An assessment of implementation science research capacity in Uganda

Background

In Uganda and other resource-poor countries, relevant research findings face a tortuous path to translation into policy and routine practice. Implementation science (ImSc) research could facilitate faster translation. Presently it is unclear what ImSc research capacity and possible training needs exist among Ugandan researchers. To assess both components, we interviewed potential trainees in Kampala, Uganda.

Methods

We used a cross-sectional design to survey potential ImSc trainees who had some research training and involvement in generating or utilizing research. Using a questionnaire, we documented eligibility for ImSc training, knowledge and interest in training, existing self-assessed confidence in initiating clinical research (SCICR) and self-assessed confidence in initiating ImSc research (SCIIR), availability for training and preferred modes of training. We developed scores from the Likert scales and used descriptive statistics, logistic regression and ordinal logistic regression to evaluate predictors of SCIIR.

Results

Between November 2016 and April 2017, we interviewed 190 participants; 60% were men, with a median age of 37 years. Among participants, 33% comprised faculty, 37% were graduate students and 30% were project staff. The majority of respondents knew about ImSc (73%) and were research-trained (80%). Only 9% reported any ImSc-related training. Previous ImSc training was associated with higher odds of a SCIIR score ≥ 75th percentile. Previous ImSc training compared to not having any training was associated with higher odds of reporting abilities in behaviour change theory integration (OR: 3.3, 95% CI: 1.3–8.5, p = 0.01) and framework use in intervention design and implementation (OR: 2.9, 95% CI: 1.1–7.4, p = 0.03), accounting for age, sex and current employment. In addition, 53% of participants preferred in-person (face-to-face) short ImSc courses compared to a year-long training, while 33% preferred online courses. Participants reported median availability of 6 hours per week (IQR: 4, 10) for training.

Conclusion

Most participants had some understanding of ImSc research, had research training and were interested in ImSc training. Those with previous ImSc training had better skills and SCIIR, compared to those without previous training. A hybrid approach with modular face-to-face training and online sessions would suit the preferences of most potential trainees.

Availability, functionality and access of blood pressure machines at the points of care in public primary care facilities in Tororo district, Uganda

BACKGROUND

Early diagnosis of hypertension prevents a significant number of complications and premature deaths. In resource-variable settings, diagnosis may be limited by inadequate access to blood pressure (BP) machines. We sought to understand the availability, functionality and access of BP machines at the points of care within primary care facilities in Tororo district, Uganda.

METHODS

This was an explanatory sequential mixed-methods study combining a structured facility checklist and key informant interviews with primary care providers. The checklist was used to collect data on availability and functionality of BP machines within their organisational arrangements. Key informant interviews explored health providers' access to BP machines.

RESULTS

The majority of health facilities reported at least one working BP machine. However, Health providers described limited access to machines because they are not located at each point of care. Health providers reported borrowing amongst themselves within their respective units or from other units within the facility. Some health providers purchase and bring their own BP machines to the health facilities or attempted to restore the functionality of broken ones. They are motivated to search the clinic for BP machines for some patients but not others based on their perception of the patient's risk for hypertension.

CONCLUSION

Access to BP machines at the point of care was limited. This makes hypertension screening selective based on health providers' perception of the patients' risk for hypertension. Training in proper BP machine use and regular maintenance will minimise frequent breakdowns.

Lessons learned from descriptions and evaluations of knowledge translation platforms supporting evidence-informed policy-making in low- and middle-income countries: a systematic review

BACKGROUND

Knowledge translation (KT) platforms are organisations, initiatives and networks that focus on supporting evidence-informed policy-making at least in part about the health-system arrangements that determine whether the right programmes, services and products get to those who need them. Many descriptions and evaluations of KT platforms in low- and middle-income countries have been produced but, to date, they have not been systematically reviewed.

METHODS

We identified potentially relevant studies through a search of five electronic databases and a variety of approaches to identify grey literature. We used four criteria to select eligible empirical studies. We extracted data about seven characteristics of included studies and about key findings. We used explicit criteria to assess study quality. In synthesising the findings, we gave greater attention to themes that emerged from multiple studies, higher-quality studies and different contexts.

RESULTS

Country was the most common jurisdictional focus of KT platforms, EVIPNet the most common name and high turnover among staff a common infrastructural feature. Evidence briefs and deliberative dialogues were the activities/outputs that were the most extensively studied and viewed as helpful, while rapid evidence services were the next most studied but only in a single jurisdiction. None of the summative evaluations used a pre-post design or a control group and, with the exception of the evaluations of the influence of briefs and dialogues on intentions to act, none of the evaluations achieved a high quality score.

CONCLUSIONS

A large and growing volume of research evidence suggests that KT platforms offer promise in supporting evidence-informed policy-making in low- and middle-income countries. KT platforms should consider as next steps expanding their current, relatively limited portfolio of activities and outputs, building bridges to complementary groups, and planning for evaluations that examine 'what works' for 'what types of issues' in 'what types of contexts'.

Ethical and human rights considerations in public health in low and middle-income countries: an assessment using the case of Uganda's responses to COVID-19 pandemic

Background

In response to COVID-19 pandemic, the Government of Uganda adopted public health measures to contain its spread in the country. Some of the initial measures included refusal to repatriate citizens studying in China, mandatory institutional quarantine, and social distancing. Despite being a public health emergency, the measures adopted deserve critical appraisal using an ethics and human rights approach. The goal of this paper is to formulate an ethics and human rights criteria for evaluating public health measures and use it to reflect on the ethical propriety of those adopted by the government of Uganda to contain the spread of COVID-19.

Main body

We begin by illustrating the value of ethics and human rights considerations for public health measures including during emergencies. We then summarize Uganda’s social and economic circumstances and some of the measures adopted to contain the spread of COVID-19. After reviewing some of the ethics and human rights considerations for public health, we reflect upon the ethical propriety of some of Uganda’s responses to COVID-19. We use content analysis to identify the measures adopted by the government of Uganda to contain the spread of COVID-19, the ethics and human rights considerations commonly recommended for public health responses and their importance. Our study found that some of the measures adopted violate ethics and human rights principles. We argue that even though some human rights can sometimes be legitimately derogated and limited to meet public health goals during public health emergencies, measures that infringe on human rights should satisfy certain ethics and human rights criteria. Some of these criteria include being effective, strictly necessary, proportionate to the magnitude of the threat, reasonable in the circumstances, equitable, and least restrictive. We reflect on Uganda’s initial measures to combat the spread of COVID-19 and argue that many of them fell short of these criteria, and potentially limit their effectiveness.

Conclusion

The ethical legitimacy of public health measures is valuable in itself and for enhancing effectiveness of the measures. Such legitimacy depends on the extent to which they conform to ethics and human rights principles recommended for public health measures.

Communities and Clinical Trials: A Case Study from the RTS,S Malaria Vaccine Trials in Eastern Africa

When clinical trials enter human communities, two complex systems merge-creating challenges for the clinical trial team and the local human community. This is of particular relevance for clinical trials in low-resource settings where the resource scarcity can intensify existing inequities. Here we present a case study of a phase III malaria vaccine clinical trial. Through qualitative interviews with researchers and caregivers of pediatric participants we elucidate themes that shape the clinical trial system. These themes can be a useful complementary planning tool to existing research guidelines for clinical trial researchers. Respondents from both groups reported financial and social contextual realities to be major drivers in the system. We found a strong historical path dependency in the community that was closely tied to the relationships with researchers and indicative of the structural inequities. We elaborate on these findings and offer recommendations to improve trial design.

HIV and syphilis testing behaviors among heterosexual male and female sex workers in Uganda

Background

In Sub-Saharan Africa where HIV disproportionately affects women, heterosexual male sex workers (HMSW) and their female clients are at risk of acquiring or transmitting HIV and other STIs. However, few studies have described HIV and STI risk among HMSW. We aimed to assess and compare recent HIV and syphilis screening practices among HMSW and female sex workers (FSW) in Uganda.

Methods

Between August and December 2019, we conducted a cross-sectional study among 100 HMSW and 240 female sex workers (FSW). Participants were enrolled through snowball sampling, and an interviewer-administered questionnaire used to collect data on HIV and syphilis testing in the prior 12 and 6 months respectively. Integrated change model constructs were used to assess intentions, attitudes, social influences, norms and self-efficacy of 3-monthly Syphilis and 6-monthly HIV testing. Predictors of HIV and syphilis recent testing behaviors were estimated using negative binomial regression.

Results

We enrolled 340 sex workers of whom 100 (29%) were HMSW. The median age was 27 years [interquartile range (IQR) 25–30] for HMSW and 26 years [IQR], (23–29) for FSW. The median duration of sex work was 36 and 30 months for HMSW and FSW, respectively. HMSW were significantly less likely than FSW to have tested for HIV in the prior 12 months (50% vs. 86%; p = 0.001). For MSW, non-testing for HIV was associated with higher education [adjusted prevalence ratio (aPR) 1.66; 95% confidence interval (CI) 1.09–2.50], poor intention to seek HIV testing (aPR 1.64; 95% CI 1.35–2.04), perception that 6-monthly HIV testing was not normative (aPR 1.33; 95% CI 1.09–1.67) and low self-efficacy (aPR 1.41; 95% CI 1.12–1.79). Not testing for syphilis was associated with low intention to seek testing (aPR 3.13; 95% CI 2.13–4.55), low self-efficacy (aPR 2.56; 95% CI 1.35–4.76), negative testing attitudes (aPR 2.33; 95% CI 1.64–3.33), and perception that regular testing was not normative (aPR 1.59; 95% CI 1.14–2.22).

Conclusions

Non-testing for HIV and syphilis was common among HMSW relative to FSW. Future studies should evaluate strategies to increase testing uptake for this neglected sub-population of sex workers.

Risk and protective factors associated with BV chronicity among women in Rakai, Uganda

OBJECTIVES

To assess risk and protective factors associated with bacterial vaginosis (BV) chronicity ascertained by Nugent score criteria.

METHODS

A longitudinal cohort study included 255 sexually experienced, postmenarcheal women who provided weekly self-collected vaginal swabs for up to 2 years. Vaginal swabs were scored using Nugent criteria and classified as normal (≤3), intermediate (4-6) and Nugent-BV (≥7). Detailed behavioural/health information were assessed every 6 months. A per-woman longitudinal summary measure of BV chronicity was defined as the percentage of each woman's weekly vaginal assessments scored as Nugent-BV over a 6-month interval. Risk and protective factors associated with BV chronicity were assessed using multiple linear regression with generalised estimating equations.

RESULTS

Average BV chronicity was 39% across all follow-up periods. After adjustment, factors associated with BV chronicity included baseline Nugent-BV (β=35.3, 95% CI 28.6 to 42.0) compared with normal baseline Nugent scores and use of unprotected water for bathing (ie, rainwater, pond, lake/stream) (β=12.0, 95% CI 3.4 to 20.5) compared with protected water sources (ie, well, tap, borehole). Women had fewer BV occurrences if they were currently pregnant (β=-6.6, 95% CI -12.1 to 1.1), reported consistent condom use (β=-7.7, 95% CI -14.2 to 1.3) or their partner was circumcised (β=-5.8, 95% CI -11.3 to 0.3).

CONCLUSIONS

Factors associated with higher and lower values of BV chronicity were multifactorial. Notably, higher values of BV chronicity were associated with potentially contaminated bathing water. Future studies should examine the role of waterborne microbial agents in the pathogenesis of BV.

Cango Lyec (Healing the Elephant): HIV incidence in post-conflict Northern Uganda

BACKGROUND

Civil war in Northern Uganda resulted in widespread atrocities, human rights violations, and death, and caused millions to flee to internally displaced persons camps. War-related traumas combined with difficulties accessing HIV prevention and health services has led to extreme HIV-related vulnerability among conflict-affected people who survived the war. Objectives were to (1) determine HIV incidence among conflict-affected people in Northern Uganda and (2) identify vulnerabilities associated with HIV infection.

METHODS

The Cango Lyec (Healing the Elephant) Project is a prospective cohort involving conflict-affected populations in three districts in Northern Uganda. In 2011, eight randomly selected communities were mapped, and a census was conducted. Consenting participants aged 13-49 years were followed over three rounds of follow-up. Longitudinal data collected included war-related experiences, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV-1 at baseline and each 12-month follow-up. Multivariable Cox proportional hazard models determined factors associated with HIV incidence.

FINDINGS

Overall, 1920 baseline HIV-negative participants with at least one follow-up contributed 3877 person-years (py) for analysis. Thirty-nine (23 female, 16 male) participants contracted HIV during follow-up. Age- and gender-standardised HIV incidence rate was 10•2 per 1000py (95%CI: 7•2-14•0). Stratified by sex, the age-adjusted HIV incidence was 11•0 per 1000py (95%CI: 6•9-16•6) among women and 9•4 per 1000py (95%CI: 5•3-15•3) among men. Adjusting for confounders, factors associated with risk of HIV included: having been abducted (HR: 3•70; 95%CI: 1•87-7•34), experiencing ≥12 war-related traumatic events (HR: 2•91 95%CI: 1•28-6•60), suicide ideation (HR: 2•83; 95%CI: 1•00-8•03), having ≥2 sexual partners (HR: 4•68; 95%CI: 1•36-16•05), inconsistent condom use (HR: 6•75; 95%CI: 2•49-18•29), and self-reported genital ulcers (HR: 4•39; 95%CI: 2•04-9•45).

INTERPRETATION

Conflict-affected participants who had experienced abduction and multiple traumas during the war were at greater risk of HIV infection. Trauma-informed HIV prevention and treatment services, and culturally-safe mental health initiatives, are urgent for Northern Uganda.

Effects of the Informed Health Choices podcast on the ability of parents of primary school children in Uganda to assess the trustworthiness of claims about treatment effects: one-year follow up of a randomised trial

INTRODUCTION

Earlier, we designed and evaluated an educational mass media intervention for improving people's ability to think more critically and to assess the trustworthiness of claims (assertions) about the benefits and harms (effects) of treatments. The overall aims of this follow-up study were to evaluate the impact of our intervention 1 year after it was administered, and to assess retention of learning and behaviour regarding claims about treatments.

METHODS

We randomly allocated consenting parents to listen to either the Informed Health Choices podcast (intervention) or typical public service announcements about health issues (control) over 7-10 weeks. Each intervention episode explained how the trustworthiness of treatment claims can be assessed by using relevant key concepts of evidence-informed decision-making. Participants listened to two episodes per week, delivered by research assistants. We evaluated outcomes immediately, and a year after the intervention. Primary outcomes were mean score and the proportion with a score indicating a basic ability to apply the key concepts (> 11 out of 18 correct answers) on a tool measuring people's ability to critically appraise the trustworthiness of treatment claims. Skills decay/retention was estimated by calculating the relative difference between the follow-up and initial results in the intervention group, adjusting for chance. Statistical analyses were performed using R (R Core Team, Vienna, Austria; version 3.4.3).

RESULTS

After 1 year, the mean score for parents in the intervention group was 58.9% correct answers, compared to 52.6% in the control (adjusted mean difference of 6.7% (95% CI 3.3% to 10.1%)). In the intervention group, 47.2% of 267 parents had a score indicating a basic ability to assess treatment claims compared to 39.5% of 256 parents in the control (adjusted difference of 9.8% more parents (95% CI 0.9% to 18.9%). These represent relative reductions of 29% in the mean scores and 33% in the proportion of parents with a score indicating a basic ability to assess the trustworthiness of claims about treatment effects.

CONCLUSIONS

Although listening to the Informed Health Choices podcast initially led to a large improvement in the ability of parents to assess claims about the effects of treatments, our findings show that these skills decreased substantially over 1 year. More active practice could address the substantial skills decay observed over 1 year.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (www.pactr.org), PACTR201606001676150. Registered on 12 June 2016.

Effects of the Informed Health Choices primary school intervention on the ability of children in Uganda to assess the reliability of claims about treatment effects, 1-year follow-up: a cluster-randomised trial

INTRODUCTION

We evaluated an intervention designed to teach 10- to 12-year-old primary school children to assess claims about the effects of treatments (any action intended to maintain or improve health). We report outcomes measured 1 year after the intervention.

METHODS

In this cluster-randomised trial, we included primary schools in the central region of Uganda that taught year 5 children (aged 10 to 12 years). We randomly allocated a representative sample of eligible schools to either an intervention or control group. Intervention schools received the Informed Health Choices primary school resources (textbooks, exercise books and a teachers' guide). The primary outcomes, measured at the end of the school term and again after 1 year, were the mean score on a test with two multiple-choice questions for each of the 12 concepts and the proportion of children with passing scores.

RESULTS

We assessed 2960 schools for eligibility; 2029 were eligible, and a random sample of 170 were invited to recruitment meetings. After recruitment meetings, 120 eligible schools consented and were randomly assigned to either the intervention group (n = 60 schools; 76 teachers and 6383 children) or the control group (n = 60 schools; 67 teachers and 4430 children). After 1 year, the mean score in the multiple-choice test for the intervention schools was 68.7% compared with 53.0% for the control schools (adjusted mean difference 16.7%; 95% CI, 13.9 to 19.5; P < 0.00001). In the intervention schools, 3160 (80.1%) of 3943 children who completed the test after 1 year achieved a predetermined passing score (≥ 13 of 24 correct answers) compared with 1464 (51.5%) of 2844 children in the control schools (adjusted difference, 39.5%; 95% CI, 29.9 to 47.5).

CONCLUSION

Use of the learning resources led to a large improvement in the ability of children to assess claims, which was sustained for at least 1 year.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (www.pactr.org), PACTR201606001679337. Registered on 13 June 2016.

Non-surgical oral hygiene interventions on disease activity of Rheumatoid arthritis patients with periodontitis: A randomized controlled trial

Background. Periodontitis and rheumatoid arthritis have similar epidemiology and pathophysiology. Understanding the interaction between these two diseases is vital in our settings. We set out to assess the effect of oral hygiene interventions on disease activity of rheumatoid arthritis patients with periodontitis in Kampala, Uganda. Methods. Fifty-eight patients attending an arthritis clinic with rheumatoid arthritis and periodontitis were randomly assigned to either an intervention group or a control group. Patients diagnosed with rheumatoid arthritis at least two years before, who were on the same medication, dose, or formulation for RA treatment during the preceding three months, were included. The patients were >18 years of age, would be available for all the study visits in the next six months, had at least six natural teeth, had periodontal disease classified as Dutch Periodontal Index (DPSI) >3 and provided written informed consent. Those who had a chronic disorder requiring chronic or intermittent use of antibiotics, were pregnant, were lactating, or had intent to become pregnant were excluded. The primary outcome measure was a change in Disease Activity Score of 28 Joints (DAS28 score) in two 3-month follow-up periods after the intervention. The secondary outcome measure was a change in periodontal status. Results. There was a statistically significant improvement in the DAS-28 score in both the intervention and control arms during the follow-up period (P<0.01). The participants carrying more than one bacterial species had worse DAS-28 scores. Conclusion. Oral hygiene interventions given to RA patients could drastically improve their RA treatment outcomes, especially in resource-limited settings.

Impact of combination HIV interventions on HIV incidence in hyperendemic fishing communities in Uganda: a prospective cohort study

BACKGROUND

Targeting combination HIV interventions to locations and populations with high HIV burden is a global priority, but the impact of these strategies on HIV incidence is unclear. We assessed the impact of combination HIV interventions on HIV incidence in four HIV-hyperendemic communities in Uganda.

METHODS

We did an open population-based cohort study of people aged 15-49 years residing in four fishing communities on Lake Victoria. The communities were surveyed five times to collect self-reported demographic, behavioural, and service-uptake data. Free HIV testing was provided at each interview, with referral to combination HIV intervention services as appropriate. From November, 2011, combination HIV intervention services were rapidly expanded in these geographical areas. We evaluated trends in HIV testing coverage among all participants, circumcision coverage among male participants, antiretroviral therapy (ART) coverage and HIV viral load among HIV-positive participants, and sexual behaviours and HIV incidence among HIV-negative participants.

FINDINGS

From Nov 4, 2011, to Aug 16, 2017, data were collected from five surveys. Overall, 8942 participants contributed 20 721 person-visits; 4619 (52%) of 8942 participants were male. HIV prevalence was 41% (1598 of 3870) in the 2011-12 baseline survey and declined to 37% (1740 of 4738) at the final survey (p<0·0001). 3222 participants who were HIV-negative at baseline, and who had at least one repeat visit, contributed 9477 person-years of follow-up, and 230 incident HIV infections occurred. From the first survey in 2011-12 to the last survey in 2016-17, HIV testing coverage increased from 68% (2613 of 3870) to 96% (4526 of 4738; p<0·0001); male circumcision coverage increased from 35% (698 of 2011) to 65% (1630 of 2525; p<0·0001); ART coverage increased from 16% (254 of 1598) to 82% (1420 of 1740; p<0·0001); and population HIV viral load suppression in all HIV-positive participants increased from 34% (546 of 1596) to 80% (1383 of 1734; p<0·0001). Risky sexual behaviours did not decrease over this period. HIV incidence decreased from 3·43 per 100 person-years (95% CI 2·45-4·67) in 2011-12 to 1·59 per 100 person-years (95% CI 1·19-2·07) in 2016-17; adjusted incidence rate ratio (IRR) 0·52 (95% CI 0·34-0·79). Declines in HIV incidence were similar among men (adjusted IRR 0·53, 95% CI 0·30-0·93) and women (0·51, 0·27-0·96). The risk of incident HIV infection was lower in circumcised men than in uncircumcised men (0·46, 0·32-0·67).

INTERPRETATION

Rapid expansion of combination HIV interventions in HIV-hyperendemic fishing communities is feasible and could have a substantial impact on HIV incidence. However, incidence remains higher than HIV epidemic control targets, and additional efforts will be needed to achieve this global health priority.

FUNDING

The National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Cancer Institute, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, Centers for Disease Control and Prevention Uganda, Karolinska Institutet, and the Johns Hopkins University Center for AIDS Research.

Psychosocial correlates of regular syphilis and HIV screening practices among female sex workers in Uganda: a cross-sectional survey

BACKGROUND

Limited data are available regarding correlates of regular sexually transmitted infections (STIs) and HIV screening among female sex workers (FSW) in Sub-Saharan Africa. In this study, we aimed to assess the frequency of regular syphilis and HIV screening and the psychosocial correlates associated with screening among FSW in Uganda.

METHODS

This cross-sectional correlational study was conducted among 441 FSW, aged 17-49 years. We enrolled FSW through peer referrals and ascertained self-reported data on number of serological tests for HIV, syphilis and other STIs in the prior 12 months using an interviewer-administered questionnaire. In addition, we assessed attitudes, norms, social influences and self-efficacy towards 3-monthly Syphilis and 6-monthly HIV testing. We estimated the correlates of regular STI and HIV testing using negative binomial regression.

RESULTS

Of the respondents 420 (95.2%) reported to have ever taken an HIV test with 297 (67.4%) testing two or more times in the prior 12 months. Over half of the respondents (59%) reported ever taking a syphilis test with only 62 (14.1%) reporting testing three or more times in the prior 12 months. After adjusting for socio-demographics, attitude and norms, high perceived self-efficacy was associated with a 33% increase in the likelihood of repeated HIV testing [prevalence ratio (PR), 1.33, 95% confidence interval (CI) 1.15-1.53] while low perceived confidence was associated with a 25% decrease in the likelihood of repeated HIV testing (PR, 0.75, 95% CI 0.63-0.89). Similarly low attitudes and norms were associated with a decrease of 52.6% (PR, 0.47, 95% CI 0.37-0.61) and 47% (PR, 0.53, 95% CI 0.41-0.69) in the likelihood of repeated syphilis testing respectively.

CONCLUSION

Compared to HIV, uptake of repeated syphilis testing was very low. Correlates of HIV testing include; perceived self-efficacy amidst barriers and perceived confidence for HIV and low attitudes and accepting norms for syphilis. Health campaigns should emphasize overcoming barriers to HIV testing while promoting attitudes and norms including integration of serological syphilis testing and other STIs into HIV services.

Xpert® MTB/RIF associated with improved treatment initiation among patients with smear-negative tuberculosis

BACKGROUND:

Delayed diagnosis and treatment initiation of smear-negative tuberculosis (TB) patients can lead to increased morbidity and mortality, particularly among those co-infected with the human immunodeficiency virus (HIV).

OBJECTIVE:

To compare TB treatment initiation among smear-negative presumptive TB patients in the 6 months before and after the introduction of Xpert^® MTB/RIF testing at five rural tertiary hospitals in Uganda.

METHODS:

Patient records of the dates and results of sputum analysis were extracted from TB laboratory registers and linked to those on treatment initiation as indicated in the TB treatment registers. The proportion of smear-negative presumptive patients who initiated anti-tuberculosis treatment was compared before and after Xpert implementation using χ² tests. Time to treatment was analysed using Kaplan-Meier survival analysis.

RESULTS:

Records from 3658 patients were analysed, 1894 before and 1764 after the introduction of Xpert testing. After the introduction of Xpert, 25% (437/1764) of smear-negative presumptive TB patients underwent testing. The proportion initiated on anti-tuberculosis treatment increased from 5.9% (112/1894) to 10.8% (190/1764) (P < 0.01). However, 37% (32/87) of patients with a confirmed TB diagnosis did not initiate treatment. Time to TB treatment initiation improved from 8 to 3.5 days between the study periods.

CONCLUSION:

Xpert testing was associated with improved TB treatment initiation among smear-negative presumptive TB patients. Improved utilisation and linkage to treatment could improve the impact of this test on patient-centred outcomes.

Terminal Effector CD8 T Cells Defined by an IKZF2+IL-7R- Transcriptional Signature Express FcγRIIIA, Expand in HIV Infection, and Mediate Potent HIV-Specific Antibody-Dependent Cellular Cytotoxicity

Chronic HIV-1 is associated with increased levels of FcγRIIIA⁺ CD8 T cells.

FcγRIIIA⁺ CD8 T cells display an innate transcriptomic profile akin to NK cells.

ADCC is mediated by FcγRIIIA⁺ CD8 T cells at levels comparable with NK cells.

HIV-1 infection expands large populations of late-stage differentiated CD8 T cells that may persist long after viral escape from TCR recognition. In this study, we investigated whether such CD8 T cell populations can perform unconventional innate-like antiviral effector functions. Chronic untreated HIV-1 infection was associated with elevated numbers of CD45RA⁺CD57⁺ terminal effector CD8 T cells expressing FcγRIIIA (CD16). The FcγRIIIA⁺ CD8 T cells displayed a distinctive transcriptional profile between conventional CD8 T cells and NK cells, characterized by high levels of IKZF2 and low expression of IL7R. This transcriptional profile translated into a distinct NKp80⁺ IL-7Rα⁻ surface phenotype with high expression of the Helios transcription factor. Interestingly, the FcγRIIIA⁺ CD8 T cells mediated HIV-specific Ab-dependent cellular cytotoxicity (ADCC) activity at levels comparable with NK cells on a per cell basis. The FcγRIIIA⁺ CD8 T cells were highly activated in a manner that correlated positively with expansion of the CD8 T cell compartment and with plasma levels of soluble mediators of antiviral immunity and inflammation such as IP-10, TNF, IL-6, and TNFRII. The frequency of FcγRIIIA⁺ CD8 T cells persisted as patients initiated suppressive antiretroviral therapy, although their activation levels declined. These data indicate that terminally differentiated effector CD8 T cells acquire enhanced innate cell-like characteristics during chronic viral infection and suggest that HIV-specific ADCC is a function CD8 T cells use to target HIV-infected cells. Furthermore, as the FcγRIIIA⁺ CD8 T cells persist in treatment, they contribute significantly to the ADCC-capable effector cell pool in patients on antiretroviral therapy.

Informed health choices intervention to teach primary school children in low-income countries to assess claims about treatment effects: process evaluation

BACKGROUND

We developed the informed health choices (IHC) primary school resources to teach children how to assess the trustworthiness of claims about the effects of treatments. We evaluated these resources in a randomised trial in Uganda. This paper describes the process evaluation that we conducted alongside this trial.

OBJECTIVES

To identify factors affecting the implementation, impact and scaling up of the intervention; and potential adverse and beneficial effects of the intervention.

METHODS

All 85 teachers in the 60 schools in the intervention arm of the trial completed a questionnaire after each lesson and at the end of the term. We conducted structured classroom observations at all 60 schools. For interviews and focus groups, we purposively selected six schools. We interviewed district education officers, teachers, head teachers, children and their parents. We used a framework analysis approach to analyse the data.

RESULTS

Most of the participants liked the IHC resources and felt that the content was important. This motivated the teachers and contributed to positive attitudes. Although some teachers started out lacking confidence, many found that the children's enthusiasm for the lessons made them more confident. Nearly everyone interviewed thought that the children learnt something important and many thought that it improved their decision-making. The main barrier to scaling up use of the IHC resources that participants identified was the need to incorporate the lessons into the national curriculum.

CONCLUSION

The mostly positive findings reflect the trial results, which showed large effects on the children's and the teachers' critical appraisal skills. The main limitations of this evaluation are that the investigators were responsible for both developing and evaluating the intervention.

Clinical trials in low-resource settings: the perspectives of caregivers of paediatric participants from Uganda, Tanzania and Kenya

Objectives

Vaccine clinical trials in low‐resource settings have unique challenges due to structural and financial inequities. Specifically, protecting participant and caregiver autonomy to participate in the research study can be a major challenge, so understanding the setting and contextual factors which influence the decision process is necessary. This study investigates the experience of caregivers consenting on behalf of paediatric participants in a malaria vaccine clinical trial where participation enables access to free, high‐quality medical care.

Methods

We interviewed a total of 78 caregivers of paediatric participants previously enrolled in a phase II or III malaria vaccine clinical trial in Uganda, Tanzania and Kenya. Interviews were qualitative and analysed using a thematic framework analysis focusing on the embodied caregiver in the political, economic and social reality.

Results

Caregivers of participants in this study made the decision to enrol their child based on economic, social and political factors that extended beyond the trial into the community and the home. The provision of health care was the dominant reason for participation. Respondents reported how social networks, rumours, hierarchal structures, financial constraints and family dynamics affected their experience with research.

Conclusions

The provision of medical care was a powerful motivator for participation. Caregiver choice was limited by structural constraints and scarce financial resources. The decision to participate in research extended beyond individual consent and was embedded in community and domestic hierarchies. Future research should assess other contexts to determine how the choice to participate in research is affected when free medical care is offered.

Resource-oriented interventions for patients with severe mental illnesses in low- and middle-income countries: trials in Bosnia-Herzegovina, Colombia and Uganda

BACKGROUND

Severe mental illness (SMI) presents a major burden to societies worldwide. Low- and middle-income countries (LMICs) often do not have sufficient financial resources and qualified staff to provide extensive specialised services for outpatients with SMI. Our research therefore aims to explore and test low-cost interventions that use existing resources in routine patient-clinician meetings, families and communities.

METHODS

In Bosnia-Herzegovina, Colombia and Uganda, three psychosocial interventions will be tested, i.e. making patient-clinician meetings therapeutically effective through DIALOG+, family involvement in multi-family group meetings, and support for patients in befriending schemes with volunteers. All interventions will be provided to patients with SMI, delivered over a six-month period and evaluated with assessments at baseline and after six and 12 months. We will conduct nine trials including non-controlled trials, non-randomised controlled trials and randomised controlled trials (RCTs). Core outcome criteria will be used across all studies. However, details of study delivery and additional outcome criteria vary to accommodate local contexts, interests and priorities. The studies will be analysed separately, but with the option to compare and combine findings.

DISCUSSION

The approach provides the opportunity to learn from commonalities and differences in the results and experiences across the three resource-oriented approaches and the three countries. If successfully implemented the studies can lead to more extensive research and are expected to inform health policies and clinical practice of community care for patients with SMI in the three participating countries and other LMICs.

TRIAL REGISTRATION

All RCTs were registered prospectively and non-randomised trials retrospectively within the ISRCTN Registry. DIALOG+ in Uganda: ISRCTN25146122 (Date of Registration: 20/11/2018, prospective); DIALOG+ in Colombia: ISRCTN83333181 (Date of Registration: 20/11/2018, prospective); DIALOG+ in Bosnia-Herzegovina: ISRCTN13347129 (Date of Registration: 20/11/2018, prospective); Volunteer Support in Uganda: ISRCTN86689958 (Date of Registration: 04/03/2019, retrospective); Volunteer Support in Colombia: ISRCTN72241383 (Date of Registration: 04/03/2019, retrospective);Volunteer Support in Bosnia-Herzegovina: ISRCTN51290984 (Date of Registration: 20/11/2018, prospective); Family Involvement in Uganda: ISRCTN78948497 (Date of Registration: 04/03/2019, retrospective); Family Involvement in Colombia: ISRCTN11440755 (Date of Registration: 04/03/2019, retrospective); Family Involvement in Bosnia-Herzegovina: ISRCTN13347355 (Date of Registration: 20/11/2018, prospective).

RTS,S malaria vaccine pilot studies: addressing the human realities in large-scale clinical trials

A malaria vaccine as part of the integrated malaria control and elimination efforts will have a major impact on public health in sub-Sahara Africa. The first malaria vaccine, RTS,S, now enters pilot implementation in three African countries. These pilot implementation studies are being initiated in Kenya, Malawi, and Ghana to inform the broader roll-out recommendation. Based on the malaria vaccine clinical trial experiences, key ethical practices for effective clinical trial research in low-resource settings are described. For successful vaccine integration into malaria intervention programs, the relational dynamics between researchers and trial communities must be made explicit. Incorporating community values and returning to research practices that serve the intended benefactors are key strategies that address the human realities in large-scale clinical trials and pilot implementation, leading to positive public health outcomes.

Ethical tensions in the informed consent process for randomized clinical trials in emergency obstetric and newborn care in low and middle-income countries

BACKGROUND

There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetric care. We present a conceptual analysis of ethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetric care and suggest ways in which these could be mitigated.

DISCUSSION

A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance of respect for autonomy and dignity. In emergency obstetric care research, obtaining informed consent can be problematic, leading to ethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors create ethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants.

CONCLUSION

Informed consent in emergency obstetric care in low- and middle-income countries poses numerous ethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie the ethical tensions in the research in emergency obstetric and newborn care. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits.

Assessing the influence of knowledge translation platforms on health system policy processes to achieve the health millennium development goals in Cameroon and Uganda: a comparative case study

There is a scarcity of empirical data on the influence of initiatives supporting evidence-informed health system policy-making (EIHSP), such as the knowledge translation platforms (KTPs) operating in Africa. To assess whether and how two KTPs housed in government-affiliated institutions in Cameroon and Uganda have influenced: (1) health system policy-making processes and decisions aiming at supporting achievement of the health millennium development goals (MDGs); and (2) the general climate for EIHSP. We conducted an embedded comparative case study of four policy processes in which Evidence Informed Policy Network (EVIPNet) Cameroon and Regional East African Community Health Policy Initiative (REACH-PI) Uganda were involved between 2009 and 2011. We combined a documentary review and semi structured interviews of 54 stakeholders. A framework-guided thematic analysis, inspired by scholarship in health policy analysis and knowledge utilization was used. EVIPNet Cameroon and REACH-PI Uganda have had direct influence on health system policy decisions. The coproduction of evidence briefs combined with tacit knowledge gathered during inclusive evidence-informed stakeholder dialogues helped to reframe health system problems, unveil sources of conflicts, open grounds for consensus and align viable and affordable options for achieving the health MDGs thus leading to decisions. New policy issue networks have emerged. The KTPs indirectly influenced health policy processes by changing how interests interact with one another and by introducing safe-harbour deliberations and intersected with contextual ideational factors by improving access to policy-relevant evidence. KTPs were perceived as change agents with positive impact on the understanding, acceptance and adoption of EIHSP because of their complementary work in relation to capacity building, rapid evidence syntheses and clearinghouse of policy-relevant evidence. This embedded case study illustrates how two KTPs influenced policy decisions through pathways involving policy issue networks, interest groups interaction and evidence-supported ideas and how they influenced the general climate for EIHSP.

A systematic review on academic research productivity of postgraduate students in low- and middle-income countries

Background

While several individual studies addressing research productivity of post-graduate students are available, a synthesis of effective strategies to increase productivity and the determinants of productivity in low-income countries has not been undertaken. Further, whether or not this research from post-graduate students’ projects was applied in evidence-informed decision-making was unknown. Therefore, we conducted a systematic review of literature to identify and assess the effectiveness of approaches that increase productivity (proportion published) or the application (proportion cited) of post-graduate students’ research, as well as to assess the determinants of post-graduate students’ research productivity and use.

Methods

We conducted a systematic review as per our a priori published protocol, also registered in PROSPERO (CRD42016042819). We searched for published articles in PubMed/MEDLINE and the ERIC databases through to July 2017. We performed duplicate assessments for included primary studies and resolved discrepancies by consensus. Thereafter, we completed a structured narrative synthesis and, for a subset of studies, we performed a meta-analysis of the findings using both fixed and random effects approaches. We aligned our results to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

We found 5080 articles in the PubMed (n = 3848) and ERIC (n = 1232) databases. After excluding duplicates (n = 33), we screened 5047 articles, of which 5012 were excluded. We then retrieved 44 full texts and synthesised 14, of which 4 had a high risk of bias. We did not find any studies assessing effectiveness of strategies for increasing publication nor citations of post-graduate research projects. We found an average publication proportion of 7% (95% CI 7–8%, Higgins I-squared 0.0% and Cochran’s Q p < 0.01) and 23% (95% CI 17–29%, Higgins I-squared of 98.4% and Cochran’s Q, p < 0.01) using fixed effects and random effects models, respectively. Two studies reported on the citation of post-graduate students’ studies, at 17% (95% CI 15–19%) in Uganda and a median citation of 1 study in Turkey (IQR 0.6–2.3). Only one included study reported on the determinants of productivity or use of post-graduate students’ research, suggesting that younger students were more likely to publish and cohort studies were more likely to be published.

Conclusions

We report on the low productivity of post-graduate students’ research in low- and middle-income countries, including the citation of post-graduate students’ research in evidence-informed health policy in low- and middle-income countries. Secondly, we did not find a single study that assessed strategies to increase productivity and use of post-graduate students’ research in evidence-informed health policy, a subject for future research.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0360-7) contains supplementary material, which is available to authorized users.

Low HIV viral suppression rates following the intensive adherence counseling (IAC) program for children and adolescents with viral failure in public health facilities in Uganda

Background

The UNAIDS 90–90-90 strategy clearly stipulates that 90% of all people on antiretroviral therapy (ART) should have a suppressed viral load. Intensified adherence counselling (IAC) was recently recommended by WHO to improve viral suppression among ART-treated paediatric and adolescent clients with virological failure. This paper describes the implementation and outcomes of IAC in the first year of implementation in a public ART program, to inform strategic interventions to reach the “third 90” among children.

Methods

A retrospective chart review was conducted for all children aged 9 months to 19 years with HIV viral loads (VL) ≥ 1000 copies/ml at 15 public health facilities from June 2015–December 2016. Data on initial VL test results, IAC sessions, repeat VL test results, and ART regimen switch were abstracted and analysed for completion of IAC and viral suppression after IAC.

Results

A total of 449 children had a detectable viral load above 1000 copies/ml, after an average of 3.5 years (SD 5.8) years of ART. 192 (43%) were 10–20 years of age, and 320 (71%) were receiving Nevirapine-based ART regimen. Out of 345 (77%) who completed the recommended three IAC sessions, 62 (23%) achieved viral suppression following IAC. The mean time from 1st to 3rd IAC session was 113 (SD 153) days and 172 (50%) of the children had completed the three sessions within 200 days.

Conclusion

Suppression rates were low among ART-treated children with virological failure that completed the recommended three IAC sessions. As we move towards having 90% of ART-treated children and adolescents achieve and maintain viral suppression, there is need to re-evaluate the implementation of IAC among children and adolescents to consider both psychosocial and biological factors such as resistance testing for those with multiple detectable viral loads.

Reaching the First 90 in Uganda: Predictors of Success in Contacting and Testing the Named Sexual Partners of HIV+ Index Clients in Kiboga District

Assisted partner notification programs represent one strategy for targeted HIV testing and treatment of exposed individuals in high-risk populations. This study of a pilot Partner Services program in rural Uganda describes predictors of successful contact tracings and testing of partners of HIV+ individuals and possible barriers to contact. Partner contact tracing data was extracted from registers at seven Ministry of Health facilities between May and October 2016, to inform program implementation and scale up. A total of 464 HIV+ index clients named 660 sexual partners; 334/660 (51%) were contacted, 193/334 (58%) tested for HIV, and 61/193 (32%) tested HIV+. Current relationship status predicted contact [AOR = 0.23; (95% CI 0.15, 0.37), p < 0.0001] and testing [AOR = 0.19; (95% CI 0.09, 0.36), p < 0.0001]. Partner contact information type was associated with contact (p < 0.0001), and assisted disclosure with testing (p < 0.0001). Partner contact tracing is an effective means of identifying undiagnosed HIV infections.

Linkage of the Medical Education Partnership Initiative (MEPI) and the Nursing Education Partnership Initiative (NEPI) to the African Forum for Research and Education in Health (AFREhealth)

The US Government funded Medical Education Partnership Initiative (MEPI) and the Nursing Education Partnership Initiative (NEPI) were large undertakings that introduced major creative changes and innovations in the approach to education of health professions and research in the participating medical and nursing institutions. The African-led MEPI Principal Investigators’ (PI) Council which provided strong leadership resolved not to lose momentum but to scale up beyond the MEPI and NEPI institutions and continue with shared learning and the transformative changes that had emerged. The Council started a multi-professional platform which would facilitate and support inter-professional collaboration as the best way forward in the post-MEPI and NEPI period. The African Forum for Research and Education in Africa (AFREhealth) was started and will have to show the value addition it brings and how it will ensure its own sustainability while strengthening South to South partnerships.

Group Mentorship Model to Enhance the Efficiency and Productivity of PhD Research Training in Sub-Saharan Africa

INTRODUCTION

High quality PhD training in sub-Saharan Africa is important to strengthen research evidence to advance development and health. Training a critical mass of independent investigators capable of original scientific research requires strong mentorship, research environments, and international networks. We sought to iteratively improve a PhD training model in Uganda through systems capacity building.

METHODS

PhD students were selected through a rigorous competitive application and selection process, which included a written proposal and a face-to-face panel interview. The program provided administrative support, paid tuition fees, tools (space, equipment, research money), skills (short research courses on study design, biostatistics, manuscript and grant writing), and infrastructure (finance, grants management support, and lab infrastructure). Guidance to identify local and international mentorship was also provided in addition to two to three group meetings per year where data was presented and progress assessed by the program leaders in addition to available local mentors.

RESULTS

Seventeen PhD students were selected, and fifteen will complete training through the MEPI-MESAU program. To date, 60% have completed, including 2 students who started 2 years into the program. So far, 169 publications have been published in the peer-reviewed literature. Our PhD students have supervised and mentored 65 Master's students, which illustrates the cascade effect of PhD training on the academic medical school environment.

CONCLUSIONS

The systems capacity building approach to PhD training is an efficient and productive training model that allowed strong outputs at lower cost and with relatively few additional mentors to rapidly achieve a critical mass of independent scientists able to conduct original research and mentor others.

Equitable Access to Health Professional Training in Uganda: A Cross Sectional Study

Objective:

We set out to assess inequalities to access health professional education, and the impact of an education improvement program supported by MEPI (Medical Education Partnership Initiative). Inequalities in the higher education system in sub-Saharan Africa remain despite some transformative policies and affirmative action.

Methods:

We reviewed enrollment data from four universities for the period 2001–2014 for various health professional training programs, and conducted group discussions through an iterative process with selected stakeholders, and including a group of education experts. Two time periods, 2001–2010 and 2011–2014, were considered. In 2010–11, the MEPI education program began. Gender ratios, regional representation, secondary schools, and the number of admissions by university and year were analysed. We used SPSS version 17 software to analyse these data with level of significance p < 0.05. We collated qualitative data along predetermined and emerging themes.

Results:

The overall male-to-female ratio among the student population was 2.3:1. In total, there were 7,023 admissions, 4,403 between 2001–2010 (440 per annum) and 2,620 between 2011–2014 (655 per annum) with p = 0.018. There were no significant increases in admissions in the central and western regions over the two time periods, 1,708 to 849 and 1,113 to 867 respectively, both p = 0.713 and p = 0.253. We propose improving the university admission criteria and increasing enrollment to health professions training schools.

Conclusion:

There were significant inequalities for higher education training in Uganda by gender, regional representation and school attended. Modifying the admission criteria and increasing enrollment may reduce these inequalities.

The Medical Education Partnership Initiative (MEPI): Innovations and Lessons for Health Professions Training and Research in Africa

MEPI was a $130 million competitively awarded grant by President's Emergency Plan for AIDS Relief (PEPFAR) and National Institutes of Health (NIH) to 13 Medical Schools in 12 Sub-Saharan African countries and a Coordinating Centre (CC). Implementation was led by Principal investigators (PIs) from the grantee institutions supported by Health Resources and Services Administration (HRSA), NIH and the CC from September, 2010 to August, 2015. The goals were to increase the capacity of the awardees to produce more and better doctors, strengthen locally relevant research, promote retention of the graduates within their countries and ensure sustainability. MEPI ignited excitement and stimulated a broad range of improvements in the grantee schools and countries. Through in-country consortium arrangements African PIs expanded the programme from the 13 grantees to over 60 medical schools in Africa, creating vibrant South-South and South-North partnerships in medical education, and research. Grantees revised curricular to competency based models, created medical education units to upgrade the quality of education and established research support centres to promote institutional and collaborative research. MEPI stimulated the establishment of ten new schools, doubling of the students' intake, in some schools, a three-fold increase in post graduate student numbers, and faculty expansion and retention.Sustainability of the MEPI innovations was assured by enlisting the support of universities and ministries of education and health in the countries thus enabling integration of the new programs into the regular national budgets. The vibrant MEPI annual symposia are now the largest medical education events in Africa attracting global participation. These symposia and innovations will be carried forward by the successor of MEPI, the African Forum for Research and Education in Health (AFREhealth). AFREhealth promises to be more inclusive and transformative bringing together other health professionals including nurses, pharmacists, and dentists.

Evaluating the Process and Extent of Institutionalization: A Case Study of a Rapid Response Unit for Health Policy in Burkina Faso

Background: Good decision-making requires gathering and using sufficient information. Several knowledge translation platforms have been introduced in Burkina Faso to support evidence-informed decision-making. One of these is the rapid response service for health. This platform aims to provide quick access for policy-makers in Burkina Faso to highquality research evidence about health systems. The purpose of this study is to describe the process and extent of the institutionalization of the rapid response service.

Methods: A qualitative case study design was used, drawing on interviews with policy-makers, together with documentary analysis. Previously used institutionalization frameworks were combined to guide the analysis.

Results: Burkina Faso’s rapid response service has largely reached the consolidation phase of the institutionalization process but not yet the final phase of maturity. The impetus for the project came from designated project leaders, who convinced policy-makers of the importance of the rapid response service, and obtained resources to run a pilot. During the expansion stage, additional policy-makers at national and sub-national levels began to use the service. Unit staff also tried to improve the way it was delivered, based on lessons learned during the pilot stage. The service has, however, stagnated at the consolidation stage, and not moved into the final phase of maturity.

Conclusion: The institutionalization process for the rapid response service in Burkina Faso has been fluid rather than linear, with some areas developing faster than others. The service has reached the consolidation stage, but now requires additional efforts to reach maturity.

Influence of community-based education on undergraduate health professions students' decision to work in underserved areas in Uganda

Background

Uganda is beset by a shortage of health workers and the few available are mal-distributed. Providing rural exposure through community-based education could positively influence students’ perspectives towards work in rural areas. We aimed to assess the impact of Community-Based Education and Research (COBERS) on health professions students’ attitudes towards working in rural areas. This was a before-and-after study among 525 students of 4 medical universities in Uganda. Data was collected using self-administered paper-based questionnaires. Logistic regression and Poisson regression respectively were used to assess intention and intended number of years of work in rural areas.

Results

Before COBERS, 228/518 (44.0%) students indicated that they intended to work in rural areas as compared to 245/506 (48.4%) after the COBERS placement. Before the COBERS placement, the factors that were associated with students considering to work in a rural area were: extra allowance (OR = 0.2; 95% CI 0.1–0.6), and availability of social amenities (OR = 0.2; 95% CI 0.1–0.7). After their COBERS placement, the factors were: access to long distance courses (OR = 2.0; 95% CI 1.0–3.7) and being posted to a facility in a rural area (OR = 15.0; 95% CI 6.5–35.5). Before the COBERS placement the factors that influenced how long students thought they would be willing to work in a rural environment were: reliable electricity (IRR = 0.6; 95% CI 0.3–1.0) and Internet (IRR = 1.5; 95% CI 1.0–2.3), high salary (IRR = 0.4; 95% CI 0.3–0.7), and having skills to practice in rural settings (IRR = 2.0; 95% CI 1.3–3.1). Reliable electricity (IRR = 0.5; 95% CI 0.3–0.8) and long distance courses (IRR = 2.1; 95% CI 1.4–3.1) were significant motivators after having undergone the COBERS placement.

Conclusions

The majority of health professions students do not intend to work in rural areas after they graduate. Improving the welfare of health professionals working in rural areas could attract more health professionals to rural areas thus addressing the maldistribution of health workers in Uganda.

HIV Prevention Efforts and Incidence of HIV in Uganda

BACKGROUND

To assess the effect of a combination strategy for prevention of human immunodeficiency virus (HIV) on the incidence of HIV infection, we analyzed the association between the incidence of HIV and the scale-up of antiretroviral therapy (ART) and medical male circumcision in Rakai, Uganda. Changes in population-level viral-load suppression and sexual behaviors were also examined.

METHODS

Between 1999 and 2016, data were collected from 30 communities with the use of 12 surveys in the Rakai Community Cohort Study, an open, population-based cohort of persons 15 to 49 years of age. We assessed trends in the incidence of HIV on the basis of observed seroconversion data, participant-reported use of ART, participant-reported male circumcision, viral-load suppression, and sexual behaviors.

RESULTS

In total, 33,937 study participants contributed 103,011 person-visits. A total of 17,870 persons who were initially HIV-negative were followed for 94,427 person-years; among these persons, 931 seroconversions were observed. ART was introduced in 2004, and by 2016, ART coverage was 69% (72% among women vs. 61% among men, P<0.001). HIV viral-load suppression among all HIV-positive persons increased from 42% in 2009 to 75% by 2016 (P<0.001). Male circumcision coverage increased from 15% in 1999 to 59% by 2016 (P<0.001). The percentage of adolescents 15 to 19 years of age who reported never having initiated sex (i.e., delayed sexual debut) increased from 30% in 1999 to 55% in 2016 (P<0.001). By 2016, the mean incidence of HIV infection had declined by 42% relative to the period before 2006 (i.e., before the scale-up of the combination strategy for HIV prevention) - from 1.17 cases per 100 person-years to 0.66 cases per 100 person-years (adjusted incidence rate ratio, 0.58; 95% confidence interval [CI], 0.45 to 0.76); declines were greater among men (adjusted incidence rate ratio, 0.46; 95% CI, 0.29 to 0.73) than among women (adjusted incidence rate ratio, 0.68; 95% CI, 0.50 to 0.94).

CONCLUSIONS

In this longitudinal study, the incidence of HIV infection declined significantly with the scale-up of a combination strategy for HIV prevention, which provides empirical evidence that interventions for HIV prevention can have a population-level effect. However, additional efforts are needed to overcome disparities according to sex and to achieve greater reductions in the incidence of HIV infection. (Funded by the National Institute of Allergy and Infectious Diseases and others.).

A Process Evaluation to Assess Contextual Factors Associated With the Uptake of a Rapid Response Service to Support Health Systems' Decision-Making in Uganda

Background: Although proven feasible, rapid response services (RRSs) to support urgent decision and policymaking are still a fairly new and innovative strategy in several health systems, more especially in low-income countries. There are several information gaps about these RRSs that exist including the factors that make them work in different contexts and in addition what affects their uptake by potential end users.

Methods: We used a case study employing process evaluation methods to determine what contextual factors affect the utilization of a RRS in Uganda. We held in-depth interviews with researchers, knowledge translation (KT) specialists and policy-makers from several research and policy-making institutions in Uganda’s health sector. We analyzed the data using thematic analysis to develop categories and themes about activities and structures under given program components that affected uptake of the service.

Results: We identified several factors under three themes that have both overlapping relations and also reinforcing loops amplifying each other: Internal factors (those factors that were identified as over which the RRS had full [or almost full] control); external factors (factors over which the service had only partial influence, a second party holds part of this influence); and environmental factors (factors over which the service had no or only remote control if at all). Internal factors were the design of the service and resources available for it, while the external factors were the service’s visibility, integrity and relationships. Environmental factors were political will and health system policy and decision-making infrastructure.

Conclusion: For health systems practitioners considering RRSs, knowing what factors will affect uptake and therefore modifying them within their contexts is important to ensure efficient use and successful utilization of the mechanisms.

Effects of the Informed Health Choices podcast on the ability of parents of primary school children in Uganda to assess claims about treatment effects: a randomised controlled trial

BACKGROUND

As part of the Informed Health Choices project, we developed a podcast called The Health Choices Programme to help improve the ability of people to assess claims about the benefits and harms of treatments. We aimed to evaluate the effects of the podcast on the ability of parents of primary school children in Uganda to assess claims about the effects of treatments.

METHODS

We did this randomised controlled trial in central Uganda. We recruited parents of children aged 10-12 years who were in their fifth year of school at 35 schools that were participating in a linked trial of the Informed Health Choices primary school resources. The parents were randomly allocated (1:1), via a web-based random number generator with block sizes of four and six, to listen to either the Informed Health Choices podcast (intervention group) or typical public service announcements about health issues (control group). Randomisation was stratified by parents' highest level of formal education attained (primary school, secondary school, or tertiary education) and the allocation of their children's school in the trial of the primary school resources (intervention vs control). The primary outcome, measured after listening to the entire podcast, was the mean score and the proportion of parents with passing scores on a test with two multiple choice questions for each of nine key concepts essential to assessing claims about treatments (18 questions in total). We did intention-to-treat analyses. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201606001676150.

FINDINGS

We recruited parents between July 21, 2016, and Oct 7, 2016. We randomly assigned 675 parents to the podcast group (n=334) or the public service announcement group (n=341); 561 (83%) participants completed follow-up. The mean score for parents in the podcast group was 67·8% (SD 19·6) compared with 52·4% (17·6) in the control group (adjusted mean difference 15·5%, 95% CI 12·5-18·6; p<0·0001). In the podcast group, 203 (71%) of 288 parents had a predetermined passing score (≥11 of 18 correct answers) compared with 103 (38%) of 273 parents in the control group (adjusted difference 34%, 95% CI 26-41; p<0·0001). No adverse events were reported.

INTERPRETATION

Listening to the Informed Health Choices podcast led to a large improvement in the ability of parents to assess claims about the effects of treatments. Future studies should assess the long-term effects of use of the podcast, the effects on actual health choices and outcomes, and how transferable our findings are to other countries.

FUNDING

Research Council of Norway.

Effects of the Informed Health Choices primary school intervention on the ability of children in Uganda to assess the reliability of claims about treatment effects: a cluster-randomised controlled trial

BACKGROUND

Claims about what improves or harms our health are ubiquitous. People need to be able to assess the reliability of these claims. We aimed to evaluate an intervention designed to teach primary school children to assess claims about the effects of treatments (ie, any action intended to maintain or improve health).

METHODS

In this cluster-randomised controlled trial, we included primary schools in the central region of Uganda that taught year-5 children (aged 10-12 years). We excluded international schools, special needs schools for children with auditory and visual impairments, schools that had participated in user-testing and piloting of the resources, infant and nursery schools, adult education schools, and schools that were difficult for us to access in terms of travel time. We randomly allocated a representative sample of eligible schools to either an intervention or control group. Intervention schools received the Informed Health Choices primary school resources (textbooks, exercise books, and a teachers' guide). Teachers attended a 2 day introductory workshop and gave nine 80 min lessons during one school term. The lessons addressed 12 concepts essential to assessing claims about treatment effects and making informed health choices. We did not intervene in the control schools. The primary outcome, measured at the end of the school term, was the mean score on a test with two multiple-choice questions for each of the 12 concepts and the proportion of children with passing scores on the same test. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201606001679337.

FINDINGS

Between April 11, 2016, and June 8, 2016, 2960 schools were assessed for eligibility; 2029 were eligible, and a random sample of 170 were invited to recruitment meetings. After recruitment meetings, 120 eligible schools consented and were randomly assigned to either the intervention group (n=60, 76 teachers and 6383 children) or control group (n=60, 67 teachers and 4430 children). The mean score in the multiple-choice test for the intervention schools was 62·4% (SD 18·8) compared with 43·1% (15·2) for the control schools (adjusted mean difference 20·0%, 95% CI 17·3-22·7; p<0·00001). In the intervention schools, 3967 (69%) of 5753 children achieved a predetermined passing score (≥13 of 24 correct answers) compared with 1186 (27%) of 4430 children in the control schools (adjusted difference 50%, 95% CI 44-55). The intervention was effective for children with different levels of reading skills, but was more effective for children with better reading skills.

INTERPRETATION

The use of the Informed Health Choices primary school learning resources, after an introductory workshop for the teachers, led to a large improvement in the ability of children to assess claims about the effects of treatments. The results show that it is possible to teach primary school children to think critically in schools with large student to teacher ratios and few resources. Future studies should address how to scale up use of the resources, long-term effects, including effects on actual health choices, transferability to other countries, and how to build on this programme with additional primary and secondary school learning resources.

FUNDING

Research Council of Norway.

The factors affecting the institutionalisation of two policy units in Burkina Faso's health system: a case study

Background

This paper is one of three linked studies that attempts to understand the process of institutionalisation of policy units within Burkina Faso’s health system. It examines the relationships between the existence of an institutional framework, data production capacity and other resource availability in the institutionalisation of policy units in health systems. It therefore contributes to our understanding of the dynamics linking the key drivers and indicators of institutionalisation. Additionally, it examines how factors within the managerial setting, including workplace environment, and budgetary and human resource availability, may influence the institutionalisation process.

Methods

The study used an explanatory qualitative case study approach, examining two policy units in Burkina Faso’s Ministry of Health, the first of which had been institutionalised successfully and the other less so. Data were collected from key policymakers, including 13 connected with the first policy unit and 10 with the second, plus two funders. We also conducted a documentary analysis of the National Program for Health Development, two mid-term strategic plans, 230 action plans, eight Ministry of Health state budgets, eight Ministry of Health annual statistics reports, 16 policy unit budgets and published literature.

Results

The framework within which the government gave the policy unit its mandate and policy focus had the strongest effect on the institutionalisation process. Institutionalisation depended on political will, in both the host government and any donors, and the priority given to the policy unit’s focus. It was also affected by the leadership of the policy unit managers. These factors were influenced by human resource capacity, and our findings suggest that, for successful institutionalisation in Burkina Faso’s health system, policy units need to be given sufficient human resources to achieve their objectives.

Conclusion

Policy units’ institutionalisation in Burkina Faso’s health system depend on the leadership of the unit managers to implement relevant activities, mobilise funding, and recruit and maintain enough human resources, as well as the mandate given by the government.

The Role of National Immunization Technical Advisory Groups (NITAGs) in the Introduction of Inactivated Polio Vaccine: Experience of the Indonesia and Uganda NITAGs

Background

National Immunization Technical Advisory Groups (NITAGs) are established by national authorities to provide them with independent, bias-free, objective, and evidence-based advice on vaccines and immunization challenges. As of December 2015, 125 countries have reported having set up an NITAG. The Health Policy and Institutional Development Center at the Agence de Médecine Préventive, a World Health Organization (WHO) Collaborative Center for evidence-informed immunization, through its Supporting Independent Immunization and Vaccine Advisory Committees (SIVAC) Initiative project, provides assistance to low- and middle-income countries in the establishment and strengthening of their NITAGs. The Indonesian NITAG (ITAGI) was formed in December 2006 and Uganda's (UNITAG) was formed in November 2014. Both Uganda and Indonesia have introduced inactivated polio vaccine (IPV) as part of the Global Polio Eradication and Endgame Strategic Plan (the Endgame plan). The authors reflect on the process and the role played by NITAGs in the introduction of IPV in the routine immunization program and the lessons learned.

Methods

This commentary is a reflection of the authors' experience on NITAG's role as observed in 2 particular local settings and applied to a global public health issue, the polio eradication Endgame plan. The reflection is backed up by the relevant (policy and technical) documents on polio eradication, along with minutes and reports from countries' ministries of health, immunization programs, WHO, and NITAGs.

Results

NITAGs are valuable tools for ministries of health to ensure sustainable, evidence-informed immunization policies that are trusted and accepted by their communities. Early engagement with NITAGs also ensures that the adoption of strategies addressing global public health threats at the country level reinforces the national immunization programs. On the other end, when NITAGs are proactive and forward-thinking, they can contribute to a smooth and effective introduction of the above-mentioned strategies. Time and resources are key factors to ensure optimal performance of NITAGs.

Does the use of the Informed Healthcare Choices (IHC) primary school resources improve the ability of grade-5 children in Uganda to assess the trustworthiness of claims about the effects of treatments: protocol for a cluster-randomised trial

BACKGROUND

The ability to appraise claims about the benefits and harms of treatments is crucial for informed health care decision-making. This research aims to enable children in East African primary schools (the clusters) to acquire and retain skills that can help them make informed health care choices by improving their ability to obtain, process and understand health information. The trial will evaluate (at the individual participant level) whether specially designed learning resources can teach children some of the key concepts relevant to appraising claims about the benefits and harms of health care interventions (treatments).

METHODS

This is a two-arm, cluster-randomised trial with stratified random allocation. We will recruit 120 primary schools (the clusters) between April and May 2016 in the central region of Uganda. We will stratify participating schools by geographical setting (rural, semi-urban, or urban) and ownership (public or private). The Informed Healthcare Choices (IHC) primary school resources consist of a textbook and a teachers' guide. Each of the students in the intervention arm will receive a textbook and attend nine lessons delivered by their teachers during a school term, with each lesson lasting 80 min. The lessons cover 12 key concepts that are relevant to assessing claims about treatments and making informed health care choices. The second arm will carry on with the current primary school curriculum. We have designed the Claim Evaluation Tools to measure people's ability to apply key concepts related to assessing claims about the effects of treatments and making informed health care choices. The Claim Evaluation Tools use multiple choice questions addressing each of the 12 concepts covered by the IHC school resources. Using the Claim Evaluation Tools we will measure two primary outcomes: (1) the proportion of children who 'pass', based on an absolute standard and (2) their average scores.

DISCUSSION

As far as we are aware this is the first randomised trial to assess whether key concepts needed to judge claims about the effects of treatment can be taught to primary school children. Whatever the results, they will be relevant to learning how to promote critical thinking about treatment claims. Trial status: the recruitment of study participants was ongoing at the time of manuscript submission.

TRIAL REGISTRATION

Pan African Clinical Trial Registry, trial identifier: PACTR201606001679337 . Registered on 13 June 2016.

Policymaker experiences with rapid response briefs to address health-system and technology questions in Uganda

Background

Health service and systems researchers have developed knowledge translation strategies to facilitate the use of reliable evidence for policy, including rapid response briefs as timely and responsive tools supporting decision making. However, little is known about users’ experience with these newer formats for presenting evidence. We sought to explore Ugandan policymakers’ experience with rapid response briefs in order to develop a format acceptable for policymakers.

Methods

We used existing research regarding evidence formats for policymakers to inform the initial version of rapid response brief format. We conducted user testing with healthcare policymakers at various levels of decision making in Uganda, employing a concurrent think-aloud method, collecting data on elements including usability, usefulness, understandability, desirability, credibility and value of the document. We modified the rapid response briefs format based on the results of the user testing and sought feedback on the new format.

Results

The participants generally found the format of the rapid response briefs usable, credible, desirable and of value. Participants expressed frustrations regarding several aspects of the document, including the absence of recommendations, lack of clarity about the type of document and its potential uses (especially for first time users), and a crowded front page. Participants offered conflicting feedback on preferred length of the briefs and use and placement of partner logos. Users had divided preferences for the older and newer formats.

Conclusion

Although the rapid response briefs were generally found to be of value, there are major and minor frustrations impeding an optimal user experience. Areas requiring further research include how to address policymakers’ expectations of recommendations in these briefs and their optimal length.

A need to accelerate health research productivity in an African University: the case of Makerere University College of Health Sciences

BACKGROUND

In the last decade, Makerere University College of Health Sciences (MakCHS) has taken strides in research and training to improve healthcare through collaborative training and research programs. However, there is limited data on the trends of MakCHS faculty contributions to research and on faculty growth to take leading roles in health research. This paper reviews MakCHS faculty research publications over 15.5 years and outlines possible strategies to enhance faculty research outputs.

METHODS

We used a mixed methods approach. A systematic review of research publications by faculty at MakCHS (PubMed and Google Scholar from January 1, 2000, to June 30, 2015) to quantify the number of research articles, areas researched, authorship contribution by MakCHS faculty, source of funding, as well as affiliated local and international collaborations. Graphs were used to shown trends in publications and leadership of authorship by faculty. Annual individual faculty research productivity was presented as publication per capita. Qualitative data on high priority needs to improve research outputs was collected through focus group discussions (FGDs) with faculty members, and analysed manually into emerging themes.

RESULTS

Of 298 faculty at MakCHS at 2015, 89 (30%) were female and 229 (77%) were junior and mid-level faculty (senior lecturer and below). The PubMed and Google Scholar searches yielded 6927 published articles, of which 3399 (49%) full-text articles were downloaded for analysis, 426/3825 (11%) available as titles/abstracts only, and 598/4423 (14%) were excluded. Only 614 articles were published in 2014, giving a publication per capita of 2.1 for any authorship, and 0.3 for first and last authorship positions. MakCHS faculty increasingly contributed as first, second, third, and last authors. Up to 57% of research was in infectious diseases, followed by non-communicable diseases (20%) and non-communicable maternal child health (11%). Priority needs to improve research outputs, as expressed by faculty, were (1) an institutionally led faculty career development program, (2) skills building in research methods and scientific writing, (3) protected time for research related activities, (4) opportunities for collaborative research, and (5) use of individual development plans.

CONCLUSION

Faculty research productivity was low and dominated by infectious diseases and non-communicable disease research. There is a need for structured institutional support to optimise faculty research outputs. Only with increased research productivity will MakCHS and other academic institutions be able to make a significant contribution in addressing national health challenges.

Academic research productivity of post-graduate students at Makerere University College of Health Sciences, Uganda, from 1996 to 2010: a retrospective review

BACKGROUND

Research is a core business of universities globally, and is crucial in the scientific process as a precursor for knowledge uptake and use. We aimed to assess the academic productivity of post-graduate students in a university located in a low-income country.

METHODS

This is an observational retrospective documentary analysis using hand searching archives, Google Scholar and PubMed electronic databases. The setting is Makerere University College of Health Sciences, Uganda. Records of post-graduate students (Masters) enrolled from 1996 to 2010, and followed to 2016 for outcomes were analysed. The outcome measures were publications (primary), citations, electronic dissertations found online or conference abstracts (secondary). Descriptive and multivariable logistic regression analyses were performed using Stata 14.1.

RESULTS

We found dissertations of 1172 Masters students over the 20-year period of study. While half (590, 50%) had completed clinical graduate disciplines (surgery, internal medicine, paediatrics, obstetrics and gynaecology), Master of Public Health was the single most popular course, with 393 students (31%). Manuscripts from 209 dissertations (18%; 95% CI, 16-20%) were published and approximately the same proportion was cited (196, 17%; 95% CI, 15-19%). Very few (4%) policy-related documents (technical reports and guidelines) cited these dissertations. Variables that remained statistically significant in the multivariable model were students' age at enrolment into the Masters programme (adjusted coefficient -0.12; 95% CI, -0.18 to -0.06; P < 0.001) and type of research design (adjusted coefficient 0.22; 0.03 to 0.40; P = 0.024). Cohort studies were more likely to be published compared to cross-sectional designs (adjusted coefficient 0.78; 95% CI, 0.2 to 1.36; P = 0.008).

CONCLUSIONS

The productivity and use of post-graduate students' research conducted at the College of Health Sciences Makerere University is considerably low in terms of peer-reviewed publications and citations in policy-related documents. The need for effective strategies to reverse this 'waste' is urgent if the College, decision-makers, funders and the Ugandan public are to enjoy the 'return on investment' from post-graduate students research.

Where is students' research in evidence-informed decision-making in health? Assessing productivity and use of postgraduate students' research in low- and middle-income countries: a systematic review

Background

Investing in research that is not accessible or used is a waste of resources and an injustice to human subject participants. Post-graduate students’ research in institutions of higher learning involves considerable time, effort and money, warranting evaluation of the return on investment. Although individual studies addressing research productivity of post-graduate students are available, a synthesis of these results in low-income settings has not been undertaken. Our first aim is to identify the types of approaches that increase productivity and those that increase the application of medical post-graduate students’ research and to assess their effectiveness. Our second aim is to assess the determinants of post-graduate students’ research productivity.

Methods

We propose a two-stage systematic review. We will electronically search for published and grey literature in PubMed/MEDLINE and the ERIC databases, as well as contact authors, research administration units of universities, and other key informants as appropriate. In stage one, we will map the nature of the evidence available using a knowledge translation framework adapted from existing literature. We will perform duplicate screening and selection of articles, data abstraction, and risk of bias assessments for included primary studies as described in the Cochrane handbook for systematic reviews. Our primary outcome is publication output as a measure of research productivity, whilst we defined research use as citations in peer-reviewed journals or policy-related documents as our secondary outcome. In stage two, we will perform a structured narrative synthesis of the findings and advance to quantitative meta-analysis if the number of studies are adequate and their heterogeneity is low. Adapting the Grading, Recommendations, Assessment, Development and Evaluation (GRADE) approach, we will assess the overall quality of evidence for effects, and report our results in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Discussion

We will share our findings with universities, other training institutions, civil society, funders as well as government departments in charge of education and health particularly in low- and middle-income countries.