Health Facilities In Uganda Research Articles

Knowledge, attitudes and practice of breast sonography among females at a rural health facility in Uganda

# Introduction Breast sonography has become an important evaluation tool in assessing breast masses and other suspicious breast changes. Despite its importance and popularity in many large hospitals, breast sonography remains under-utilized in many rural health facilities. # Objective The purpose of this study was to explore the knowledge, attitudes and practice of breast sonography amongst a group women in a rural health context. # Methods It was a cross-sectional study in which data from women was collected using interviewer-administered questionnaires. The qualitative component of the data was analysed using thematic analysis. For the quantitative component, SPSS was used for analysis. Association between socio-demographic characteristics and adequacy of knowledge, attitudes and practice of breast sonography were determined using both bivariate and logistic regression analysis. A Chi-square was used to test statistical significance. # Results Majority (95%) of the women in this study lacked knowledge of breast sonography, and generally all the women demonstrated a negative attitude towards breast sonography. Knowledge about breast sonography as well as recommendation by a health worker remained the only significant factors that seemed to influence the practice of seeking for breast sonography services. # Conclusions The women in this study demonstrated limited knowledge of breast sonography which perhaps contributed to the negative attitude and poor practice of seeking breast sonography services at the health facility.

Knowledge, attitudes and practice of breast sonography among females at a rural health facility in Uganda

Knowledge, attitudes and practice of breast sonography among females at a rural health facility in Uganda

Beneath the Surface: Crude and Sensitive Quality of Care Measures for Maternal and Neonatal Healthcare in Rural Uganda

Background: Efforts to improve access to healthcare in low-income countries will not achieve the maternal and child health (MCH) Sustainable Development Goals unless there is a concomitant improvement in the quality of care (QoC) provided. This study measures infrastructure and QoC indicators in rural Ugandan health facilities. Valid and sensitive measures of the quality of current clinical practices in resource-limited settings are critical for effectively intervening to reduce adverse maternal and neonatal outcomes. Methods: Facility-based assessments of infrastructure and clinical quality during labor and delivery were conducted in six primary care health facilities in the greater Masaka area, Uganda in 2017. Data were collected using direct observation of clinical encounters and facility checklists. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum hemorrhage, neonatal resuscitation). Health providers were assessed on their adherence to best practice standards of care. Findings: The quality of facility infrastructure was relatively high in facilities, with little variation in availability of equipment and supplies. However, heterogeneity in adherence to best clinical practices was noted across procedure type and facility. Adherence to crude measures of clinical quality were relatively high but more sensitive measures of the same clinical practice were found to be much lower. Interpretation: Crude QoC indicators are insufficient to validly measure MCH clinical quality, and more sensitive measures of input and process quality of clinical care, with an emphasis on the timing of these processes, are needed to develop effective MCH interventions. Funding Statement: The study was funded by LifeNet International Declaration of Interests: The authors report a grant from LifeNet International during the conduct of the study. Three of the authors of this publication (JK, LA, SW) were paid employees of LifeNet International, the funder, at the time this study was carried out and assisted with study design, data collection and manuscript preparation. However, no LifeNet author had access to aggregate study data during data collection, nor was any LifeNet employee involved with data analysis or in the initial presentation of study results. Ethics Approval Statement: Ethical approval was obtained from the Uganda National Council of Science and Technology (UNCST), The AIDS Support Organization (TASO) in Uganda, and the Duke University Campus institutional review board.

Effect of TB/HIV Integration on TB and HIV Indicators in Rural Ugandan Health Facilities.

The World Health Organization recommends integrating services for patients coinfected with tuberculosis (TB) and HIV. We assessed the effect of TB/HIV integration on antiretroviral therapy (ART) initiation and TB treatment outcomes among TB/HIV-coinfected patients using data collected from 14 rural health facilities during 2 previous TB and HIV quality of care studies. A facility was considered to have integrated TB/HIV services if patients with TB/HIV had combined treatment for both illnesses by 1 provider or care team at 1 treatment location. We analyzed the effect of integration by conducting a cross-sectional analysis of integrated and nonintegrated facility periods comparing performance on ART initiation and TB treatment outcomes. We conducted logistic regression, with the patient as the unit of analysis, controlling for other intervention effects, adjusting for age and sex, and clustering by health facility. From January 2012 to June 2014, 996 patients with TB were registered, 97% were tested for HIV, and 404 (42%) were HIV-positive. Excluding transfers, 296 patients were eligible for analysis with 117 and 179 from nonintegrated and integrated periods, respectively. Being treated in a facility with TB/HIV integration was associated with lower mortality [adjusted odds ratio (aOR) = 0.38, 95% confidence interval (CI): 0.18 to 0.77], but there was no difference in the proportion initiating ART (aOR = 1.34, 95% CI: 0.40 to 4.47), with TB treatment success (aOR = 1.43, 95% CI: 0.73 to 2.82), lost to follow-up (aOR = 1.64, 95% CI: 0.53 to 5.04), or failure (aOR = 1.21, 95% CI: 0.34 to 4.32). TB/HIV service integration was associated with lower mortality during TB treatment even in settings with suboptimal proportions of patients completing TB treatment and starting on ART.

Decentralisation of child tuberculosis services increases case finding and uptake of preventive therapy in Uganda.

A lack of capacity to diagnose tuberculosis (TB) in children at peripheral health facilities and limited contact screening and management contribute to low case finding in TB-endemic settings. To evaluate the implementation of a pilot project that strengthened diagnosis, treatment and prevention of child TB at peripheral health facilities in Uganda. In June 2015, health care workers at peripheral health facilities were trained to diagnose and treat child TB. Community health care workers were trained to screen household TB contacts. Before-and-after analysis as well as comparisons with non-intervention districts were used to evaluate impact on caseload and treatment outcomes. By December 2016, the average number of children (age < 15 years) diagnosed with TB increased from 45 to 108 per quarter. The proportion of child TB among all TB cases increased from 8.8% to 15%, and the proportion completing treatment increased from 65% to 82%. Of 2270 child TB contacts screened, 55 (2.4%) were diagnosed with TB. Of 910 eligible child contacts, 670 (74%) started preventive therapy, 569 (85%) of whom completed therapy. The strengthening of child TB services at peripheral health facilities in Uganda was associated with increased case finding, improved treatment outcomes and the successful implementation of contact screening and management.

Do incentives matter when working for god? The impact of performance-based financing on faith-based healthcare in Uganda

Abstract Can extrinsic incentives motivate faith-based healthcare providers? This paper challenges the finding that religious providers are intrinsically motivated to serve (poor) patients, and that extrinsic incentives may crowd-out such motivation. We use a unique panel of output and expenditure data from small faith-based nonprofit healthcare facilities in Uganda to estimate the effect of introducing performance-based financing. The output of the observed facilities is less than 50% of their potential. Performance-based financing increases output and efficiency robustly by at least 27%, with no apparent reduction in the perceived quality of services. Religious nonprofit healthcare providers may well be intrinsically motivated, but respond positively to extrinsic incentives. Whether working for god or not, incentives matter.

Assessing feasibility of resources at health facilities in Uganda to diagnose pregnancy and neonatal outcomes

Standardized case definitions for obstetric and neonatal outcomes were developed by the Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project. These definitions can facilitate comparable assessment of maternal immunization safety surveillance and research. This study assessed the capabilities of health centers (HC) in Uganda to implement these definitions in a low income country, which has not been explored. Healthcare practitioners at 15 government-accredited health centers and one government-funded district hospital in the Iganga-Mayuge Health and Demographic Surveillance Site (IMHDSS) in Uganda were interviewed about the facility's clinical diagnostic and laboratory capabilities. Five obstetric and five neonatal case definitions were evaluated. Definitions with the highest diagnostic certainty were designated as level 1, while definitions that decreased in certainty were designated as level 2 or 4. HCs were evaluated on diagnostic and laboratory capabilities to apply the GAIA definitions. Higher-level facilities in the IMHDSS demonstrated the ability to diagnose more specific levels of the GAIA obstetric and neonatal outcomes than lower-level facilities. Furthermore, for the neonatal outcome assessment, there was an increased ability to diagnose outcomes moving from GAIA level 1 to level 3. The ability of health centers to implement globally standardized definitions is promising for implementation of standardized data collection methods for global vaccine safety surveillance and research.

Water, Sanitation, and Hygiene Service Availability at Rural Health Care Facilities in Southwestern Uganda.

There is a paucity of information on the state of water, sanitation, and hygiene (WASH) at health care facilities in Uganda. A survey on WASH service availability was conducted at 50 health care facilities across 4 districts of rural southwestern Uganda between September and November 2015. The main water points at the majority (94%) of the health care facilities were improved sources, while improved toilets were available at 96% of the health care facilities visited. Hospitals had the poorest toilet to patient ratio (1 : 63). Only 38% of the health care facilities had hand washing facilities at the toilets. The lack of hand washing facilities was most prominent at the level IV health centre toilets (71%). Hand washing facilities were available at other points within most (76%) of the health care facilities. However, both water and soap were present at only 24% of these health care facilities. The poor toilet to patient/caregiver ratios particularly in the high volume health care facilities calls for the provision of cheaper options for improved sanitation in these settings. Priority should also be given to the sustainable provision of hygiene amenities such as soap for hand washing particularly the high patient volume health care facilities, in this case the level IV health centres and hospitals.

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

BackgroundThe 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.MethodsA 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.ResultsA 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.ConclusionSuppression 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.

Long term trends and spatial distribution of animal bite injuries and deaths due to human rabies infection in Uganda, 2001-2015.

BackgroundIn the absence of accurate data on trends and the burden of human rabies infection in developing countries, animal bite injuries provide useful information to bridge that gap. Rabies is one of the most deadly infectious diseases, with a case fatality rate approaching 100%. Despite availability of effective prevention and control strategies, rabies still kills 50,000 to 60,000 people worldwide annually, the majority of whom are in the developing world. We describe trends and geographical distribution of animal bite injuries (a proxy of potential exposure to rabies) and deaths due to suspected human rabies in Uganda from 2001 to 2015.MethodsWe used 2001–2015 surveillance data on suspected animal bite injuries, collected from health facilities in Uganda. To describe annual trends, line graphs were used and linear regression tested significance of observed trends at P<0.05. We used maps to describe geographical distribution of animal bites by district.ResultsA total of 208,720 cases of animal bite injuries were reported. Of these, 27% were in Central, 22% in Eastern, 27% in Northern and 23% in Western regions. Out of 48,720 animal bites between 2013 and 2015, 59% were suffered by males and 81% were persons aged above 5 years. Between 2001 and 2015, the overall incidence (per 100,000 population) of animal bites was 58 in Uganda, 76 in Northern, 58 in Central, 53 in Western and 50 in Eastern region. From 2001 to 2015, the annual incidence (per 100,000 population) increased from 21 to 47 (P = 0.02) in Central, 27 to 34 (P = 0.04) in Eastern, 23 to 70 (P = 0.01) in Northern and 16 to 46 (P = 0.001) in Western region. A total of 486 suspected human rabies deaths were reported, of which 29% were reported from Eastern, 28% from Central, 27% from Northern and 17% from Western region.ConclusionAnimal bite injuries, a potential exposure to rabies infection, and mortality attributed to rabies infection are public health challenges affecting all regions of Uganda. Eliminating rabies requires strengthening of rabies prevention and control strategies at all levels of the health sector. These strategies should utilize the “One Health” approach with strategic focus on strengthening rabies surveillance, controlling rabies in dogs and ensuring availability of post exposure prophylaxis at lower health facilities.

Article 2: Longitudinal study assessing the one-year effects of supervision performance assessment and recognition strategy (SPARS) to improve medicines management in Uganda health facilities

BackgroundIn late 2010, Uganda introduced a supervision, performance assessment, and recognition strategy (SPARS) to improve staff capacity in medicines management in government and private not-for-profit health facilities. This paper assesses the impact of SPARS in health facilities during their first year of supervision.MethodsSPARS uses health workers trained as Medicines Management Supervisors (MMS) to supervise health facilities and address issues identified through indicatorbased performance assessment in five domains: stock management, storage management, ordering and reporting, prescribing quality, and dispensing quality. We used routine data generated during SPARS visits to 1222 health facilities to evaluate performance changes during the first year of supervision as well as the time until achieving an adequate score in this period. We also explored variables related to facilities, MMS, and intensity of implementation as predictors of performance improvement and time until achieving an adequate score.ResultsHealth facilities received an average of 3.4 MMS visits during the first year of supervision, with an average of 88 days between visits; each MMS implemented a median of 28 visits per year. Overall SPARS scores (maximum of 25) improved by 2.3 points (22.3%) per visit from a mean baseline score of 10.3. The adjusted improvement in overall SPARS score was significantly higher in primary health care facilities (2.36) versus higher-level health facilities and hospitals (2.15) (p = 0.001). The incremental improvement was highest at visit 2, with decreasing but continuing positive gains in subsequent visits. The adjusted mean incremental improvement per visit was highest in the prescribing quality domain, followed by dispensing quality, ordering and reporting, stock management, and storage management. Adjusted improvement in SPARS scores varied by region, year of implementation, and facility ownership. After one year of SPARS, 22% of facilities achieved an adequate score of 18.75 (75% of maximum score).ConclusionsSPARS was effective in building health facility capacity in medicines management, with a median overall improvement of almost 70% during the first year. The greatest improvements occurred in prescribing quality and at lower levels of care, although the highest level of performance was achieved in storage management. We recommend broad dissemination of the SPARS approach in all Ugandan health facilities as well as in other countries seeking a practical strategy to improve medicines management performance.

Evaluating inter-rater reliability of indicators to assess performance of medicines management in health facilities in Uganda

BackgroundTo build capacity in medicines management, the Uganda Ministry of Health introduced a nationwide supervision, performance assessment and recognition strategy (SPARS) in 2012. Medicines management supervisors (MMS) assess performance using 25 indicators to identify problems, focus supervision, and monitor improvement in medicines stock and storage management, ordering and reporting, and prescribing and dispensing. Although the indicators are well-recognized and used internationally, little was known about the reliability of these indicators. An initial assessment of inter-rater reliability (IRR), which measures agreement among raters (i.e., MMS), showed poor IRR; subsequently, we implemented efforts to improve IRR. The aim of this study was to assess IRR for SPARS indicators at two subsequent time points to determine whether IRR increased following efforts to improve reproducibility.MethodsIRR was assessed in 2011 and again after efforts to improve IRR in 2012 and 2013. Efforts included targeted training, providing detailed guidelines and job aids, and refining indicator definitions and response categories. In the assessments, teams of three MMS measured 24 SPARS indicators in 26 facilities. We calculated IRR as a team agreement score (i.e., percent of the MMS teams in which all three MMS had the same score). Two sample tests for proportions were used to compare IRR scores for each indicator, domain, and overall for the initial assessment and the following two assessments. We also compared the IRR scores for indicators classified as simple (binary) versus complex (multi-component). Logistic regression was used to identify supervisor group characteristics associated with domain-specific and overall IRR scores.ResultsInitially only five (21%) indicators had acceptable reproducibility, defined as an IRR score ≥ 75%. At the initial assessment, prescribing quality indicators had the lowest and stock management indicators had the highest IRR. By the third IRR assessment, 12 (50%) indicators had acceptable reproducibility, and the overall IRR score improved from 57% to 72%. The IRR of simple indicators was consistently higher than that of complex indicators in the three assessment periods. We found no correlation between IRR scores and MMS experience or professional background.ConclusionsAssessments of indicator reproducibility are needed to improve IRR. Using simple indicators is recommended.

The Burden of Adverse Drug Reactions Due to Artemisinin-Based Antimalarial Treatment in Selected Ugandan Health Facilities: An Active Follow-Up Study.

IntroductionUganda has rapidly increased access to antimalarial medicines in an effort to address the huge malaria disease burden. Pharmacovigilance information is important to guide policy decisions.ObjectivesThe purpose of this study was to establish the burden of adverse drug reactions (ADRs) and associated risk factors for developing ADRs to artemisinin-based antimalarial treatment in Uganda.MethodsAn active follow-up study was conducted between April and July 2017 in a cohort of patients receiving treatment for uncomplicated malaria in the Iganga, Mayuge, and Kampala districts.ResultsA total of 782 patients with a median age of 22 years (58.6% females) were recruited into this study, with the majority recruited from public health facilities (97%). Diagnostic tests before treatment were performed for 76% of patients, and 97% of patients received artemether/lumefantrine. The prevalence of ADRs was 22.5% (176/782); however, the total number of ADRs was 245 since some patients reported more than one ADR. The most commonly reported reactions were general body weakness (24%), headache (13%), and dizziness (11%). Women were more likely to develop an ADR (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1–2.9), urban dwellers were more likely to develop an ADR than rural residents (aOR 9.9, 95% CI 5.4–17.9), and patients with comorbidities were more likely to develop an ADR than those without (aOR 7.4, 95% CI 4.4–12.3).ConclusionThe burden of ADRs is high among women and in patients from urban settings and those with comorbidities. Such risk factors need to be considered in order to optimise therapy. Close monitoring of ADRs is key in implementation of the malaria treatment policy.Electronic supplementary materialThe online version of this article (10.1007/s40264-018-0659-x) contains supplementary material, which is available to authorized users.

Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study

BackgroundWhile antiretroviral therapy (ART) availability for HIV patients has increased dramatically in Uganda, patient linkage to and retention in care remains a challenge. We assessed patterns of engagement in care in 20 Ugandan health facilities with low retention based on national reporting.MethodsWe assessed patient linkage to care (defined as registering for pre-ART or ART care at the facility within 1 month of HIV diagnosis) and 6-month retention in care (having a visit 3-6 months after ART initiation) and associations with patient−/facility-level factors using multivariate logistic regression.ResultsAmong 928 newly HIV-diagnosed patients, only 53.0% linked to care within 1 month. Of these, 83.7% linked within 1 week. Among 678 newly initiated ART patients, 14.5% never returned for a follow-up visit at the facility. Retention was 71.7% according to our primary definition but much lower if stricter definitions were used. Most patients were already falling behind appointment schedules at their first ART follow-up (median: 28 days post-initiation vs. recommended 14 days). 27.3% of newly-initiated patients had follow-up appointments scheduled 45+ days apart rather than monthly per national guidelines. Linkage and retention were not strongly correlated with each other within facilities (rs = 0.06; p = 0.82). Females, adolescents, and patients in rural settings tended to have lower linkage and retention in multivariable-adjusted models.ConclusionsLinkage support may be most critical immediately after testing positive, as patients are less likely to link over time. More information is needed on reasons for appointment schedules by clinicians and implications on retention.Trial registrationThis study was registered in the Pan African Clinical Trial Registry database (#PACTR201611001756166).

Disparities in availability of essential medicines to treat non-communicable diseases in Uganda: A Poisson analysis using the Service Availability and Readiness Assessment.

ObjectiveAlthough the WHO-developed Service Availability and Readiness Assessment (SARA) tool is a comprehensive and widely applied survey of health facility preparedness, SARA data have not previously been used to model predictors of readiness. We sought to demonstrate that SARA data can be used to model availability of essential medicines for treating non-communicable diseases (EM-NCD).MethodsWe fit a Poisson regression model using 2013 SARA data from 196 Ugandan health facilities. The outcome was total number of different EM-NCD available. Basic amenities, equipment, region, health facility type, managing authority, NCD diagnostic capacity, and range of HIV services were tested as predictor variables.FindingsIn multivariate models, we found significant associations between EM-NCD availability and region, managing authority, facility type, and range of HIV services. For-profit facilities’ EM-NCD counts were 98% higher than public facilities (p < .001). General hospitals and referral health centers had 98% (p = .004) and 105% (p = .002) higher counts compared to primary health centers. Facilities in the North and East had significantly lower counts than those in the capital region (p = 0.015; p = 0.003). Offering HIV care was associated with 35% lower EM-NCD counts (p = 0.006). Offering HIV counseling and testing was associated with 57% higher counts (p = 0.048).ConclusionWe identified multiple within-country disparities in availability of EM-NCD in Uganda. Our findings can be used to identify gaps and guide distribution of limited resources. While the primary purpose of SARA is to assess and monitor health services readiness, we show that it can also be an important resource for answering complex research and policy questions requiring multivariate analysis.

Where have all the children gone? High HIV prevalence in infants attending nutrition and inpatient entry points.

IntroductionDespite notable progress towards PMTCT, only 50% of HIV‐exposed infants in sub‐Saharan Africa were tested within the first 2 months of life and only 30% of HIV‐infected infants are on antiretroviral treatment. This study assessed HIV prevalence in infants and children receiving care at various service entry points in primary healthcare facilities in Uganda.MethodsA total of 3600 infants up to 24 months of age were systematically enrolled and tested at four regional hospitals across Uganda. Six hundred infants were included and tested from six facility entry points: PMTCT, immunization, inpatient, nutrition, outpatient and community outreach services.FindingsThe traditional EID entry point, PMTCT, had a prevalence of 3.8%, representing 19.6% of the total HIV‐positive infants identified in the study. Fifty percent of the 117 identified HIV‐positive infants were found in the nutrition wards, which had a prevalence of 9.8% (p < 0.001 compared to PMTCT). Inpatient wards had a prevalence of 3.5% and yielded 17.9% of the HIV‐positive infants identified. Infants tested at immunization wards and through outreach services identified 0.8% and 1.7% of the HIV‐positive infants respectively, and had a prevalence of less than 0.3%.ConclusionsExpanding routine early infant diagnosis screening beyond the traditional PMTCT setting to nutrition and inpatient entry points will increase the identification of HIV‐infected infants. Careful reflection for appropriate testing strategies, such as maternal re‐testing to identify new HIV infections and HIV‐exposed infants in need of follow‐up testing and care, at immunization and outreach services should be considered given the expectedly low prevalence rates. These findings may help HIV care programmes significantly expand testing to improve access to early infant diagnosis and paediatric treatment.

Assessment of health provider readiness for telemedicine services in Uganda.

There are few telemedicine projects in Africa that have reached scale. One of the reasons proposed for this has been failure to assess health provider readiness for telemedicine prior to implementation. To assess health provider readiness for implementation and integration of telemedicine services at three levels of Uganda's health facilities, namely, a national referral hospital (NRH), regional referral hospitals (RRHs) and level 4 health centres (HC-IVs) and to investigate factors associated with readiness for telemedicine. A cross-sectional descriptive study was conducted at public healthcare facilities in Uganda. One RRH and HC-IV was identified from each of the Western, Eastern and Northern regions using a multistage random sampling technique. Mulago Hospital, which doubles as an RRH and HC-IV in the central region, was purposively identified for the study. After validation, a questionnaire was distributed for self-administration to senior administrators and doctors selected at the NRH, RRHs and HC-IVs. Data were analysed using bivariate associations between the outcome and the potential independent variables. In total, 114 healthcare workers completed the questionnaire. Of the respondents, 24 (21%) were from HC-IVs, 44 (39%) were from RRHs, and 46 (40%) from NRH. Doctors made up 45.8% (11) of respondents at HC-IVs, 59% (26) at RRHs, and 30.4% (14) at NRH. Administrators across all health facility levels were more likely to integrate telemedicine into the healthcare system than doctors (odd ratio = 1.39 [95% confidence interval = 0.38-4.95]). A significant association existed between the state of readiness and type of health facility, p < 0.001. The NRH and RRHs are more likely to integrate telemedicine into their systems than the HC-IVs. Among the factors investigated (job title, health facility, technology type, reason for referral and frequency of electronic communication), the level of health facility and title or role of healthcare worker were found to have a significant statistical association with being ready to integrate telemedicine into the healthcare system. Health provider readiness to integrate telemedicine services varies at the different levels of the health facility and job title or role. However, referral hospitals and administrators were more likely to integrate telemedicine than HC-IVs and doctors, respectively. While this study shows physicians and administrators are ready, other sectors (nurses, allied healthcare workers, public) will also need to be assessed.

Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability

ABSTRACTBackground: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy.Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization.Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review.Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities.Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.

Enhancing Workforce Capacity to Improve Vaccination Data Quality, Uganda.

In Uganda, vaccine dose administration data are often not available or are of insufficient quality to optimally plan, monitor, and evaluate program performance. A collaboration of partners aimed to address these key issues by deploying data improvement teams (DITs) to improve data collection, management, analysis, and use in district health offices and health facilities. During November 2014–September 2016, DITs visited all districts and 89% of health facilities in Uganda. DITs identified gaps in awareness and processes, assessed accuracy of data, and provided on-the-job training to strengthen systems and improve healthcare workers’ knowledge and skills in data quality. Inaccurate data were observed primarily at the health facility level. Improvements in data management and collection practices were observed, although routine follow-up and accountability will be needed to sustain change. The DIT strategy offers a useful approach to enhancing the quality of health data.

Health workers\u2019 perceptions of private-not-for-profit health facilities\u2019 organizational culture and its influence on retention in Uganda

BackgroundAn in-depth understanding of how organizational culture is experienced by health workers (HWs), and influences their decisions to leave their jobs is a fundamental, yet under-examined, basis for forming effective retention strategies. This research examined HWs’ working experiences and perceptions of organisational culture within private-not-for-profit, largely mission-based hospitals, and how this influenced retention.MethodsThirty-two HWs, including managers, in 19 health facilities in Uganda were interviewed using a semi-structured topic guide. Interview transcripts were analysed using thematic content analysis.ResultsInterviews showed that the organizational culture was predominantly hierarchical, with non-participative management styles which emphasized control and efficiency. HWs and managers held different perceptions of the organizational culture. While the managers valued results and performance, HWs valued team work, recognition and participative management.ConclusionsThe findings of this study indicate that organizational culture influences retention of HWs in health facilities and provide a useful context to inform health care managers in the PNFP sub-sector in Uganda and similar contexts. To improve retention of HWs, a gradual shift in organizational culture will be necessary, focussing on the values, beliefs and perceptions which have the greatest influence on observable behaviour.