alle 12, S-14183 Huddinge, Sweden..
    Hassan, Farida
    Ifakara Hlth Inst, Plot 463 Kiko Ave,POB 78 373, Dar Es Salaam, Tanzania..
    Hanson, Claudia
    Karolinska Inst, Widerstromska Huset, Dept Publ Hlth Sci Global Hlth Hlth Syst & Policy, Tomtebodavagen 18 A, S-17177 Stockholm, Sweden.;London Sch Hyg & Trop Med, Dept Dis Control, London WC1E 7HT, England..
    Manzi, Fatuma
    Ifakara Hlth Inst, Plot 463 Kiko Ave,POB 78 373, Dar Es Salaam, Tanzania..
    Marchant, Tanya
    London Sch Hyg & Trop Med, Dept Dis Control, London WC1E 7HT, England..
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Karolinska Inst, Widerstromska Huset, Dept Publ Hlth Sci Global Hlth Hlth Syst & Policy, Tomtebodavagen 18 A, S-17177 Stockholm, Sweden. ;Makerere Sch Publ Hlth, Kampala, Uganda..
    Hylander, Ingrid
    Karolinska Inst, Div Family Med, Dept Neurobiol Care Sci & Soc, Nobels Alle 12, S-14183 Huddinge, Sweden..
    Unpredictability dictates quality of maternal and newborn care provision in rural Tanzania: A qualitative study of health workers' perspectives2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 55Article in journal (Refereed)
    Abstract [en]

    Background: Health workers are the key to realising the potential of improved quality of care for mothers and newborns in the weak health systems of Sub Saharan Africa. Their perspectives are fundamental to understand the effectiveness of existing improvement programs and to identify ways to strengthen future initiatives. The objective of this study was therefore to examine health worker perspectives of the conditions for maternal and newborn care provision and their perceptions of what constitutes good quality of care in rural Tanzanian health facilities. Methods: In February 2014, we conducted 17 in-depth interviews with different cadres of health workers providing maternal and newborn care in 14 rural health facilities in Tandahimba district, south-eastern Tanzania. These facilities included one district hospital, three health centres and ten dispensaries. Interviews were conducted in Swahili, transcribed verbatim and translated into English. A grounded theory approach was used to guide the analysis, the output of which was one core category, four main categories and several sub-categories. Results: `It is like rain' was identified as the core category, delineating unpredictability as the common denominator for all aspects of maternal and newborn care provision. It implies that conditions such as mothers' access to and utilisation of health care are unreliable; that availability of resources is uncertain and that health workers have to help and try to balance the situation. Quality of care was perceived to vary as a consequence of these conditions. Health workers stressed the importance of predictability, of `things going as intended', as a sign of good quality care. Conclusions: Unpredictability emerged as a fundamental condition for maternal and newborn care provision, an important determinant and characteristic of quality in this study. We believe that this finding is also relevant for other areas of care in the same setting and may be an important defining factor of a weak health system. Increasing predictability within health services, and focusing on the experience of health workers within these, should be prioritised in order to achieve better quality of care for mothers and newborns.

  • 9. Baker, Ulrika
    et al.
    Okuga, Monica
    Waiswa, Peter
    Manzi, Fatuma
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Hanson, Claudia
    Bottlenecks in the implementation of essential screening tests in antenatal care: Syphilis, HIV, and anemia testing in rural Tanzania and Uganda2015In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 130 Suppl 1, p. S43-S50Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To identify and compare implementation bottlenecks for effective coverage of screening for syphilis, HIV, and anemia in antenatal care in rural Tanzania and Uganda; and explore the underlying determinants and perceived solutions to overcome these bottlenecks.

    METHODS: In this multiple case study, we analyzed data collected as part of the Expanded Quality Management Using Information Power (EQUIP) project between November 2011 and April 2014. Indicators from household interviews (n=4415 mothers) and health facility surveys (n=122) were linked to estimate coverage in stages of implementation between which bottlenecks can be identified. Key informant interviews (n=15) were conducted to explore underlying determinants and analyzed using a framework approach.

    RESULTS: Large differences in implementation were found within and between countries. Availability and effective coverage was significantly lower for all tests in Uganda compared with Tanzania. Syphilis screening had the lowest availability and effective coverage in both countries. The main implementation bottleneck was poor availability of tests and equipment. Key informant interviews validated these findings and perceived solutions included the need for improved procurement at the central level.

    CONCLUSION: Our findings reinforce essential screening as a missed opportunity, caused by a lack of integration of funding and support for comprehensive antenatal care programs.

  • 10. Baker, Ulrika
    et al.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Marchant, Tanya
    Mbaruku, Godfrey
    Temu, Silas
    Manzi, Fatuma
    Hanson, Claudia
    Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania2015In: Bulletin of the World Health Organization, ISSN 0042-9686, E-ISSN 1564-0604, Vol. 93, no 6, p. 380-389Article in journal (Refereed)
    Abstract [en]

    Objective To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania. Methods Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We adapted Tanahashi's model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care. Findings Effective coverage was low in both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts. Conclusion The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context.

  • 11.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Namusoko, Sarah
    School of Public Health, Makerere University College of Health Sciences, New Mulago Hospital Complex, Uganda.
    Waiswa, Peter
    Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Sweden.
    Wallin, Lars
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Sweden.
    Knowledge translation in Uganda: a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, no 1, p. 117-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this 'know-do' gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the subelements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting.

    METHODS:

    This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data.

    RESULTS:

    The sub-elements of organizational context in the PARIHS framework--i.e., receptive context, culture, leadership, and evaluation--also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT.

    CONCLUSIONS:

    In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings--resources, community involvement, and commitment and informal payment--should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate subelement of the PARIHS framework as a whole.

  • 12.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Skeen, Sarah
    Duc, Duong M.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Blandon, Elmer Zelaya
    Estabrooks, Carole
    Gustavsson, Petter
    Hoa, Dinh Thi Phuong
    Kallestal, Carina
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nga, Nguyen Thu
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pervin, Jesmin
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Rahman, Anisur
    Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Squires, Janet E.
    Tomlinson, Mark
    Waiswa, Peter
    Wallin, Lars
    Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, article id 120Article in journal (Refereed)
    Abstract [en]

    Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

  • 13.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Tomlinson, M.
    Squires, J.
    Duong, Duc
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Hoa, D. P.
    Källestål, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pervin, J.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nga, Nguyen Thu
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Rahman, A.
    Waiswa, P.
    Zelaya, E.
    Estabrooks, C.
    Wallin, L.
    The context assessment for community health tool: investigating why what works where2013In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 18, no SI, p. 203-204Article in journal (Other academic)
  • 14.
    Bloom, Gerald
    et al.
    STEPS Centre, Institute of Development Studies, University of Sussex, Brighton, U.K.
    Wilkinson, Annie
    STEPS Centre, Institute of Development Studies, University of Sussex, Brighton, U.K.
    Tomson, Göran
    Karolinska Institutet, Stockholm, Sweden.
    Awor, Phyllis
    Makerere School of Public Health, Kampala, Uganda.
    Zhang, Xiulan
    School of Social Development and Public Policy, Beijing Normal University, China.
    Ahmed, Syed Masud
    icddr,b, Dhaka, Bangladesh.
    Ali Khan, Wasif
    icddr,b, Dhaka, Bangladesh.
    Blessing, Victoria
    STEPS Centre, Institute of Development Studies, University of Sussex, Brighton, U.K.
    Wang, Li
    School of Social Development and Public Policy, Beijing Normal University, China.
    Liang, Xiaoyun
    School of Social Development and Public Policy, Beijing Normal University, China.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Karolinska Institutet, Stockholm, Sweden.
    Addressing Resistance to Antibiotics in Pluralistic Health Systems2015Report (Other academic)
  • 15. Byaruhanga, Romano N.
    et al.
    Nsungwa-Sabiiti, Jesca
    Kiguli, Juliet
    Balyeku, Andrew
    Nsabagasani, Xavier
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Hurdles and opportunities for newborn care in rural Uganda2011In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 27, no 6, p. 775-780Article in journal (Refereed)
    Abstract [en]

    Introduction: a set of evidence-based delivery and neonatal practices have the potential to reduce neonatal mortality substantially. However, resistance to the acceptance and adoption of these practices may still be a problem and challenge in the rural community in Uganda. Objectives: to explore the acceptability and feasibility of the newborn care practices at household and family level in the rural communities in different regions of Uganda with regards to birth asphyxia, thermo-protection and cord care. Methods: a qualitative design using in-depth interviews and focus group discussions were used. Participants were purposively selected from rural communities in three districts. Six in-depth interviews targeting traditional birth attendants and nine focus group discussions composed of 10-15 participants among post childbirth mothers, elderly caregivers and partners or fathers of recently delivered mothers were conducted. All the mothers involved has had normal vaginal deliveries in the rural community with unskilled birth attendants. Latent content analysis was used. Findings: two main themes emerged from the interviews: 'Barriers to change' and 'Windows of opportunities'. Some of the recommended newborn practices were deemed to conflict with traditional and cultural practices. Promotion of delayed bathing as a thermo-protection measure, dry cord care were unlikely to be accepted and spiritual beliefs were attached to use of local herbs for bathing or smearing of the baby's skin. However, several aspects of thermo-protection of the newborn, breast feeding, taking newborns for immunisation were in agreement with biomedical recommendations, and positive aspects of newborn care were noticed with the traditional birth attendants. Conclusions: some of the evidence based practices may be accepted after modification. Behaviour change communication messages need to address the community norms in the country. The involvement of other newborn caregivers than the mother at the household and the community early during pregnancy may influence change of behaviour related to the adoption of the recommended newborn care practices.

  • 16.
    Ettarh, Remare
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Galiwango, Edward
    Iganga/Mayuge Health and Demographic Surveillance Site, Uganda.
    Rutebemberwa, Elizeus
    Makerere University School of Public Health, Kampala, Uganda.
    Pariyo, George
    Makerere University School of Public Health, Kampala, Uganda.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Spatial analysis of determinants of choice of treatment provider for fever in under-five children in Iganga, Uganda2011In: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 17, no 1, p. 320-326Article in journal (Refereed)
    Abstract [en]

    Although health facilities and drug shops are the main alternatives to home management of fever in children in Uganda, the influence of distance on the choice of treatment provider by caretakers is still unclear. We examined the spatial distribution of choice of treatment provider for fever in under-five children and the influence of household and geographical factors. Spatial and regression analysis of choices of treatment provider was done using data from a 2-week recall survey conducted in the Iganga-Mayuge Health and Demographic Surveillance Site. Of 3483 households with febrile children, 45% of caretakers treated the child at home, 33% took the child to a health facility, and 22% obtained treatment at drug shops. The distance to access care outside the home was crucial as seen in the greater preference for treatment at home or at drug shops among caretakers living more than 3km from health facilities. The influence of proximity to health facilities in the choice of treatment provider highlights the need for greater access to health care services. The current Uganda Ministry of Health threshold of 5km for access to health facilities needs to be reviewed for rural areas.

  • 17.
    Frielingsdorf, Helena
    et al.
    Psykiatri Nordväst, Karolinska universitetssjukhuset.
    Bushayija, Eugene
    ­Läkare utan gränser.
    Nordström, Anders
    global hälsa, ­Utrikesdepartementet.
    Nyberg, Filippa
    Svenska Läkaresällskapet.
    Rosling, Hans
    global hälsa, Karolinska ­institutet.
    von Schreeb, Johan
    Kunskapscentrum katastrof­medicin, Karolinska institutet.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nilsson, Kerstin
    Örebro universitet.
    Nordenstedt, Helena
    global hälsa, Karolinska ­institutet.
    Utmaningar och möjligheter för nästa generation inom global hälsa2014In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 111, no 46, p. C7T7-Article in journal (Other academic)
  • 18. Friends of the UN HLM on NCDs, .
    The how: a message for the UN high-level meeting on NCDs.2018In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 392, no 10143, p. e4-e5, article id S0140-6736(18)31475-2Article in journal (Refereed)
  • 19.
    George, Asha
    et al.
    Univ Western Cape, Sch Publ Hlth, Bellville, South Africa.
    Tetui, Moses
    Makerere Univ, Makerere Univ Sch Publ Hlth MakSPH, New Mulago Complex, Kampala, Uganda; Umea Univ, Dept Publ Hlth & Clin Med, Epidemiol & Global Hlth Unit, Umea, Sweden.
    Pariyo, George W
    Johns Hopkins Univ, Johns Hopkins Bloomberg Sch Publ Hlth, Dept Int Hlth, Baltimore, MD USA.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Maternal and newborn health implementation research: programme outcomes, pathways of change and partnerships for equitable health systems in Uganda.2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no sup4, article id 1359924Article in journal (Refereed)
  • 20.
    Guwatudde, David
    et al.
    Makerere Univ, Sch Publ Hlth, Dept Epidemiol & Biostat, Coll Hlth Sci, Kampala, Uganda.
    Absetz, Pilvikki
    Collaborat Care Syst Finland, Helsinki, Finland.
    Delobelle, Peter
    Univ Cape Town, Chron Dis Initiat Africa, Cape Town, South Africa;Univ Western Cape, Sch Publ Hlth, Cape Town, South Africa.
    Ostenson, Claes-Goran
    Karolinska Inst, Dept Mol Med & Surg, Diabet & Endocrine Unit, Stockholm, Sweden.
    Van, Josefien Olmen
    Inst Trop Med, Dept Publ Hlth, Antwerp, Belgium.
    Alvesson, Helle Molsted
    Karolinska Inst, Dept Publ Hlth Sci, Stockholm, Sweden.
    Mayega, Roy William
    Makerere Univ, Sch Publ Hlth, Dept Epidemiol & Biostat, Coll Hlth Sci, Kampala, Uganda.
    Kiracho, Elizabeth Ekirapa
    Makerere Univ, Sch Publ Hlth, Coll Hlth Sci, Dept Hlth Policy Planning & Management, Kampala, Uganda.
    Kiguli, Juliet
    Makerere Univ, Dept Community Hlth & Behav Sci, Sch Publ Hlth, Kampala, Uganda.
    Sundberg, Carl Johan
    Karolinska Inst, Dept Physiol & Pharmacol, Stockholm, Sweden;Karolinska Inst, Dept Learning Informat Management & Eth, Stockholm, Sweden.
    Sanders, David
    Univ Western Cape, Sch Publ Hlth, Cape Town, South Africa.
    Tomson, Goran
    Karolinska Inst, Dept Publ Hlth Sci, Stockholm, Sweden;Royal Acad Sci, SIGHT, Stockholm, Sweden.
    Puoane, Thandi
    Univ Western Cape, Sch Publ Hlth, Cape Town, South Africa.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Karolinska Inst, Dept Publ Hlth Sci, Stockholm, Sweden.
    Daivadanam, Meena
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics. Karolinska Inst, Dept Publ Hlth Sci, Stockholm, Sweden.
    Study protocol for the SMART2D adaptive implementation trial: a cluster randomised trial comparing facility-only care with integrated facility and community care to improve type-2 diabetes outcomes in Uganda, South Africa and Sweden2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 3, article id e019881Article in journal (Refereed)
    Abstract [en]

    Introduction Type 2 diabetes (T2D) is increasingly contributing to the global burden of disease. Health systems in most parts of the world are struggling to diagnose and manage T2D, especially in low-income and middle-income countries, and among disadvantaged populations in high-income countries. The aim of this study is to determine the added benefit of community interventions onto health facility interventions, towards glycaemic control among persons with diabetes, and towards reduction in plasma glucose among persons with prediabetes. Methods and analysis An adaptive implementation cluster randomised trial is being implemented in two rural districts in Uganda with three clusters per study arm, in an urban township in South Africa with one cluster per study arm, and in socially disadvantaged suburbs in Stockholm, Sweden with one cluster per study arm. Clusters are communities within the catchment areas of participating primary healthcare facilities. There are two study arms comprising a facility plus community interventions arm and a facility-only interventions arm. Uganda has a third arm comprising usual care. Intervention strategies focus on organisation of care, linkage between health facility and the community, and strengthening patient role in self-management, community mobilisation and a supportive environment. Among T2D participants, the primary outcome is controlled plasma glucose; whereas among prediabetes participants the primary outcome is reduction in plasma glucose. Ethics and dissemination The study has received approval in Uganda from the Higher Degrees, Research and Ethics Committee of Makerere University School of Public Health and from the Uganda National Council for Science and Technology; in South Africa from the Biomedical Science Research Ethics Committee of the University of the Western Cape; and in Sweden from the Regional Ethical Board in Stockholm. Findings will be disseminated through peer-reviewed publications and scientific meetings.

  • 21. Hamer, Davidson H.
    et al.
    Marsh, David R.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pagnoni, Franco
    Integrated Community Case Management: Next Steps in Addressing the Implementation Research Agenda2012In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 87, no suppl 5, p. 151-153Article in journal (Refereed)
  • 22.
    Hanson, Claudia
    et al.
    Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Waiswa, Peter
    Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Marchant, Tanya
    Department of Disease Control, London School of Hygiene and Tropical Medicine, United Kingdom.
    Marx, Michael
    Evaplan GmbH the University of Heidelberg, Germany.
    Manzi, Fatuma
    Ifakara Health Institute, Dar-es-Salaam, Tanzania.
    Mbaruku, Godfrey
    Ifakara Health Institute, Dar-es-Salaam, Tanzania.
    Rowe, Alex
    Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA.
    Tomson, Göran
    Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Schellenberg, Joanna
    Department of Disease Control, London School of Hygiene and Tropical Medicine, United Kingdom.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Expanded Quality Management Using Information Power (EQUIP): protocol for a quasi-experimental study to improve maternal and newborn health in Tanzania and Uganda.2014In: Implementation science : IS, ISSN 1748-5908, Vol. 9, article id 41Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa. Tanzania and Uganda are committed to reduce maternal and newborn mortality, but progress has been limited and many essential interventions are unavailable in primary and referral facilities. Quality management has the potential to overcome low implementation levels by assisting teams of health workers and others finding local solutions to problems in delivering quality care and the underutilization of health services by the community. Existing evidence of the effect of quality management on health worker performance in these contexts has important limitations, and the feasibility of expanding quality management to the community level is unknown. We aim to assess quality management at the district, facility, and community levels, supported by information from high-quality, continuous surveys, and report effects of the quality management intervention on the utilization and quality of services in Tanzania and Uganda.

    METHODS: In Uganda and Tanzania, the Expanded Quality Management Using Information Power (EQUIP) intervention is implemented in one intervention district and evaluated using a plausibility design with one non-randomly selected comparison district. The quality management approach is based on the collaborative model for improvement, in which groups of quality improvement teams test new implementation strategies (change ideas) and periodically meet to share results and identify the best strategies. The teams use locally-generated community and health facility data to monitor improvements. In addition, data from continuous health facility and household surveys are used to guide prioritization and decision making by quality improvement teams as well as for evaluation of the intervention. These data include input, process, output, coverage, implementation practice, and client satisfaction indicators in both intervention and comparison districts. Thus, intervention districts receive quality management and continuous surveys, and comparison districts-only continuous surveys.

    DISCUSSION: EQUIP is a district-scale, proof-of-concept study that evaluates a quality management approach for maternal and newborn health including communities, health facilities, and district health managers, supported by high-quality data from independent continuous household and health facility surveys. The study will generate robust evidence about the effectiveness of quality management and will inform future nationwide implementation approaches for health system strengthening in low-resource settings.

    TRIAL REGISTRATION: PACTR201311000681314.

  • 23.
    Henriksson, Dorcus Kiwanuka
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Karolinska Inst, Stockholm, Sweden.
    Ayebare, Florence
    Makerere Univ, Sch Publ Hlth, Coll Hlth Sci, Kampala, Uganda..
    Waiswa, Peter
    Karolinska Inst, Stockholm, Sweden.;Makerere Univ, Sch Publ Hlth, Coll Hlth Sci, Kampala, Uganda..
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Sch Publ Hlth, Coll Hlth Sci, Kampala, Uganda..
    Tumushabe, Elly K.
    Mukono Dist Local Govt, Mukono, Uganda..
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 103Article in journal (Refereed)
    Abstract [en]

    Background: The District Health System was endorsed as the key strategy to achieve 'Health for all' during the WHO organized inter-regional meeting in Harare in 1987. Many expectations were put upon the district health system, including planning. Although planning should be evidence based to prioritize activities, in Uganda it has been described as occurring more by chance than by choice. The role of planning is entrusted to the district health managers with support from the Ministry of Health and other stakeholders, but there is limited knowledge on the district health manager's capacity to carry out evidence-based planning. The aim of this study was to determine the barriers and enablers to evidence-based planning at the district level.

    Methods: This qualitative study collected data through key informant interviews with district managers from two purposefully selected districts in Uganda that have been implementing evidence-based planning. A deductive process of thematic analysis was used to classify responses within themes.

    Results: There were considerable differences between the districts in regard to the barriers and enablers for evidence-based planning. Variations could be attributed to specific contextual and environmental differences such as human resource levels, date of establishment of the district, funding and the sociopolitical environment. The perceived lack of local decision space coupled with the perception that the politicians had all the power while having limited knowledge on evidence-based planning was considered an important barrier.

    Conclusion: There is a need to review the mandate of the district managers to make decisions in the planning process and the range of decision space available within the district health system. Given the important role elected officials play in a decentralized system a concerted effort should be made to increase their knowledge on evidence-based planning and the district health system as a whole.

  • 24.
    Henriksson, Dorcus Kiwanuka
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Waiswa, Peter
    Karolinska Institutet, Sweden; Makerere University College of Health Sciences, Uganda.
    Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Swartling Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
    Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1327256Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. However, there is limited understanding of health system barriers to utilization and delivery of appropriate, high-impact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. In this study we illustrate the use of the bottleneck analysis approach, which could be used to identify bottlenecks in service delivery within the district health system.

    METHODS: A modified Tanahashi model with six determinants for effective coverage was used to determine bottlenecks in service provision for maternal and newborn care. The following interventions provided during antenatal care were used as tracer interventions: use of iron and folic acid, intermittent presumptive treatment for malaria, HIV counseling and testing, and syphilis testing. Data from cross-sectional household and health facility surveys in Mayuge and Namayingo districts in Uganda were used in this study.

    RESULTS: Effective coverage and human resource gaps were identified as the biggest bottlenecks in both districts, with coverage ranging from 0% to 66% for effective coverage and from 46% to 58% for availability of health facility staff. Our findings revealed a similar pattern in bottlenecks in both districts for particular interventions although the districts are functionally independent.

    CONCLUSION: The modified Tanahashi model is an analysis tool that can be used to identify bottlenecks to effective coverage within the district health system, for instance, the effective coverage for maternal and newborn care interventions. However, the analysis is highly dependent on the availability of data to populate all six determinants and could benefit from further validation analysis for the causes of bottlenecks identified.

  • 25.
    Heyman, Gabriel
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Cars, Otto
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Infectious Diseases.
    Bejarano, Maria-Teresa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Access, excess, and ethics—towards a sustainable distribution model for antibiotics2014In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 119, no 2, p. 134-141Article, review/survey (Refereed)
    Abstract [en]

    The increasing antibiotic resistance is a global threat to health care as we know it. Yet there is no model of distribution ready for a new antibiotic that balances access against excessive or inappropriate use in rural settings in low-and middle-income countries (LMICs) where the burden of communicable diseases is high and access to quality health care is low. Departing from a hypothetical scenario of rising antibiotic resistance among pneumococci, 11 stakeholders in the health systems of various LMICs were interviewed one-on-one to give their view on how a new effective antibiotic should be distributed to balance access against the risk of inappropriate use. Transcripts were subjected to qualitative 'framework' analysis. The analysis resulted in four main themes: Barriers to rational access to antibiotics; balancing access and excess; learning from other communicable diseases; and a system-wide intervention. The tension between access to antibiotics and rational use stems from shortcomings found in the health systems of LMICs. Constructing a sustainable yet accessible model of antibiotic distribution for LMICs is a task of health system-wide proportions, which is why we strongly suggest using systems thinking in future research on this issue.

  • 26.
    Hildenwall, Helena
    et al.
    Division of International Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
    Tomson, Göran
    Division of International Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
    Kaija, Judith
    Iganga/Mayuge Demographic Surveillance Site, Uganda.
    Pariyo, George
    School of Public Health, Makerere University, Kampala, Uganda.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    "I never had the money for blood testing" - caretakers' experiences of care-seeking for fatal childhood fevers in rural Uganda: a mixed methods study2008In: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 8, p. 12-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The main killer diseases of children all manifest as acute febrile illness, yet are curable with timely and adequate management. To avoid a fatal outcome, three essential steps must be completed: caretakers must recognize illness, decide to seek care and reach an appropriate source of care, and then receive appropriate treatment. In a fatal outcome some or all of these steps have failed and it remains to be elucidated to what extent these fatal outcomes are caused by local disease perceptions, inappropriate care-seeking or inadequate resources in the family or health system. This study explores caretakers' experiences of care-seeking for childhood febrile illness with fatal outcome in rural Uganda to elucidate the most influential barriers to adequate care.

    METHODS:

    A mixed methods approach using structured Verbal/Social autopsy interviews and in-depth interviews was employed with 26 caretakers living in Iganga/Mayuge Demographic Surveillance Site who had lost a child 1-59 months old due to acute febrile illness between March and June 2006. In-depth interviews were analysed using content analysis with deductive category application.

    RESULTS:

    Final categories of barriers to care were: 1) "Illness interpretation barriers" involving children who received delayed or inappropriate care due to caretakers' labelling of the illness, 2) "Barriers to seeking care" with gender roles and household financial constraints hindering adequate care and 3) "Barriers to receiving adequate treatment" revealing discontents with providers and possible deficiencies in quality of care. Resource constraints were identified as the underlying theme for adequate management, both at individual and at health system levels.

    CONCLUSION:

    The management of severely ill children in this rural setting has several shortcomings. However, the majority of children were seen by an allopathic health care provider during the final illness. Improvements of basic health care for children suffering from acute febrile illness are likely to contribute to a substantial reduction of fatal outcomes. Health care providers at all levels and private as well as public should receive training, support, equipment and supplies to enable basic health care for children suffering from common illnesses.

  • 27.
    Johansson, Emily White
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Gething, Peter W
    Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom.
    Hildenwall, Helena
    Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Mappin, Bonnie
    Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom.
    Petzold, Max
    Center for Applied Biostatistics, University of Gothenburg, Gothenburg, Sweden.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Diagnostic Testing of Pediatric Fevers: Meta-Analysis of 13 National Surveys Assessing Influences of Malaria Endemicity and Source of Care on Test Uptake for Febrile Children under Five Years2014In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 4, p. e95483-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation.

    METHODS AND FINDINGS:

    We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009–2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2–10<5%), moderate (PfPR2–10 5–40%), high (PfPR2–10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%–21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56–0.69) and community health workers (OR: 0.31, 95% CI: 0.23–0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42–0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39–1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16–1.54).

    CONCLUSIONS:

    Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.

  • 28.
    Johansson, Emily White
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Gething, Peter W
    Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, UK.
    Hildenwall, Helena
    Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Mappin, Bonnie
    Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, UK.
    Petzold, Max
    University of Gothenburg, The Sahlgrenska Academy, Health Metrics, Gothenburg, Sweden.
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study2015In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 14, article id 194Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age.

    METHODS: Data were compiled from 12 Demographic and Health Surveys in 2010-2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n = 16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis.

    RESULTS: Significant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology.

    CONCLUSIONS: Significant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.

  • 29.
    Johansson, Emily White
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kitutu, Freddy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere University School of Public Health, College of Health Sciences.
    Mayora, Chrispus
    Makerere University School of Public Health, College of Health Sciences.
    Awor, Phyllis
    Makerere University School of Public Health, College of Health Sciences.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wamani, Henry
    Makerere University School of Public Health, College of Health Sciences.
    Hildenwall, Helena
    Karolinska Institutet, Global Health - Health Systems and Policy Research Group.
    "It could be viral, but you don't know. You have not diagnosed it": Health worker challenges in managing non-malaria pediatric fevers in the low transmission area of Mbarara District, Uganda2016In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 15, article id 197Article in journal (Refereed)
    Abstract [en]

    Background: In 2012, Uganda initiated nationwide deployment of malaria rapid diagnostic tests (RDT) as recommended by national guidelines. Yet growing concerns about RDT non-compliance in various settings have spurred calls to deploy RDT as part of enhanced support packages. An understanding of how health workers currently manage non-malaria fevers, particularly for children, and challenges faced in this work should also inform efforts.

    Methods: A qualitative study was conducted in the low transmission area of Mbarara District (Uganda). In-depth interviews with 20 health workers at lower level clinics focused on RDT perceptions, strategies to differentiate non-malaria pediatric fevers, influences on clinical decisions, desires for additional diagnostics, and any challenges in this work. Seven focus group discussions were conducted with caregivers of children less than five years in facility catchment areas to elucidate their RDT perceptions, understandings of non-malaria pediatric fevers and treatment preferences. Data were extracted into meaning units to inform codes and themes in order to describe response patterns using a content analysis approach. 

    Findings: Differential diagnosis strategies included studying fever patterns, taking histories, assessing symptoms and analyzing other factors such as child’s age or home environment. If no alternative cause was found, malaria treatment was reportedly often prescribed despite a negative result. Other reasons for malaria over-treatment stemmed from RDT perceptions, system constraints and provider-client interactions. RDT perceptions included mistrust driven largely by expectations of false negative results due to low parasite/antigen loads, previous anti-malarial treatment or test detection of only one species. System constraints included poor referral systems, working alone without opportunity to confer on difficult cases, and lacking skills and/or tools for differential diagnosis. Provider-client interactions included reported caregiver RDT mistrust, demand for certain drugs, and desire to know the ‘exact’ disease cause if not malaria. Many health workers expressed uncertainty about how to manage non-malaria pediatric fevers, feared doing wrong and patient death, worried caregivers would lose trust, or felt unsatisfied without a clear diagnosis.  

    Conclusions: Enhanced support is needed to improve RDT adoption at lower level clinics that focuses on empowering providers to successfully manage non-severe non-malaria pediatric fevers without referral. This includes building trust in negative results, reinforcing integrated care initiatives (e.g. Integrated Management of Childhood Illness) and fostering communities of practice according to the Diffusion of Innovation model.

     

  • 30.
    Johansson, Emily White
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Humphreys, Nsona
    Malawi Ministry of Health.
    Bonnie, Mappin
    University of Oxford, Department of Zoology, Spatial Ecology and Epidemiology Group.
    Peter, Gething
    University of Oxford, Department of Zoology, Spatial Ecology and Epidemiology Group.
    Petzold, Max
    University of Gothenburg, The Sahlgrenska Academy, Center for Applied Biostatistics.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Hildenwall, Helena
    Karolinska Institutet, Global Health - Health Systems and Policy Research Group.
    Integrated pediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census2016Article in journal (Refereed)
  • 31.
    Kadobera, Daniel
    et al.
    Iganga Mayuge Hlth & Demog Surveillance Syst, Indepth Network Maternal Newborn & Child Hlth Wor, Iganga, Uganda.;Minist Hlth, Dept Clin Serv, Kampala, Uganda..
    Waiswa, Peter
    Iganga Mayuge Hlth & Demog Surveillance Syst, Indepth Network Maternal Newborn & Child Hlth Wor, Iganga, Uganda.;Karolinska Inst, Dept Publ Hlth Sci, Hlth Syst Policy, Stockholm, Sweden.;Makerere Univ, Coll Hlth Sci, Sch Publ Hlth, Maternal Newborn & Child Hlth Ctr Excellence, Kampala, Uganda..
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Coll Hlth Sci, Sch Publ Hlth, Maternal Newborn & Child Hlth Ctr Excellence, Kampala, Uganda.;Karolinska Inst, Dept Publ Hlth Sci Global Hlth IHCAR, Stockholm, Sweden..
    Blencowe, Hannah
    London Sch Hyg & Trop Med, Ctr Maternal Adolescent Reprod & Child Hlth MARCH, London, England..
    Lawn, Joy
    London Sch Hyg & Trop Med, Ctr Maternal Adolescent Reprod & Child Hlth MARCH, London, England..
    Kerber, Kate
    Save Children US, Saving Newborn Lives, Washington, DC USA..
    Tumwesigye, Nazarius Mbona
    Makerere Univ, Coll Hlth Sci, Sch Publ Hlth, Dept Epidemiol & Biostat, Kampala, Uganda..
    Comparing performance of methods used to identify pregnant women, pregnancy outcomes, and child mortality in the Iganga-Mayuge Health and Demographic Surveillance Site, Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1356641Article in journal (Refereed)
    Abstract [en]

    Background: In most low and middle-income countries vital events registration for births and child deaths is poor, with reporting of pregnancy outcomes highly inadequate or nonexistent. Health and Demographic Surveillance System (HDSS) sites and periodic population- based household-level surveys can be used to identify pregnancies and retrospectively capture pregnancy outcomes to provide data for decision making. However, little is known about the performance of different methods in identifying pregnancy and pregnancy outcomes, yet this is critical in assessing improvements in reducing maternal and newborn mortality and stillbirths.

    Objective: To explore differences between a population-based household pregnancy survey and prospective health demographic surveillance system in identifying pregnancies and their outcomes in rural eastern Uganda.

    Methods: The study was done within the Iganga-Mayuge HDSS site, a member centre of the INDEPTH Network. Prospective data about pregnancies and their outcomes was collected in the routine biannual census rounds from 2006 to 2010 in the HDSS. In 2011 a cross-sectional survey using the pregnancy history survey (PHS) tool was conducted among women aged 15 to 49 years in the HDSS area. We compared differences between the HDSS biannual census updates and the PHS capture of pregnancies identified as well as neonatal and child deaths, stillbirths and abortions.

    Findings: A total of 10,540 women aged 15 to 49 years were interviewed during the PHS. The PHS captured 12.8% more pregnancies than the HDSS in the most recent year (20102011), though between 2006 and 2010 (earlier periods) the PHS captured only 137 (0.8%) more pregnancies overall. The PHS also consistently identified more stillbirths (18.2%), spontaneous abortions (94.5%) and induced abortions (185.8%) than the prospective HDSS update rounds.

    Conclusions: Surveillance sites are designed to prospectively track population-level outcomes. However, the PHS identified more pregnancy-related outcomes than the HDSS in this study. Asking about pregnancy and its outcomes may be a useful way to improve measurement of pregnancy outcomes. Further research is needed to identify the most effective methods of improving the capture of pregnancies and their outcomes within HDSS sites, household surveys and routine health information systems.

  • 32. Kakooza-Mwesige, Angelina
    et al.
    Ndyomugyenyi, Donald
    Pariyo, George
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Waiswa, Paul Michael
    Galiwango, Edward
    Chengo, Eddie
    Odhiambo, Rachael
    Ssewanyana, Derrick
    Bottomley, Christian
    Ngugi, Anthony K
    Newton, Charles R J C
    Adverse perinatal events, treatment gap, and positive family history linked to the high burden of active convulsive epilepsy in Uganda: A population-based study2017In: Epilepsia Open, ISSN 2470-9239, Vol. 2, no 2, p. 188-198Article in journal (Refereed)
  • 33.
    Kalyango, Joan N
    et al.
    Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
    Alfven, Tobias
    Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mugenyi, Kevin
    African Field Epidemiology Network (AFENET), Kampala, Uganda.
    Karamagi, Charles
    Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda.
    Rutebemberwa, Elizeus
    Department of Health Policy, Makerere University College of Health Scineces, Kampala, Uganda.
    Integrated community case management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms in children under five years in Eastern Uganda2013In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 12, p. 340-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Efforts 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.ObjectivesTo 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[degree sign]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. Trial registrationISRCTN: ISRCTN52966230.

  • 34. Kalyango, Joan N.
    et al.
    Lindstrand, Ann
    Rutebemberwa, Elizeus
    Ssali, Sarah
    Kadobera, Daniel
    Karamagi, Charles
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Alfven, Tobias
    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 Fever2012In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 87, no suppl 5, p. 36-45Article in journal (Refereed)
    Abstract [en]

    We 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 cross-sectional 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.

    Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of Swedish International Development Cooperation Agency or the United Nations Children's Fund/ United Nations Development Program/World Bank/World Health Organization Special Program for Research and Training in Tropical Diseases.

  • 35.
    Kalyango, Joan N
    et al.
    Dept of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
    Rutebemberwa, Elizeus
    Dept of Health Policy, Planning and Management, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
    Alfven, Tobias
    Dept of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
    Ssali, Sarah
    Dept of Gender and Women Studies, Makerere University College of Health Sciences, Kampala, Uganda.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Karamagi, Charles
    Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda.
    Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda2012In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 11, no 1, p. 282-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Curative interventions delivered by community health workers (CHWs) were introduced to increase access to health services for children less than five years and have previously targeted single illnesses. However, CHWs in the integrated community case management of childhood illnesses strategy adopted in Uganda in 2010 will manage multiple illnesses. There is little documentation about the performance of CHWs in the management of multiple illnesses. This study compared the performance of CHWs managing malaria and pneumonia with performance of CHWs managing malaria alone in eastern Uganda and the factors influencing performance.

    METHODS:

    A mixed methods study was conducted among 125 CHWs providing either dual malaria and pneumonia management or malaria management alone for children aged four to 59 months. Performance was assessed using knowledge tests, case scenarios of sick children, review of CHWs' registers, and observation of CHWs in the dual management arm assessing respiratory symptoms. Four focus group discussions with CHWs were also conducted.

    RESULTS:

    CHWs in the dual- and single-illness management arms had similar performance with respect to: overall knowledge of malaria (dual 72 %, single 70 %); eliciting malaria signs and symptoms (50 % in both groups); prescribing anti-malarials based on case scenarios (82 % dual, 80 % single); and correct prescription of anti-malarials from record reviews (dual 99 %, single 100 %). In the dual-illness arm, scores for malaria and pneumonia differed on overall knowledge (72 % vs 40 %, p < 0.001); and correct doses of medicines from records (100 % vs 96 %, p < 0.001). According to records, 82 % of the children with fast breathing had received an antibiotic. From observations 49 % of CHWs counted respiratory rates within five breaths of the physician (gold standard) and 75 % correctly classified the children. The factors perceived to influence CHWs' performance were: community support and confidence, continued training, availability of drugs and other necessary supplies, and cooperation from formal health workers.

    CONCLUSION:

    CHWs providing dual-illness management handled malaria cases as well as CHWs providing single-illness management, and also performed reasonably well in the management of pneumonia. With appropriate training that emphasizes pneumonia assessment, adequate supervision, and provision of drugs and necessary supplies, CHWs can provide integrated treatment for malaria and pneumonia.

  • 36.
    Kalyango, Joan N
    et al.
    Department of Public Health Sciences, Global Health, Karolinska Institutet, Stockholm, Sweden.
    Rutebemberwa, Elizeus
    Department of Health Policy, Planning and Management, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
    Karamagi, Charles
    Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda.
    Mworozi, Edison
    Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda.
    Ssali, Sarah
    epartment of Gender and Women Studies, Makerere University, Kampala, Uganda.
    Alfven, Tobias
    Department of Public Health Sciences, Global Health, Karolinska Institutet, Stockholm, Sweden.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    High Adherence to Antimalarials and Antibiotics under Integrated Community Case Management of Illness in Children Less than Five Years in Eastern Uganda2013In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 3, p. e60481-Article in journal (Refereed)
    Abstract [en]

    Background

    Development 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.

    Objective

    To compare adherence to antimalarials alone versus antimalarials combined with antibiotics under ICCM in children less than five years.

    Methods

    A cohort study was nested within a cluster randomized trial that had CHWs treating children less than five years with antimalarials and antibiotics (intervention areas) and CHWs treating children with antimalarials only (control areas). Children were consecutively sampled from the CHWs' registers in the control areas (667 children); and intervention areas (323 taking antimalarials only and 266 taking antimalarials plus antibiotics). The sampled children were visited at home on day one and four of treatment seeking. Adherence was assessed using self reports and pill counts.

    Results

    Adherence in the intervention arm to antimalarials alone and antimalarials plus antibiotics arm was similar (mean 99% in both groups) but higher than adherence in the control arm (antimalarials only) (mean 96%). Forgetfulness (38%) was the most cited reason for non-adherence. At adjusted analysis: absence of fever (OR = 3.3, 95%CI = 1.6–6.9), seeking care after two or more days (OR = 2.2, 95%CI = 1.3–3.7), not understanding instructions given (OR = 24.5, 95%CI = 2.7–224.5), vomiting (OR = 2.6, 95%CI = 1.2–5.5), and caregivers' perception that the child's illness was not severe (OR = 2.0, 95%CI = 1.1–3.8) were associated with non-adherence.

    Conclusions

    Addition of antibiotics to antimalarials did not lower adherence. However, caregivers should be adequately counseled to understand the dosing regimens; continue with medicines even when the child seems to improve; and re-administer doses that have been vomited.

  • 37.
    Katahoire, Anne Ruhweza
    et al.
    Child Health and Development Centre, Makerere University, Kampala, Uganda.
    Henriksson, Dorcus Kiwanuka
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Ssegujja, Eric
    School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
    Waiswa, Peter
    School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
    Ayebare, Florence
    School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
    Bagenda, Danstan
    College of Public Health, University of Nebraska Medical Center, Omaha, USA.
    Mbonye, Anthony K.
    Ministry of Health, Kampala, Uganda.
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda2015In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, article id 797Article in journal (Refereed)
    Abstract [en]

    Background: The Community and District Empowerment for Scale-up (CODES) project pioneered the implementation of a comprehensive district management and community empowerment intervention in five districts in Uganda. In order to improve effective coverage and quality of child survival interventions CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. This paper presents early implementation experiences in five pilot districts and lessons learnt during the first 2 years of implementation. Methods: This qualitative study was comprised of 38 in-depth interviews with members of the District Health Teams (DHTs) and two implementing partners. These were supplemented by observations during implementation and documents review. Thematic analysis was used to distill early implementation experiences and lessons learnt from the process. Results: All five districts health teams with support from the implementing partners were able to adopt the UNICEF tools and to develop district health operational work plans that were evidence-based. Members of the DHTs described the approach introduced by the CODES project as a more systematic planning process and very much appreciated it. Districts were also able to implement some of the priority activities included in their work plans but limited financial resources and fiscal decision space constrained the implementation of some activities that were prioritized. Community dialogues based on Citizen Report Cards (CRC) increased community awareness of available health care services, their utilization and led to discussions on service delivery, barriers to service utilization and processes for improvement. Community dialogues were also instrumental in bringing together service users, providers and leaders to discuss problems and find solutions. The dialogues however are more likely to be sustainable if embedded in existing community structures and conducted by district based facilitators. U report as a community feedback mechanism registered a low response rate. Conclusion: The UNICEF tools were adopted at district level and generally well perceived by the DHTs. The limited resources and fiscal decision space however can hinder implementation of prioritized activities. Community dialogues based on CRCs can bring service providers and the community together but need to be embedded in existing community structures for sustainability.

  • 38.
    Kayemba Nalwadda, Christine
    et al.
    School of Public Health, Makerere University, Kampala, Uganda.
    Guwatudde, David
    School of Public Health, Makerere University, Kampala, Uganda.
    Waiswa, Peter
    School of Public Health, Makerere University, Kampala, Uganda.
    Kiguli, Juliet
    School of Public Health, Makerere University, Kampala, Uganda.
    Namazzi, Gertrude
    School of Public Health, Makerere University, Kampala, Uganda.
    Namutumba, Sarah
    Uganda Newborn Survival Study, Iganga- Mayuge Demographic Surveillance Site, Kampala, Uganda.
    Tomson, Göran
    Division of Global Health, Karolinska Institutet, Stockholm, Sweden.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Community health workers: a resource for identification and referral of sick newborns in rural Uganda2013In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 18, no 7, p. 898-906Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To 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.

  • 39.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). United Nations Childrens Fund UNICEF, UN House, Lalitpur, Nepal.
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nelin, Viktoria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Clark, Robert
    Latter-day Saint Charities, Salt Lake City, Utah, USA.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Global Health, Public Health Sciences, Karolinska Institute, Sweden.; School of Public Health, Makerere University, Uganda.; United Nations Children Fund UNICEF, Hlth Sect, Programme Div, United Nations Plaza, New York, NY 10017 USA.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal2017In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 17, article id 103Article in journal (Refereed)
    Abstract [en]

    Background: Each year 700,000 infants die due to intrapartum-related complications. Helping Babies Breathe (HBB) uses an algorithm to increase knowledge and improve skills on neonatal resuscitation. Implementation of HBB in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB as quality improvement cycle (HBB-QIC) on retention of neonatal resuscitation skills in a tertiary hospital of Nepal.

    Methods: A Time series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at six months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis.

    Results: 137 health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4  1.4 compared to 12.8  1.6 before (out of 17), and the knowledge was retained six months after the training (16.5  1.1). Bag-and-mask skills improved immediately after the training and were retained six months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9-13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4-9.7).

    Conclusions: Health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists and attended weekly review meetings retained their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing.

  • 40. Kerber, Kate
    et al.
    Peterson, Stefan
    Saving Newborn Lives, Save the Children, London, UK.
    Waiswa, Peter
    Special issue: newborn health in Uganda2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 27365Article in journal (Refereed)
  • 41.
    Kiguli, Juliet
    et al.
    Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.
    Namusoko, Sarah
    Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.
    Kerber, Kate
    Saving Newborn Lives program, Save the Children, Cape Town, South Africa.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Waiswa, Peter
    Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.
    Weeping in silence: community experiences of stillbirths in rural eastern Uganda2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 24011Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Stillbirths do not register amongst national or global public health priorities, despite large numbers and known solutions. Although not accounted in statistics - these deaths count for families. Part of this disconnect is that very little is known about the lived experiences and perceptions of those experiencing this neglected problem.

    OBJECTIVE:

    This study aimed to explore local definitions and perceived causes of stillbirths as well as coping mechanisms used by families affected by stillbirth in rural eastern Uganda.

    DESIGN:

    A total of 29 in-depth interviews were conducted with women who had a stillbirth (14), men whose wives experienced a stillbirth (6), grandmothers (4), grandfathers (1), and traditional birth attendants (TBAs) (4). Participants were purposively recruited from the hospital maternity ward register, with additional recruitment done through community leaders and other participants. Data were analysed using content analysis.

    RESULTS:

    Women and families affected by stillbirth report pregnancy loss as a common occurrence. Definitions and causes of stillbirth included the biomedical, societal, and spiritual. Disclosure of stillbirth varies with women who experience consecutive or multiple losses, subject to potential exclusion from the community and even the family. Methods for coping with stillbirth were varied and personal. Ritual burial practices were common, yet silent and mainly left to women, as opposed to public mourning for older children. There were no formal health system mechanisms to support or care for families affected by stillbirths.

    CONCLUSION:

    In a setting with strong collective ties, stillbirths are a burden borne by the affected family, and often just by the mother, rather than the community as a whole. Strategies are needed to address preventable stillbirths as well as to follow up with supportive services for those affected.

  • 42.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Chrispus, Mayora
    Johansson, Emily White
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wamani, Henry
    Bigdeli, Maryam
    Shroff, Zubin Cyrus
    Health system effects of implementing integrated community case management (iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative study2017In: BMJ Global Health, ISSN 2059-7908, Vol. 2, no e000334Article in journal (Refereed)
    Abstract [en]

    Background Intervening 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.

  • 43.
    Kitutu, Freddy Eric
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Kalyango, Joan Nakayaga
    Mayora, Chrispus
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wamani, Henry
    Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi-experimental study.2017In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 16, no 1, article id 425Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Fever 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 care-seeker 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.

  • 44.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Martensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wamani, Henry
    Makerere University School of Public Health.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kalyango, Joan
    Makerere University College of Health Sciences, Department of Pharmacy.
    Perceived quality of paediatric fever care from private drug shops and care-seeking choice in South Western Uganda: data from household surveys.In: Article in journal (Refereed)
    Abstract [en]

    Background

    Child mortality is influenced by interventions beyond the health sector such as adequate access to education, quality water and sanitation, transport and general socio-economic wellbeing. Child mortality due to febrile illnesses remains unevenly distributed within countries. The role of context and variables that act at a higher level such as a geographical location has been largely under-examined. Factors that act at group level are commonly described in literature as neighbourhood factors. The aim of the study was to investigate whether contextual differences in choice of childhood fever care-seeking in South Western Uganda remain after relevant individual and household characteristics have been taken into account, for three outcome variables, namely, choice of care-seeking in private versus government health facilities, choice of care-seeking in private health facilities versus community level and perceived quality of childhood fever care at drug shops, among households in Mbarara and Bushenyi districts.

    Methods

    Two household surveys were conducted at different time periods in Bushenyi and Mbarara districts. The first survey of 2261 households was conducted from July to October 2013 before implementation of an adapted integrated Community Case Management (iCCM) intervention for paediatric febrile illness in drug shops in Mbarara district. The second survey of 3073 households was done from April to May 2015 after the intervention. These data were analysed for effect of contextual factors, the iCCM intervention and other predictors on choice of care-seeking and perceived quality of care among the households in Mbarara and Bushenyi.

     

    Results:

    In the pre-intervention survey , more households in both Mbarara and Bushenyi reported time required to travel to either a private clinic (31%) or drug shop (43%) of 15 minutes or less as compared to a government health facility (12%). The crude second level (neighbourhood) variance of the odds ratio for care-seeking in private versus government health facility was 0.446 (SE, 0.089). The intra-neighbourhood correlation and median odds ratio were 11.9% and 1.89, respectively, for the crude model. After adjusting for covariates that were kept in the prediction model, the estimates of neighbourhood variance, intra-neighbourhood correlation and mean odds ratio decreased to 0.241 (0.069), 6.8% and 1.6, respectively.

     

    Conclusion:         

    In addition to individual factors, contextual characteristics of the neighbourhoods predict the choice of care-seeking from private versus government health facilities, private health facilities versus in the community and perceived quality of pediatric fever care at drug shops.

  • 45.
    Kitutu, Freddy
    et al.
    Makerere University College Health Sciences, Kampala, Uganda.
    Mayora, Chrispus
    Makerere University College Health Sciences, Kampala, Uganda.
    Awor, Phyllis
    Makerere University College Health Sciences, Kampala, Uganda.
    Forsberg, Birger
    Karolinska Institute, Stockholm, Sweden.
    Peterson, Stefan
    Karolinska Institute, Stockholm, Sweden.
    Wamani, Henry
    Makerere University College Health Sciences, Kampala, Uganda.
    Inclusion of private sector in district helath systems; case study of private drug shops implementing modified Integrated Community Case Management (iCCM) strategy in Rural Uganda2014Conference paper (Other academic)
  • 46.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wamani, Henry
    Makerere University School of Public Health.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Katabazi, Fred
    Makerere University College of Health Sciences, Department of Medical Microbiology.
    Kuteesa, Ronald
    Makerere University College of Health Sciences, Infectious Disease Institute.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kalyango, Joan
    Makerere University College of Health Sciences, Department of Pharmacy.
    Martensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Can malaria rapid diagnostic tests by drug sellers under field conditions classify children five years old or less with or without Plasmodium falciparum malaria? Comparison with nested PCR analysis.2018In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875Article in journal (Refereed)
    Abstract [en]

    Background

    Malaria 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 malaria RDT results is a challenge to drug sellers. Thus, drug seller interpretation of malaria RDT strips was compared with laboratory scientist re-reading, and PCR analysis of Plasmodium DNA extracted from malaria RDT nitrocellulose strips and Fast Transient Analysis (FTA) cards. Malaria RDT cassettes are also assessed as 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 west Uganda participated in the study. Duplicate 5μL samples of capillary blood were picked from the 212 children, dispensed onto the sample well of the CareStartTM Pf-HRP2 RDT cassette and a fast transient analysis (FTA), WhatmanTM 3MM filter paper in parallel. The malaria RDT strip was interpreted by the drug seller within 15 to 20 minutes, 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 malaria 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 malaria RDT strip was 93% with kappa value of 0.8 (95 % CI 0.7, 0.9). The drug seller compliance with the reported malaria RDT results and kappa value were 92.5% and 0.8 (95% CI 0.7, 0.9), respectively. 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 value ranging from 79% to 89.8% and negative predictive value above 90%.

    Conclusion:

    Drug sellers can use of malaria RDTs in field conditions and achieve acceptable accuracy for malaria diagnosis, and they comply with the malaria RDT results. Plasmodium DNA can be recovered from malaria RDT nitrocellulose strips even in the context of drug shops. Future malaria surveillance and diagnostic quality control studies with malaria RDT cassette as a source of Plasmodium DNA are recommended.

  • 47.
    Kozuki, Naoko
    et al.
    Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
    Guenther, Tanya
    Save the Children, Washington, DC, USA.
    Vaz, Lara
    Save the Children, Washington, DC, USA.
    Moran, Allisyn
    Save the Children, Washington, DC, USA.
    Soofi, Sajid B
    Aga Khan University, Karachi, Pakistan.
    Kayemba, Christine Nalwadda
    Makerere University College of Health Sciences School of Public Health, Kampala, Uganda.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Bhutta, Zulfiqar A
    Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
    Khanal, Sudhir
    Morang Innovative Neonatal Intervention/John Snow Inc. Research and Training Institute, Kathmandu, Nepal.
    Tielsch, James M
    Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA.
    Doherty, Tanya
    Health Systems Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa.
    Nsibande, Duduzile
    Health Systems Research Unit, South African Medical Research Council, Durban, South Africa.
    Lawn, Joy E
    Maternal Reproductive and Child Health (MARCH) Center, London School of Hygiene and Tropical Medicine, London, UK.
    Wall, Stephen
    Save the Children, Washington, DC, USA.
    A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia2015In: BMC public health, ISSN 1471-2458, Vol. 15, no 1, p. 989-Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: An estimated 2.8 million neonatal deaths occur annually worldwide. The vulnerability of newborns makes the timeliness of seeking and receiving care critical for neonatal survival and prevention of long-term sequelae. To better understand the role active referrals by community health workers play in neonatal careseeking, we synthesize data on referral completion rates for neonates with danger signs predictive of mortality or major morbidity in low- and middle-income countries.

    METHODS: A systematic review was conducted in May 2014 of the following databases: Medline-PubMed, Embase, and WHO databases. We also searched grey literature. In addition, an investigator group was established to identify unpublished data on newborn referral and completion rates. Inquiries were made to the network of research groups supported by Save the Children's Saving Newborn Lives project and other relevant research groups.

    RESULTS: Three Sub-Saharan African and five South Asian studies reported data on community-to-facility referral completion rates. The studies varied on factors such as referral rates, the assessed danger signs, frequency of home visits in the neonatal period, and what was done to facilitate referrals. Neonatal referral completion rates ranged from 34 to 97 %, with the median rate of 74 %. Four studies reported data on the early neonatal period; early neonatal completion rates ranged from 46 to 97 %, with a median of 70 %. The definition of referral completion differed by studies, in aspects such as where the newborns were referred to and what was considered timely completion.

    CONCLUSIONS: Existing literature reports a wide range of neonatal referral completion rates in Sub-Saharan Africa and South Asia following active illness surveillance. Interpreting these referral completion rates is challenging due to the great variation in study design and context. Often, what qualifies as referral and/or referral completion is poorly defined, which makes it difficult to aggregate existing data to draw appropriate conclusions that can inform programs. Further research is necessary to continue highlighting ways for programs, governments, and policymakers to best aid families in low-resource settings in protecting their newborns from major health consequences.

  • 48.
    Lawn, Joy E
    et al.
    London Sch Hyg & Trop Med, Maternal Adolescent & Reprod Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Bhutta, Zulfiqar A
    Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan.; Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.
    Wall, Steve N
    Saving Newborn Lives, Save the Children, Washington, DC, USA.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. UNICEF, New York, NY, USA.; Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
    Daviaud, Emmanuelle
    Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
    Cadres, content and costs for community-based care for mothers and newborns from seven countries: implications for universal health coverage2017In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, no suppl_1, p. i1-i5Article in journal (Other academic)
  • 49.
    Lindstrand, Ann
    et al.
    Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Kalyango, Joan
    Makerere University School of Public Health, Kampala, Uganda.
    Alfvén, Tobias
    Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Darenberg, Jessica
    Public Health Agency of Sweden, Stockholm, Sweden.
    Kadobera, Daniel
    Makerere University School of Public Health, Kampala, Uganda.
    Bwanga, Freddie
    Makerere University Faculty of Medicine, Kampala, Uganda.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Henriques-Normark, Birgitta
    Public Health Agency of Sweden, Stockholm, Sweden.
    Källander, Karin
    Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Pneumococcal Carriage in Children under Five Years in Uganda-Will Present Pneumococcal Conjugate Vaccines Be Appropriate?2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 11, article id e0166018Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Pneumonia is the major cause of death in children globally, with more than 900,000 deaths annually in children under five years of age. Streptococcus pneumoniae causes most deaths, most often in the form of community acquired pneumonia. Pneumococcal conjugate vaccines (PCVs) are currently being implemented in many low-income countries. PCVs decrease vaccine-type pneumococcal carriage, a prerequisite for invasive pneumococcal disease, and thereby affects pneumococcal disease and transmission. In Uganda, PCV was launched in 2014, but baseline data is lacking for pneumococcal serotypes in carriage.

    OBJECTIVES: To study pneumococcal nasopharyngeal carriage and serotype distribution in children under 5 years of age prior to PCV introduction in Uganda.

    METHODS: Three cross-sectional pneumococcal carriage surveys were conducted in 2008, 2009 and 2011, comprising respectively 150, 587 and 1024 randomly selected children aged less than five years from the Iganga/Mayuge Health and Demographic Surveillance Site. The caretakers were interviewed about illness history of the child and 1723 nasopharyngeal specimens were collected. From these, 927 isolates of S. pneumoniae were serotyped.

    RESULTS: Overall, the carriage rate of S. pneumoniae was 56% (957/1723). Pneumococcal carriage was associated with illness on the day of the interview (OR = 1.50, p = 0.04). The most common pneumococcal serotypes were in descending order 19F (16%), 23F (9%), 6A (8%), 29 (7%) and 6B (7%). One percent of the strains were non-typeable. The potential serotype coverage rate for PCV10 was 42% and 54% for PCV13.

    CONCLUSION: About half of circulating pneumococcal serotypes in carriage in the Ugandan under-five population studied was covered by available PCVs.

  • 50.
    Lubega, Muhamadi
    et al.
    District Health Office, Iganga District Administration, PO Box 358, Iganga, Uganda.
    Nsabagasani, Xavier
    Tumwesigye, Nazarius M.
    Wabwire-Mangen, Fred
    Ekström, Anna Mia
    Pariyo, George
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Policy and practice, lost in transition: Reasons for high drop-out from pre-antiretroviral care in a resource-poor setting of eastern Uganda2010In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 95, no 2-3, p. 153-158Article in journal (Refereed)
    Abstract [en]

    Objective: This study explores reasons for drop-out from pre-ARV care in a resource-poor setting where premature death is a common consequence of delayed ARV initiation. Methods: In Iganga, Uganda, we conducted key informant interviews with staff at the pre-ARV clinic, focus group discussions with persons who looked after people living with HIV (PLWH) and in-depth interviews with PLWH half of whom had dropped out of pre-ARV care. Content data analysis was done to identify recurrent themes. Results: Reasons cited for dropping out of pre-ARV care include: inadequate post-test counseling due to staff work overload, competition from the holistic and less stigmatizing traditional/spiritual healers. Others were transportation costs, long waiting time lack of incentives to seek pre-ARV care by healthy looking PLWH and gender inequalities. Conclusions: Pre-ARV adherence counseling should be improved through recruitment of counselors or multi-skilling in counseling skills for the available staff to reduce on the work load. Traditional/ spiritual healers should be integrated and supervised to offer pre-ARV care. Door step supply of cotrimoxazole using agents could reduce transport costs, waiting time and increase access to pre-ARV. Women should be sensitized on comprehensive HIV care through the local media and local leaders to address gender inequalities.

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