Category: Uganda

As Programme Coordinator for Malaria Consortium’s pneumonia diagnostics project, I visited Uganda last week to see the preparations underway for the final stage of the project: the field evaluation. During three months, our teams will study the usability and acceptability of previously selected devices to find the best one for diagnosing pneumonia – a major killer of children under five in sub-Saharan Africa.

I recently attended a training conducted by three master trainers in Mpigi town where seven village health team members (VHTs) were learning how to assess the first pair of devices: a respiratory rate phone application called RRate and a pulse oximeter called UTECH. The training went very well, with six out of seven assessors passing with a 90 percent competency score. We will now continue to train all 25 assessors who will be participating in the study for the next three months.

I then joined the Malaria Consortium research team who were conducting assessments in the field with previously trained VHTs. This was to support the research team with on the ground training on conducting this element of the study and on providing supervision to the VHTs to ensure they were able to assess the diagnostic devices.

As sensitisation of key audiences before the field evaluation activity is key to the success of this phase, this part of the project was very well planned and executed by the Ugandan team.

Firstly, the team held a pneumonia diagnostics sensitisation meeting with 40 heads of health centres in Mpigi district at the Health Centre IV in the town. The objective was to inform these key stakeholders of the project and ensure they understood why and how patients might come their way during the three-month field evaluation period.

After my presentation on the overall project aims and objectives, I  received interesting comments on inclusion criteria, the rationale for the study and on how pulse oximetry is an unknown tool in Uganda. The master trainers then demonstrated the devices and had good questions on the background for the study and how referrals would be handled. It was agreed that Malaria Consortium would provide an oxygen concentrator to Mpigi Health Centre IV to ensure oxygen would be available for any referred patients if required.

On the following day, I attended a sensitisation meeting of 20 district health officials, including the District Health Officer (DHO) and their assistants, at the Mpigi District Health Office where I presented on the project and the implications for the district. The DHO confirmed the need for the study and while expressing his gratitude for the support to date. All attendants were very interested to see the devices and were happy to hear Malaria Consortium had supported the Health Centre with an oxygen concentrator.

The field evaluation started in Mpigi district in October and will continue running during the months of November and December 2015. The dissemination of results on the usability and acceptability of the devices is planned for January and February 2016.

Kevin Baker is the Pneumonia Diagnostics Programme Coordinator

Alany and Majole are South Sudanese women living in refugee camps in West Nile province, Northern Uganda. Both are pregnant.

I met Alany and Majole as I travelled to a rural health facility, where they were attending their first antenatal care (ANC) visit.  The midwife sat with each of the women and gave them a basic health education lesson. Then there were the physical examinations, followed by the provision of required medicines for their stage of pregnancy – including intermittent preventive treatment in pregnancy (IPTp) to reduce the risk of malaria for themselves and their babies. Before they returned home under the shelter of their sun umbrella, they were each given a mosquito net to protect them further from malaria. These last two aspects of the ANC visit are especially important since pregnant women are at increased risk of malaria – as are their unborn babies.

Malaria in pregnancy (MIP) is a significant public health threat which affects more than 30 million pregnant women each year in malaria-endemic areas. It poses substantial risks to mother and unborn child, including maternal anaemia, stillbirth, miscarriage and low birth weight – a leading cause of child mortality. To prevent malaria infections among pregnant women living in areas of moderate or high transmission, the World Health Organization recommends IPTp, a full therapeutic course of antimalarial medicine given to pregnant women regardless of whether or not they are infected with malaria.

Uganda’s Malaria Control Strategic Plan identifies IPTp as one of three main elements to prevent MIP. It is delivered as part of the focused ANC package and has been implemented countrywide since 2002. Yet, despite having made significant progress, Uganda is far from meeting the government’s target of 85 percent of pregnant women receiving two doses of IPTp by the end of 2015. In 2014-15, less than half of pregnant women in Uganda received two or more doses of IPTp, despite overall one time ANC attendance being 94 percent in Uganda.

What we are doing about it

To explore the factors that continue to impede IPTp uptake, Malaria Consortium is leading a research project to assess and address barriers to pregnant women taking IPTp in Uganda. The study is conducted through COMDIS-HSD, a Research Programme Consortium, and also through our programme partnership arrangement  with funding from the UK government.

We discovered a range of barriers. In particular, health workers were found to have mixed knowledge of IPTp guidelines with regard to dosage, timing, and frequency. They did not always offer IPTp and encourage pregnant women to take it, at times incorrectly judging them to be ineligible.

Based on these findings, we designed a pilot intervention to align with the Ministry of Health training programme on MIP. This pilot intervention is being implemented in West Nile province, complementing the standard training course on MIP by sending daily reminder text messages for five weeks, summarising the key points relating to IPTp of the training. The intervention is being implemented in eight health facilities. A neighbouring district acts as control with a further eight health facilities receiving the training but not the text messages.

How things are progressing

With the text messages having been sent out in June and July, I travelled to Uganda to check up on progress and to gain a better understanding of the project sites. I also visited health facilities in the study districts to observe how things are managed and the processes involved in an ANC visit.  This will feed into the evaluation of the pilot intervention in December, which will also look at data on ANC attendance, IPTp doses, IPTp stock levels, as well as follow up with a random sample of pregnant women who visited the health facilities for their ANC visits.  In preparation for this evaluation, I looked at all of the ANC registers and other records in close detail. I met with health facility staff to ask questions about their ANC clinics – roughly how many pregnant women they see, and how many midwives they have. I also met with some of the midwives to discuss ANC services they provide, specifically relating to malaria.

The visit was a great opportunity to see the hard work going into protecting pregnant women from malaria in West Nile. The pregnant women who visit these clinics return home better equipped to protect themselves and their babies from malaria.

By observing visits and discussing with staff at the ANC clinics, I could see first-hand some of the challenges and barriers to uptake of IPTp and other malaria control measures. For example, some steps of the process are not completed as they should be; medicines which should be taken at the health facility and in front of the midwife are being given to women to take at home at a later time; and shortages of some medicines and of ANC cards have led to difficulties administering the drugs and making sure women attend all of their ANC appointments on the correct dates.

However these obstacles are not insurmountable – and with further study and appropriate action they can be overcome. Obstacles such as these which get in the way of pregnant women receiving the best possible prevention and treatment from malaria are the motivation for studies such as the IPTp study in Uganda, as well as our other work in sub-Saharan Africa and Southeast Asia.

Georgia Gore-Langton is the COMDIS-HSD Research Officer at Malaria Consortium in London.

Pregnant women are particularly susceptible to malaria partly because of their reduced immunity to the disease, but also because of their vulnerable social and economic status. Their unborn babies are also at high risk, with malaria potentially leading to spontaneous abortion and low birth weight. Babies born with low birth weight will often be weak and more likely to get sick. However, malaria in pregnancy is preventable. The World Health Organization recommends a combination of three interventions for the prevention and treatment of malaria in pregnancy: the use of long-lasting insecticidal nets, prompt diagnosis and effective treatment of malaria infections, and the administration of intermittent preventive treatment in pregnancy (IPTp).

It is this last method that we have been concerned with at Malaria Consortium. IPTp is low-cost, safe and generally acceptable to pregnant women, and can be provided at antenatal check-ups. However, despite generally high antenatal care (ANC) attendance, most countries in sub-Saharan Africa do not come close to meeting the targets set by organisations like Roll Back Malaria, which advocate for universal coverage.  In Uganda, for example, current surveys suggest that only about a quarter of pregnant women receive two doses of IPTp (IPT2, the indicator commonly used to assess IPTp uptake). This suggests that many opportunities for the provision of IPTp are being missed.

Research results

We have coordinated a study conducted in 2014, which explored the barriers that continue to impede IPTp uptake in Uganda. This has involved carrying out in-depth interviews with pregnant women and mothers who attended ANC, health workers, district health officials and community leaders.  Conducted through COMDIS-HSD, a research programme consortium funded by UK aid from the UK government, the study looked at both the supply side (i.e. the health system, including health workers) and demand side factors (i.e. women’s and communities’ perceptions).

The research concluded that, despite a range of minor concerns (for example with regard to taking IPTp on an empty stomach), women and communities have largely positive views of ANC and IPTp. Refusal rates of IPTp are low and given the high ANC attendance figures, the main obstacles to the provision of IPTp are therefore likely to be supply-side challenges. In the past, many health facilities struggled with frequent stock-outs of the drug used for IPTp, although this has been improving thanks to recent efforts from the Ministry of Health. Private facilities on the other hand have to buy their own supplies, which means stock-outs are still a problem.

Another major barrier to the provision of IPTp is health workers’ inadequate knowledge with regard to when and how to provide IPTp. This is compounded by the incoherent and out-of-date information provided in many policy documents and job aids that are supposed to guide health workers. Moreover, the policies in use are not in line with the most recent WHO policy recommendations for the provision of IPTp.

What next?

Malaria Consortium is about to implement a small-scale pilot intervention in collaboration with the Ministry of Health to address some of the key barriers to IPTp uptake in Uganda. The main focus of the intervention is to ensure adequate knowledge of IPTp guidelines among health workers. This will support the Ministry’s plans to roll out a country-wide classroom-based training programme on malaria in pregnancy, which will include updated IPTp guidelines that comply with current WHO recommendations.

However, it is unfortunately not feasible for everyone involved in ANC provision to attend traditional classroom training sessions. Therefore, in order to reinforce the guidelines and ensure all relevant health workers receive the necessary information, we will pilot the use of text messaging to communicate key messages. Following the classroom-based training, health workers providing ANC services at a number of health facilities in West Nile province will receive a series of text messages emphasising the importance of IPTp, explaining the new guidelines and the rationale behind the changes. This approach has recently been shown to be highly effective in communicating clinical recommendations to health workers in China, and we believe that the rapid spread of mobile technology in Africa means that the time is right to test this innovative solution in Uganda.

In order to assess the effect of the intervention, the pilot will also include health workers in a neighbouring district who will only receive the classroom-based malaria in pregnancy training. We will assess knowledge of IPTp at all facilities six months after the training. If text messaging works, we would expect to see better levels of knowledge among those health workers who attended the training and subsequently received the messages compared with those who only received the training. We would also expect that better knowledge of the IPTp guidelines will lead to fewer missed opportunities and hence an increase in IPTp coverage. The pilot is scheduled to start in May 2015 and evaluation results are expected to be available in 2016.

Christian Rassi is COMDIS-HSD Project Coordinator at Malaria Consortium