Mobile Ecological Momentary Assessment and Intervention and Health Behavior Change Among Adults in Rakai, Uganda: Pilot Randomized Controlled Trial

Background:
An extraordinary increase in mobile phone ownership has revolutionized the opportunities to use mobile health approaches in lower- and middle-income countries (LMICs). Ecological momentary assessment and intervention (EMAI) uses mobile technology to gather data and deliver timely, personalized behavior change interventions in an individual’s natural setting. To our knowledge, there have been no previous trials of EMAI in sub-Saharan Africa.

Objective:
To advance the evidence base for mobile health (mHealth) interventions in LMICs, we conduct a pilot randomized trial to assess the feasibility of EMAI and establish estimates of the potential effect of EMAI on a range of health-related behaviors in Rakai, Uganda.

Methods:
This prospective, parallel-group, randomized pilot trial compared health behaviors between adult participants submitting ecological momentary assessment (EMA) data and receiving behaviorally responsive interventional health messaging (EMAI) with those submitting EMA data alone. Using a fully automated mobile phone app, participants submitted daily reports on 5 different health behaviors (fruit consumption, vegetable consumption, alcohol intake, cigarette smoking, and condomless sex with a non–long-term partner) during a 30-day period before randomization (P1). Participants were then block randomized to the control arm, continuing EMA reporting through exit, or the intervention arm, EMA reporting and behavioral health messaging receipt. Participants exited after 90 days of follow-up, divided into study periods 2 (P2: randomization + 29 days) and 3 (P3: 30 days postrandomization to exit). We used descriptive statistics to assess the feasibility of EMAI through the completeness of data and differences in reported behaviors between periods and study arms.

Results:
The study included 48 participants (24 per arm; 23/48, 48% women; median age 31 years). EMA data collection was feasible, with 85.5% (3777/4418) of the combined days reporting behavioral data. There was a decrease in the mean proportion of days when alcohol was consumed in both arms over time (control: P1, 9.6% of days to P2, 4.3% of days; intervention: P1, 7.2% of days to P3, 2.4% of days). Decreases in sex with a non–long-term partner without a condom were also reported in both arms (P1 to P3 control: 1.9% of days to 1% of days; intervention: 6.6% of days to 1.3% of days). An increase in vegetable consumption was found in the intervention (vegetable: 65.6% of days to 76.6% of days) but not in the control arm. Between arms, there was a significant difference in the change in reported vegetable consumption between P1 and P3 (control: 8% decrease in the mean proportion of days vegetables consumed; intervention: 11.1% increase; P=.01).

Conclusions:
Preliminary estimates suggest that EMAI may be a promising strategy for promoting behavior change across a range of behaviors. Larger trials examining the effectiveness of EMAI in LMICs are warranted.

Trial Registration:
ClinicalTrials.gov NCT04375423; https://www.clinicaltrials.gov/ct2/show/NCT04375423

Feasibility of establishing an infant hearing screening program and measuring hearing loss among infants at a regional referral hospital in south western Uganda

Introduction
Despite the high burden of hearing loss (HL) globaly, most countries in resource limited settings lack infant hearing screening programs(IHS) for early HL detection. We examined the feasibility of establishing an IHS program in this setting, and in this pilot program measured the prevalence of infant hearing loss (IHL) and described the characteristics of the infants with HL.

Methods
We assessed feasibility of establishing an IHS program at a regional referral hospital in south-western Uganda. We recruited infants aged 1 day to 3 months and performed a three-staged screening. At stage 1, we used Transient Evoked Oto-acoustic Emissions (TEOAEs), at stage 2 we repeated TEOAEs for infants who failed TEOAEs at stage 1 and at stage 3, we conducted Automated brainstem responses(ABRs) for those who failed stage 2. IHL was present if they failed an ABR at 35dBHL.

Results
We screened 401 infants, mean age was 7.2 days (SD = 7.1). 74.6% (299 of 401) passed stage 1, the rest (25.4% or 102 of 401) were referred for stage 2. Of those referred (n = 102), only 34.3% (35 of 102) returned for stage 2 screening. About 14.3% (5/35) failed the repeat TEOAEs in at least one ear. At stage 3, 80% (4 of 5) failed the ABR screening in at least one ear, while 25% (n = 1) failed the test bilaterally. Among the 334 infants that completed the staged screening, the prevalence of IHL was 4/334 or 12 per 1000. Risk factors to IHL were Newborn Special Care Unit (NSCU) admission, gentamycin or oxygen therapy and prematurity.

Conclusions
IHS program establishment in a resource limited setting is feasible. Preliminary data indicate a high prevalence of IHL. Targeted screening of infants at high risk may be a more realistic and sustainable initial step towards establishing IHS program s in a developing country like Uganda.

Increasing Antimicrobial Resistance in Surgical Wards at Mulago National Referral Hospital, Uganda, from 2014 to 2018—Cause for Concern?

Antimicrobial Resistance (AMR) and Healthcare Associated Infections (HAIs) are major global public health challenges in our time. This study provides a broader and updated overview of AMR trends in surgical wards of Mulago National Referral Hospital (MNRH) between 2014 and 2018. Laboratory data on the antimicrobial susceptibility profiles of bacterial isolates from 428 patient samples were available. The most common samples were as follows: tracheal aspirates (36.5%), pus swabs (28.0%), and blood (20.6%). Klebsiella (21.7%), Acinetobacter (17.5%), and Staphylococcus species (12.4%) were the most common isolates. The resistance patterns for different antimicrobials were: penicillins (40–100%), cephalosporins (30–100%), β-lactamase inhibitor combinations (70–100%), carbapenems (10–100%), polymyxin E (0–7%), aminoglycosides (50–100%), sulphonamides (80–100%), fluoroquinolones (40–70%), macrolides (40–100%), lincosamides (10–45%), phenicols (40–70%), nitrofurans (0–25%), and glycopeptide (0–20%). This study demonstrated a sustained increase in resistance among the most commonly used antibiotics in Uganda over the five-year study period. It implies ongoing hospital-based monitoring and surveillance of AMR patterns are needed to inform antibiotic prescribing, and to contribute to national and global AMR profiles. It also suggests continued emphasis on infection prevention and control practices (IPC), including antibiotic stewardship. Ultimately, laboratory capacity for timely bacteriological culture and sensitivity testing will provide a rational choice of antibiotics for HAI.

Understanding health-seeking and adherence to treatment by patients with esophageal cancer at the Uganda cancer Institute: a qualitative study

Background
In the low- and middle-income countries, most patients with esophageal cancer present with advanced stage disease and experience poor survival. There is inadequate understanding of the factors that influence decisions to and actual health-seeking, and adherence to treatment regimens among esophageal cancer patients in Uganda, yet this knowledge is critical in informing interventions to promote prompt health-seeking, diagnosis at early stage and access to appropriate cancer therapy to improve survival. We explored health-seeking experiences and adherence to treatment among esophageal cancer patients attending the Uganda Cancer Institute.

Methods
We conducted an interview based qualitative study at the Uganda Cancer Institute (UCI). Participants included patients with established histology diagnosis of esophageal cancer and healthcare professionals involved in the care of these patients. We used purposive sampling approach to select study participants. In-depth and key informant interviews were used in data collection. Data collection was conducted till point of data saturation was reached. Thematic content analysis approach was used in data analyses and interpretations. Themes and subthemes were identified deductively.

Results
Sixteen patients and 17 healthcare professionals were included in the study. Delayed health-seeking and poor adherence to treatment were related to (i) emotional and psychosocial factors including stress of cancer diagnosis, stigma related to esophageal cancer symptoms, and fear of loss of jobs and livelihood, (ii) limited knowledge and recognition of esophageal cancer symptoms by both patients and primary healthcare professionals, and (iii) limited access to specialized cancer care, mainly because of long distance to the facility and associated high transport cost. Patients were generally enthused with patient – provider relationships at the UCI. While inadequate communication and some degree of incivility were reported, majority of patients thought the healthcare professionals were empathetic and supportive.

Conclusion
Health system and individual patient factors influence health-seeking for symptoms of esophageal cancer and adherence to treatment schedule for the disease. Interventions to improve access to and acceptability of esophageal cancer services, as well as increase public awareness of esophageal cancer risk factors and symptoms could lead to earlier diagnosis and potentially better survival from the disease in Uganda.

Starting and Operating a Public Cardiac Catheterization Laboratory in a Low Resource Setting: The Eight-Year Story of the Uganda Heart Institute Catheter Laboratory

Abstract
Background: Low- and-middle-income-countries (LMICs) currently bear 80% of the world’s cardiovascular disease (CVD) mortality burden. The same countries are underequipped to handle the disease burden due to critical shortage of resources. Functional cardiac catheterization laboratories (cath labs) are central in the diagnosis and management of CVDs. Yet, most LMICs, including Uganda, fall remarkably below the minimum recommended standards of cath lab:population ratio due to a host of factors including the start-up and recurring costs.

Objectives: To review the performance, challenges and solutions employed, lessons learned, and projections for the future for a single cath lab that has been serving the Ugandan population of 40 million people in the past eight years.

Methods: A retrospective review of the Uganda Heart Institute cath lab clinical database from 15 February 2012 to 31 December 2019 was performed.

Results: In the initial two years, this cath lab was dependent on skills transfer camps by visiting expert teams, but currently, Ugandan resident specialists independently operate this lab. 3,542 adult and pediatric procedures were conducted in 8 years, including coronary angiograms and percutaneous coronary interventions, device implantations, valvuloplasties, and cardiac defect closures, among others. There was a consistent expansion of the spectrum of procedures conducted in this cath lab each year. The initial lack of technical expertise and sourcing for equipment, as well as the continual need for sundries present(ed) major roadblocks. Government support and leveraging existing multi-level collaborations has provided a platform for several solutions. Sustainability of cath lab services remains a significant challenge especially in relation to the high cost of sundries and other consumables amidst a limited budget.

Conclusion: A practical example of how centers in LMIC can set up and sustain a public cardiac catheterization laboratory is presented. Government support, research, and training collaborations, if present, become invaluable leverage opportunities.

Factors Associated with Congenital Heart Diseases Among Children in Uganda: A Case-Control Study at Mulago National Referral Hospital (Uganda Heart Institute)

Congenital Heart Diseases (CHD) are among the leading causes of morbidity and mortality associated with congenital malformations among children. Not knowing the risk profile of CHD among children in Uganda impedes development of effective prevention interventions. In this hospital based unmatched case-control study we examined risk
factors for all types of CHD among 179 pair of case and control children aged 0-10 years old at Mulago National Referral Hospital. Odds ratios and their corresponding 95% confidence intervals were calculated using multivariate logistic regression. Low birth weight (adjusted OR: 3.15, 95% CI 1.48 – 6.69), high birth order ≥5th birth order (adjusted OR: 3.69 (1.10 – 12.54), maternal febrile illness during pregnancy, maternal and paternal alcohol consumption, and paternal socio-economic status were associated with CHD. Family history of CHD, maternal education level, maternal chronic illness, and paternal education level were not associated with CHD. The results suggest: low birth weight, high birth order, and maternal febrile illness during pregnancy, parental alcohol use and paternal socio-economic status as dominant risk factors for CHD among children. Rigorous implementation of public health policies and strategies targeting prevention of febrile illness during pregnancy, maternal malnutrition, parental alcohol consumption, delivery of high number of children per woman, might be important in reducing the burden of CHD among children in Uganda

The ethical development and sustainability of trauma registries in low- and middle-income countries

Trauma registries are an anonymized, systematic, prospective data banks for trauma patients that may include details on demographics, injury details, hospital processes, and outcomes. They are an important component of trauma care systems and a tool for improving outcomes in trauma. Given the high rates of morbidity and mortality from trauma in low- and middle-income countries (LMICs), the implementation of trauma registries in LMICs is a growing area of interest; however, while many pilot trauma registries have been demonstrated to be feasible in LMICs, very few are sustainable in the long term. In this thesis, a trauma registry established in 2017 in Mbarara Regional Referral Hospital (MRRH), Uganda is examined. Since the establishment of this registry, data for over 3000 trauma patients has been collected, however, the registry faces questions of how to achieve long-term viability without the financial support of external partnerships. The aim of this thesis is therefore to evaluate several aspects of sustainability of trauma registries for low-income settings. First, the ethical importance of sustainability in global surgery was established through a scoping review on the literature on the ethics of global surgery. A grounded theory content analysis was completed to identify themes and gaps in the existing literature. Four major ethical domains in global surgery were identified: clinical care and delivery; education and exchange of trainees; research, monitoring, and evaluation; and engagement in collaborations and partnerships. While the literature on ethics in global surgery was sparse, mostly in the form of commentaries or editorials, and largely published by authors in high-income countries (HICs), the importance of including LMIC authors in the conversation on ethics in global surgery and the value of building sustainable collaborations and partnerships were key findings of this scoping review. Next, a literature review of considerations for the implementation of ethical and sustainable trauma registries in LMICs was completed. A number of practical challenges were identified for the development of trauma registries in LMICs and included funding sources, personnel requirements, technology access, and quality assurance mechanisms. Ethical considerations for trauma registry development were also identified, and included concerns of patient confidentiality, informed consent, and sustaining the registry. Strategies for these ethical and practical considerations for trauma registry development in LMICs are discussed, and opportunities for future research opportunities are explored. The widespread nature and accessibility of mobile phones in most low- and middle-income countries, including Uganda, makes the use of mobile phone technology in health a potential avenue for inexpensive health care innovation. A mobile application trauma registry was designed and implemented to minimize workload and contribute to sustainability of the registry. Healthcare workers involved in trauma then completed a validated questionnaire known as the Unified Theory of Acceptance and Use of Technology (UTAUT) for evaluating the usability of the mobile application trauma registry and predicting future use behaviours. Healthcare workers scored the mobile application highly, indicating a high potential for ongoing use. The UTAUT was also identified as a method for other trauma registries to predict future use and opportunities for sustainability. Finally, a potential means of financial self-sustainability for trauma registries in low-income countries was evaluated. In many public hospitals in low-income settings, government funding for patients seen is dependent on documentation of those patients. This study evaluated the improvements to patient documentation following the implementation of a trauma registry and concurrent patient registration system at MRRH. A significant improvement in patient documentation was found, with a 20-fold increase in trauma patients documented following the implementation of patient registration and a trauma registry. This more accurate documentation could then be used to apply for increased government funding for trauma patients and for sustaining the trauma registry in the long-term. The concurrent implementation of a patient registration system with a trauma registry therefore could be an avenue for financial viability for other trauma registries in low-income contexts. Taken together, these studies represent a compelling picture for the ethical imperative to develop sustainable trauma registries in LMICs and some of the strategies that may be undertaken to achieve this. By combining these techniques, we hope to achieve a sustainable, long-term trauma registry at MRRH that can serve as a model for other trauma registries in LMICs going forward.

Challenges faced by cancer patients in Uganda: Implications for health systems strengthening in resource limited settings

Background
Uganda Cancer Institute (UCI), the only comprehensive cancer treatment center in Uganda, registers about 4000 new cancer patients a year. However, many cancer patients in Uganda never receive treatment due to a variety of challenges. We therefore conducted a study to identify and assess the challenges faced by cancer patients in Uganda.

Methods
A cross-sectional study conducted in April-May 2017 among adult cancer patients. 359 participants participated in an interviewer-administered survey. We used stratified random sampling to select the study participants. Data was analyzed in SPSS Statistics 24.

Results
35 % of the patients delayed initiating cancer treatment and 41 % missed medical appointments along their care journey. Delayed and missed appointments were mainly due to lack of money for cancer medicines, transportation and accommodation. Patients also expressed challenges with side effects of cancer treatment: 52 % sought help from health workers when they experienced side effects; 14 % used alternative medicine; and 21 % did not inform anyone. In addition, 55 % of the participants had limited knowledge about their disease and treatment. Other challenges when at UCI included: being hungry and thirsty throughout the day, long waiting hours, not having a resting place, not understanding what comes next, and having their records lost by hospital staff.

Conclusion
Challenges faced by cancer patients in Uganda result in enormous delays in initiation and continuation of cancer treatment. These challenges are often a result of the poor social-economic status of the patients; inadequate infrastructure for cancer care; and inefficiencies in the health care system.

Policy Summary
To improve the experience of patients, the National Cancer Control Plan should consider establishing regional cancer centers; creating a reliable supply of cancer medicines; and integrating navigation programmes into cancer care. Strengthening the whole health system, in relation to cancer service delivery, should remain a top priority for Uganda and other resource limited settings.

The embodiment of low-field MRI for the diagnosis of infant hydrocephalus in Uganda

Compared to other parts of the world, theincidence of hydrocephalus in children is very high in subSaharan Africa. Magnetic resonance imaging (MRI) would be the
preferred diagnostic method for infant hydrocephaleus. However, in practice, MRI is seldom used in sub-Saharan Africa due to its high prize, low mobility, and high power consumption.
A low-cost MRI technology is under development by reducing the strength of the magnetic field and the use of alternative technologies to create the magnetic field. This paper describes the embodiment design process to match this new MRI technology under development with the specific characteristics of the healthcare system in Uganda.

A context exploration was performed to identify factors that may affect the design and implementation of the low-field MRI in Ugandan hospitals and Ugandan healthcare environment. The key-insights from the technology- and context-exploration were translated into requirements which were the starting point for the design process. The concept development did have a focus on Cost-effective design, Design for durability & reliability, and Design for repairability. The final design was validated by stakeholders from the Ugandan Healthcare context.

Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

Introduction
Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality.

Methods
A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded.

Results
Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6).

Conclusion
Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.