Browsing by Subject "Uganda"

Background. The confluence of a capacity-exceeding disease burden and persistent resource shortages have resulted in traumatic brain injury’s (TBI) devastating impact in low and middle income countries (LMIC). Lifesaving care for TBI depends on accurate and timely decision making within the hospital. As result of technology and highly skilled provider shortages, treatment delays are common in low resource settings. This reality demands a low cost, scalable and accurate alternative to support decision making. Decision support tools leveraging the accuracy of modern prognostic modeling techniques represents one possible solution. This thesis is a collation of research dedicated to the advancement of TBI decision support technology in low resource settings. Methods. The study location included three national and referral hospitals in Uganda and Tanzania. We performed a survival analysis, externally validated existing TBI prognostic models, developed our own prognostic model, and performed a feasibility study for TBI decision support tools in an LMIC. Results. The survival analysis revealed a greater surgical benefit for mild and moderate head injuries compared to severe injuries. However, severe injury patients experienced a higher surgery rate than mild and moderate injuries. We developed a prognostic model using machine learning with a good level of accuracy. This model outperformed existing TBI models in regards to discrimination but not calibration. Our feasibility study captured the need for improved prognostication of TBI patients in the hospital. Conclusions. This pioneering work has provided a foundation for further investigation and implementation of TBI decision support technologies in low resource settings.

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Objective: The prevalence of cognitive impairment in HIV-positive patients is estimated to be 39% in Uganda [1]. Despite the high prevalence of impairment, routine HIV management in Uganda does not include neuropsychological assessment. The objective of this study was to compare performance on the gold standard neuropsychological exam and on the CogState computerized exam. We hypothesized that there would be a high degree of correlation between performance on the two exams.

Methods: This cross-sectional survey was conducted from August to October 2011. Each participant completed the standard neuropsychological exam, which consisted of 10 tasks across 7 cognitive ability domains. Patients also completed CogState, which consisted of 4 tasks using playing cards. Performance for each exam was standardized using normative data from HIV seronegative controls to produce z-scores. The primary outcome measures were average z-scores of performance for each exam.

Results: Out of 181 patients tested, 130 (72%) were classified as impaired on the gold standard neuropsychological exam, while 104 (57%) were classified as impaired on CogState. The sensitivity of CogState compared to the gold standard was 65% (95% CI = 56% - 73%) and the specificity was 63% (95% CI = 48% - 73%). The Pearson's correlation of cumulative performance between the exams is 0.552, which is significant at the 0.01 level. Finally, those patients with normal cognition performed the best on CogState, while those with the most severe impairment performed the worst.

Conclusions: Our findings suggest that CogState is a feasible and useful tool to screen for and monitor impairment in HIV-positive patients, especially in resource-limited settings. Future studies are needed to examine how individual performance on CogState changes over time.

Background: Nutrition is a key determinant of pediatric cancer patient outcomes in sub-Saharan Africa. Accurately identifying pediatric cancer patients at risk of malnutrition remains a challenge. There is a need for a standardized nutritional screening tool, developed and validated in sub-Saharan Africa. Study aims: The aims of this study were to: 1) select candidate variables in the development of a nutritional screening from predictors associated with malnutrition in pediatric cancer patients and, 2) conduct a secondary data analysis estimating the prevalence of pediatric cancer in Uganda from cases presented at the Uganda Cancer Institute between January 1, 2017 and December 31, 2019. Methods: This study is a longitudinal hospital-based study, carried out at the Bugando Medical Center in Tanzania and Uganda Cancer Institute in Uganda. The study enrolled clinically confirmed pediatric cancer patients (<18 years) at the study sites. Measures of interest include: nutritional status, symptom duration, abdominal distention, anthropometric measures such as height, weight, mid-upper arm circumference, abdominal circumference, triceps skinfold thickness, and clinical characteristics such as serum albumin, mean corpuscular volume, and protein. Logistic regression models examined predictors of nutritional status in pediatric cancer patients. Lastly, geospatial analysis estimated the prevalence and examined the country-wide distribution of the pediatric cancers presented at the Uganda Cancer Institute between 2017 and 2019. Results: The sample of 77 pediatric cancer patients enrolled at the two study sites ranged from 1 to 17 years old. Solid tumor malignancies like Wilms tumor comprise of 40% of all diagnoses. 60% of cancer patients were malnourished at baseline. The strongest predictors of nutritional status were mid-upper arm circumference (AOR 0.52, 95% CI: 0.31 – 0.87), abdominal circumference (AOR 1.38, 95% CI: 1.16 – 1.65) and serum albumin (AOR 0.73, 95% CI: 0.62 - 0.86). Secondary analysis of the Uganda Cancer Institute registry shows 11607 patients with confirmed cancer diagnosis between 2017 and 2019. Acute lymphoblastic leukemia (31.4%) is the most common cancer diagnosis, followed by Wilms tumor (19.1%), rhabdomyosarcoma (9.4%) and Burkitt’s lymphoma (6.9%). Blood cancers are most common cancer types, of them the most frequent cases being leukemia (37%). 2018 saw the highest number of cancer presentations within the study timeframe. Conclusions: The results show abdominal circumference, serum albumin, and muac are candidate variables in developing a nutritional screening tool for pediatric cancer patients in SSA. Blood and solid cancers are prevalent in Uganda; thus, a customized nutritional screening tool is much needed.

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Background: Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the quality of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala Uganda.

Methods: We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.

Results: 563 TBI patients were enrolled from 1 June – 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category (mild, moderate, severe GCS 6-8, severe GCS 3-5), mortality differed by management pathway. The variables predictive of mortality were: moderate to severe TBI (GCS 9-12, GCS 6-8, and GCS 3-5), more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.

Conclusions: The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

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The incidence of Kaposi sarcoma (KS) has increased rapidly since the advent of the HIV epidemic. Although patient outcomes have improved significantly in high-income countries after the introduction of highly-active antiretroviral medication, incidence and mortality of KS still remain high in low-incomes countries. Delaying treatment may be a factor in explaining these poor outcomes, but there exists no empirical evidence measuring the association between delay and patient prognosis for KS patients. In response, a prospective, cross-sectional study was conducted at the Uganda Cancer Institute (UCI) among 161 HIV positive patients to measure the association between delay and overall stage risk from June-October 2012. Standardized interviews were conducted to measure delay and chart data were abstracted to obtain the cancer stage the patient received during their initial physician consultation upon admission to the UCI. Patients who experienced delay were over three and a half times as likely to have an overall poor stage risk than those who did not experience delay (OR: 3.59, P-value: 0.001, CI: 1.74-7.41). In multivariate analysis after controlling for gender, age, income, and exposure to HAART, patients who experienced delay were still three times as likely to have an overall poor diagnosis compared to those who did not delay (OR: 3.07, P-value: 0.002, CI: 1.35-6.96). Eliminating harmful delays can be an important factor to intervene upon to improve patient prognosis and outcomes among HIV-associated KS patients in Uganda.

Health system strengthening is now recognized as a pressing global health priority. Motivated and productive health workers are a critical component of health systems. Low and middle-income countries need many more health workers, but not simply more of the same. Insufficient collaboration between the health and education sectors creates a crippling mismatch between professional health service education and the realities of health service delivery. A transformative scale-up of health education is needed to increase the capacity of health systems to respond to population needs. We make the case for multi-sector innovation during the scale-up of health education-- ranging from new recruitment strategies, faculty development and curricular reform on the institutional level to cross-sector planning and investment on the national level. Such a transformation will require a broad process of multi-sector reform.

In Uganda the lack of formal health management education is a barrier to improved health systems and improved population health outcomes. Duke University partnered with executive leadership from the Ugandan Catholic and Protestant medical bureaus, the public health sector and the three leading schools of health management in Uganda to conduct a series of activities to strengthen the capacity for health management and leadership in Uganda. After a formative research process to describe the national health management training landscape, the partnership surveyed health managers in the Kabarole District in western Uganda. The partnership then designed and led a five day workshop on leadership, management and governance in the Kabarole District in western Uganda.

A series of pre- and post- surveys asked workshop participants to self-report their confidence, previous use and predicted use of skills in each of the five workshop modules as well as evaluate the course content, design and instruction. These data were analyzed to determine if the workshop showed potential for health system improvement.

All but one module demonstrated significant pre to post confidence effect-size change, as well as significant self-reported intent to practice new management skills. A module-based workshop that (1) is designed with evidence gathered with a country-level and local needs assessment; (2) combines global content with local context; and (3) uses experiential learning techniques, may be an effective intervention for organizational change. Further follow-up after post-workshop mentoring activities will be important to document this process. We describe a vision for how this follow-up might take place within the larger context of the partnership's future activities. We also include a manual based on the workshop instructional materials entitled: A Teaching Manual for Health Facility Management, Leadership and Governance in Uganda.

Background: Barriers to surgical care in low- and middle-income countries have basis in theoretical frameworks, but are often left undefined and understudied. Based on the Access Evaluation Framework and Healthcare Barrier Model, this study implemented two consumer decision tools and a qualitative interview to elucidate significant barriers to seeking surgical care in Uganda.

Methods: Participants were recruited from a convenience sample within the surgical wards of one national referral hospital and one regional referral hospital in Uganda. Individuals selected for the study answered a brief questionnaire and a ranking and rating exercise followed by an in-depth semi-structured interview. The questionnaire evaluated demographic, economic, transportation, and care-seeking characteristics, while the ranking and rating exercises assessed potential barriers to surgical care. Descriptive statistics were used to assess characteristics of the sample. Ranking and rating medians were compared between the two exercises for each barrier.

Results: Among the 214 participants, cost of surgery, distance to hospital, and transportation to hospital were identified as the most significant barriers to care. Language barrier, no control over decision making, and no caretaker available at the hospital were identified as the least significant barriers to care. Mulago National Referral Hospital had significantly greater costs and transportation times indicating larger scale barriers to care than Jinja Regional Referral Hospital even though top barriers were similar.

Conclusions: Both the ranking and rating exercises and interviews indicated that cost was the most significant barrier to surgical care among care-seekers in Uganda. Transportation to the hospital and distance from the hospital remain large barriers that need to be considered as well. These complementary analysis tools provide evidence that future policies and research need to consider mitigating cost, distance, and transportation issues for patients that need a surgical intervention. Next steps in determining more granular level differences between barriers will help understand how best to address these issues.