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Acceptability and satisfaction of male partners with antenatal clinic-based HIV testing for PMTCT at Old-Mulago Hospital, Uganda

(Makerere University, 2010-12) Drasiku, Amos

Introduction: Despite benefits of and strategies to increase male partner participation in AHCT at Old-Mulago ANC, their attendance has remained very low (15.8% tested). It is not clear whether they accept AHCT and how satisfied those who have undergone it are. Methodology: A cross-sectional study of 214 male partners of antenatal mothers at Old- Mulago ANC selected by simple random sampling was done. Quantitative data was collected using semi-structured interviewer administered questionnaires. Multivariable logistic regression analysis were performed in Stata 10SE to obtain Odds ratios of satisfaction and their 95% CI so as to identify factors which influence satisfaction with AHCT services. Qualitative data was obtained through four FGDs and analyzed by thematic content analysis method. Results: AHCT acceptance was 99.8%, most respondents (81%) were satisfied with their overall AHCT experience and 71% were satisfied with service setting. FGD participants reported that AHCT for male partners is good but some men do not want to be tested together with their wives. The FGD participants too reported satisfaction with AHCT services. Factors with statistically significant association towards overall satisfaction were cleanliness/hygiene (AOR 2.53, 95% CI 1.12-5.70) and service duration (AOR 13.05, 95% CI 2.97-57.44). Conclusion/Recommendation: Men who escort their wives to the antenatal clinic tend to accept AHCT and tend to be satisfied with the testing experience. However, service duration should be reduced by minimizing delays and commencing work early. More staffs should be allocated to the antenatal clinic especially for antenatal examinations and laboratory.
ACCEPTABILITY AND WILLINGNESS TO PAY FOR UGANDA’S PROPOSED NATIONAL HEALTH INSURANCE SCHEME AMONG INFORMAL SECTOR WORKERS IN IGANGA AND MAYUGE DISTRICTS

(Makerere University, 2019) Namuhani, Noel

Introduction: Access to health care remains a challenge especially among the informal sector in most of the low-income countries due to out of pocket (OOP) expenditures, with Uganda spending over 40.0% out of pocket on health care. To solve this, Uganda has proposed a National health insurance scheme (NHI). However, the acceptability, willingness and ability to pay for the proposed NHI scheme within the informal sector has not been explored. Objective: To assess the willingness to pay for the proposed NHI scheme and its determinants among the informal sector workers in Iganga and Mayuge districts Methodology: This was a cross sectional study. It was conducted in Iganga and Mayuge districts in June 2019. A contingent valuation method using the bidding game technique was used to elicit the willingness to pay. A total of 853/781,948 informal sector workers were randomly selected to participate in the study. Six key informant interviews with health workers and 7 FGDs with informal sector workers were also conducted. Logistic regression was done to identify the determinants for willingness to pay for the proposed NHI scheme. Results: The majority (85.2%) of the respondents would accept the proposed scheme. Most respondents (81.5%) were willing to pay for NHI, the median WTP was UGX 25,000 (USD 6.8) and 74.2% of the respondents believed that they were able to pay for health insurance. The factors that were significantly associated with WTP included; Occupation. Wealth, hearing about health insurance, use of traditional medicine and having saving group membership. Conclusion and Recommendation: The level of acceptability and willingness to pay was high. Therefore, it is viable for MOH to introduce and extend NHI to the informal sector but with affordable premiums while ensuring that the quality of services is enhanced.
Acceptability of healthy lifestyle recommendations for blood pressure reduction, and its associated factors, among hypertensive people living with HIV in a tertiary HIV clinic in Kampala, Uganda

(Makerere University, 2023-11) Nalugga, Esther Alice

Introduction: Hypertension is a significant public health problem with a prevalence ranging between 11% and 29% among people living with HIV (PLWH) in Uganda. Healthy lifestyle recommendations are essential in the prevention and management of hypertension, although determinants of their uptake may differ by regional/cultural context. I aimed to assess the acceptability of healthy lifestyle recommendations for blood pressure reduction among PLWH and hypertension at the Infectious Diseases Institute (IDI), Kampala Uganda, guided by the health belief model (HBM). Methods: A facility-based cross-sectional study was conducted among PLWH aged ≥ 18 years with hypertension receiving care at IDI. I collected data on socio-demographics, clinical history and patients’ ratings on the HBM. Healthy lifestyle recommendations assessed included dietary intake, physical activity, alcohol reduction and smoking cessation. Summary statistics were used to describe the data while logistic regression was used to determine the factors associated with acceptability of the interventions. Results: The study enrolled 427 participants with a mean age of 53 years (SD± 9.4), 57% of them females and 26% obese. Overall, 26.5% of the participants had good knowledge on healthy lifestyle recommendations, 86.9% considered healthy lifestyle recommendations acceptable while 24.4% engaged in healthy lifestyle practices. Urban residents [AOR: 0.35, 95% CI (0.14-0.90)] and participants with high self-efficacy [AOR: 162, 95% CI (37.1-704.4)] were significantly associated with acceptability. Conclusion: This study showed that acceptability of healthy lifestyle recommendations was high, however, knowledge and healthy lifestyle recommendations were low among PLWH and hypertension. Behaviour change programs, including intensive health education, targeting PLWH should be advocated for and integrated into routine HIV care to manage hypertension among PLWH in Uganda.
Acceptability of integration of cervical cancer screening into routine HIV care, associated factors and perceptions among HIV-infected women: a mixed methods study at Mbarara regional referral hospital

(Makerere University, 2021-05-07) Ninsiima, Mackline

Background: Integrating Cervical Cancer Screening (CCS) into routine HIV care has been endorsed as an effective strategy for increasing uptake of CCS, and facilitating early detection and treatment of pre-cancerous lesions among HIV-infected women in Sub Saharan Africa. In Uganda, this strategy has not been implemented yet in most HIV clinics. Assessing the acceptability of this intervention among HIV-infected women is of great relevance to inform its implementation. Objective: To assess the acceptability of integration of Cervical Cancer Screening (CCS) into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the Immune Suppression Syndrome clinic at Mbarara Regional Referral Hospital (MRRH). Methodology: A mixed methods study utilizing the explanatory sequential approach was conducted among 327 eligible HIV-infected women. Acceptability of integration of CCS into routine HIV care was measured using the Theoretical Framework of acceptability (TFA). A pre-tested questionnaire was used to collect quantitative data. Focus group discussions to explore perceptions regarding the intervention were conducted among purposively selected HIV-infected women. Descriptive analyses for all categorical dependent and independent variables were done. Modified poisson regression with robust variance analysis was utilized to determine factors associated with the acceptability of the intervention. Statistical significance was determined at p-value <0.05. The analysis was performed using STATA Version 14.0. Thematic analysis utilizing inductive coding was used to analyze qualitative data in Atlas.ti 6.0. Results: Majority of the HIV-infected women (64.5%) accepted the integration of CCS into routine HIV care. Religion, perceived risk of developing CC and ever screened for CC were statistically significantly associated with the acceptability of integration of CCS into routine HIV care. Perceived benefits of the proposed intervention were: convenience to seek for CCS, motivation to undergo CCS, improved archiving of CCS results, the confidentiality of HIV patient information, and preference to interact with ISS clinic health workers. Shame to expose their privacy to the ISS clinic health workers and increased waiting time were the only perceived challenges of the integration of CCS into routine HIV care. Conclusion: Study findings highlight the need to take advantage of this acceptability to prioritize implementation of the integration of CCS into routine HIV care, conduct intensified health education and awareness about the increased risk of developing CC among HIV-infected women. HIV-infected women should be reassured of confidentiality and reduced waiting time to increase the uptake of the integrated CCS and HIV services among HIV-infected women along the continuum of HIV care and treatment services.
Acceptability of male infant medical circumcision as an HIV prevention strategy among patients attending a Health Centre IV in Kampala District

(Makerere University, 2011) Nsereko, Mary N.

Background: Medical Male Circumcision (MMC) has been shown to reduce the risk of HIV infection by 50-60%. UNAIDS has recommended that MMC be integrated into prevention strategies in countries of high prevalence. Circumcision in infancy has the added advantages of being easier to perform and cheaper through faster healing and less complications. Objectives: The general objective was to establish the factors that influence acceptability of Male Infant Medical Circumcision (MIMC) as an HIV prevention strategy. The specific objectives were to determine knowledge of Male Medical Circumcision (MMC) and identify factors influencing acceptability of MIMC. Methods: A descriptive cross sectional design was used. Participants were selected randomly from people attending a health centre. Data from consenting adults aged 18 years and above was collected using interviewer administered questionnaires. Bivariate analysis to determine factors associated with acceptability and logistic regression was done to remove confounders. Odds ratios (ORs), 95% confidence intervals and p values are reported. Results: A total of 323 participants were interviewed. The mean age was 28.6 with a SD of 9 years. One hundred ninety three of them had 1 or more male children. At bivariate analysis, positive associations with acceptability were prior knowledge of Male Medical Circumcision (MMC) and a belief that MMC improved personal hygiene and prevented STDS/HIV. More than 80% of the respondents preferred circumcision in infancy because of a belief that it healed faster. Significant predictors of acceptability at multivariate analysis were found with being female (AOR 3.36; 95%CI 1.14-9.8), having knowledge about the preventive effect of MMC (AOR 5.61 95%CI 1.17-26.92), perceived family approval for MMC (AOR 23.59; 95%CI 6.43-86.50), and if the service were to be provided safely at affordable prices (AOR 3.27 95%CI1.17-917). Conclusion: MIMC appears to be highly acceptable in Kampala. The option for safe and affordable MIMC should be made available to all parents.
Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: a qualitative study

(J Public Health, 2011) Buregyeya, Esther ; Mitchell, Ellen M. H. ; Rutebemberwa, Elizeus ; Colebunders, Robert ; Criel, Bart ; Kiguli, Juliet ; Nuwaha, Fred

Objectives: This study explored the acceptability of cough etiquette, wearing masks and separation by tuberculosis (TB) suspects and TB patients in two districts in Uganda. Design: The study was conducted in Mukono and Wakiso districts in central Uganda. Eighteen in-depth interviews with patients and eight focus group discussions with health workers were conducted. Patients were asked for their opinions on cough etiquette, patient separation and wearing of masks. Results: Patients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness. Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Good counseling and health education were suggested to improve patients’ adoption of separation and masking. However patients expressed concerns about equity, coercive and stigmatizing approaches. Universal precautions were more acceptable than targeted ones, with the exception of separating TB patients. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures. Conclusion: Scaling up effective TB infection control norms and behaviors requires a patient-centered, rights-based, and evidence-based approach. Socially acceptable measures like covering the mouth and nose with a handkerchief should be promoted. We recommend that further studies are needed to explore how community advocacy impacts on acceptability of masking. Furthermore, the efficacy of covering the mouth using a handkerchief or piece of cloth compared to wearing a mask in TB prevention needs to be evaluated.
Acceptability of modified directly observed therapy for Antiretroviral Therapy (ART) and associated factors among HIV patients in Arua Hospital

(Makerere University, 2010-10) Afayo, Robert

Introduction: Combination ART has led to dramatic reductions in morbidity and mortality among patients with HIV/AIDS in Uganda. Successful treatment with ART requires the patient to maintain consistent adherence to the prescribed regimen on a long term basis. However, only 68% of the Ugandan urban patients interviewed reported an adherence rate of 95% to HAART. Modified directly observed therapy for ART has been suggested as an intervention for non-adherence. This study has shed light on acceptability of modified DOT and associated factors before its adoption. Objective: To assess acceptability of modified DOT-ART and associated factors among HIV-infected patients attending Arua hospital HIV clinic in 2010 Methods: Cross–sectional design using both qualitative and quantitative methods was conducted between February and March, 2010 among HIV-infected patients attending Arua hospital. Data were collected on acceptability of a modified DOT-ART, preference of different forms of modified DOT-ART, and associated factors. The proportion of patients who were willing to accept modified DOT-ART and proportion of patients who preferred different forms modified DOT-ART were determined. Using bivariate and multivariate analysis, factors associated with acceptability of modified DOT-ART were assessed. Statistical significance was determined using 95% confidence Interval and p-value (<0.05) of Odds Ratios as the measure of effect. Qualitative data was analyzed into themes. Results: A total of 358 participants were enrolled. Of these, 55.9% (200/358) were willing to accept modified DOT. The proportion of patients on ART who accepted modified DOT was 61.5% (110/179) and those not on ART was 50.3% (90/179). The majority, (58.5%, 117/200) of participants preferred home/family-based DOT among different forms of modified DOT-ART. Male patients (OR= 0.463, 95%CI= 0.68-0.799, P= 0.006), married patients (OR= 0.354, 95%CI= 0.129-0.973, P= 0.044), patients with low social support (OR= 0.616, 95%CI= 0.384-0.990, P= 0.045), and patients not receiving co-trimoxazole prophylaxis (OR=0.324, 95%CI= 0.151-0.696, P=0.004), were less likely to accept modified DOT for ART. While patients on ART (OR= 2.431, 95%CI= 1.357-4.353, P=0.003) and those who never ever missed ARV dose (OR= 2.192, 95%CI= 1.134-4.234, P=0.020) were more likely to accept modified DOT-ART. Conclusion: The study showed that over half of the participants were willing to accept modified DOT- ART. Home/Family-based approach was the most preferred form of modified DOT-ART. Acceptability of modified DOT was higher among patients on ART compared to those not on ART. Non-acceptance of modified DOT-ART was more common particularly among the males, the married; patients with low social support, non-adherent patients and patients not taking co-trimoxazole prophylaxis. Recommendations: There is need to further explore into the acceptability and feasibility of modified DOT to other populations before MOH can consider the use of mDOT as a strategy to strengthen adherence to ART particularly to highly non-adherent patients. As MOH considers use of mDOT, education of patients on what mDOT-ART entails will be key to the success of this program.
Acceptability of SMS reminders as an HIV PREP adherence support tool and associated factors among adolescent girls and young women in Mukono District

(Makerere University, 2022-12) Muteebwa, Laban

Background: Young Women in Uganda contributed 29% of new HIV infections despite representing only 10% of the total population and are priority beneficiaries of PrEP, yet they have been found to have low adherence. SMS reminders have been found to improve adherence to PrEP in AGYW. There is paucity of literature about their acceptability among AGYW in Mukono district. Objective: To estimate the level of acceptability, the associated factors and explore the perceptions toward use of SMS reminders as a PrEP adherence support tool and among AGYW in Mukono district. Methods: This parallel convergent mixed-methods study enrolled 142 AGYW using PrEP. A structured questionnaire and In-depth interview guide were used to collect quantitative and qualitative data respectively. Quantitative data were analyzed in STATA 17.0 Continuous variables were summarized using median (IQR) and factors associated with acceptability of SMS reminders were analyzed using a modified Poisson regression. Qualitative data were analyzed by inductive thematic analysis in open code version 4.03. Results: The acceptability of SMS reminders was 90.9% (95% CI (84.9, 95.0)). Being from rural residence and not believing that SMS can breach individual’s privacy were significantly associated with acceptability of SMS reminders with adjusted prevalence ratios of 0.92 (95% CI (0.84, 0.99)) and 1.4 (95% CI (1.07, 1.84)) respectively. AGYW perceived that SMS reminders are highly acceptable to support adherence. However, they felt that the success of this intervention hinges on whether it ensures confidentiality about their PrEP use. Conclusions: SMS reminders are highly acceptable to AGYW provided they ensure confidentiality is maintained however, AGYW living in rural areas may need additional support to use this intervention.
Access to health care for febrile children in Uganda: symptom recognition, care seeking practices and provider choice

(Karolinska Institutet and Makerere University, 2009) Rutebemberwa, Elizeus Kabareebe

Background: Febrile illnesses including malaria and pneumonia are leading causes of death among children under five in Uganda. Despite government efforts to increase health care access by offering free services at government facilities, the majority of the sick children receive care after 24 hours, often with less efficacious drugs. one of the strategies suggested for increasing access is the distribution of antimalarials and antibiotics at community level. However, determinants on access to health care for febrile children are not sufficiently understood. Main aim: The aim of this study was to assess the factors associated with access to treatment for febrile children under five in order to inform the implementation of child survival interventions at community level. Methods: Four studies were conducted in Iganga-Mayuge Demographic Surveillance Site in Eastern Uganda (I-IV). Study used key informant interviews (KIIs) with eight health workers and eight traditional healers and five focus group discussions (FGDs) with mothers of children under five. Study II was a cross sectional survey of 9,176 children under five. Study III was a survey of a random sample of 1078 households with children under five. Study IV used four FGDs with fathers and mothers of children under five and eight KIIs with health workers in government and Non-Governmental Organization facilities, community medicine distributors (CMDs), and attendant in drug shops and private clinics. Content analysis was used for qualitative data. Quantitative data was analysed at univariate, bivariate and multivariate levels to determine the independent predictors of delayed care or choice of provider. Results: There is general lack of knowledge on antibiotics as first treatment for fever with pneumonia symptoms (I) and use of less efficacious drugs for malaria acquired from the open market (IV). Caretakers prefer health care providers with a variety of drugs and able to do diagnostic investigations (IV). Two thirds of the caretakers consult the private sector and 27% of them among other things because they can get treatment on credit (III). There are diverse perceptions on drug efficacy among caretakers (IV). Being of low socio-economic status (OR 1.45; 95% CI 1.06┤1.97) and presenting with pallor (OR 1.58; 95% CI 1.10-2.25) are associated with delay in care seeking >24 hours after onset. Children seeking care outside the home <24 hours had fast breathing (OR 0.75; 95% CI 0.60-0.87), had had tepid sponging (OR 0.43; 95% CI 0.27-0.68), had provider proximity (OR 0.72; 95% CI 0.60-0.87) and went to drug shops (OR 0.70; 95% CI 0.59-0.84) or CMDs (OR 0.33; 95% CI 0.15-0.74) (II). Caretakers more likely went to government facilities when children had vomiting (OR 2.07; 95% CI 1.10-3.89), or when expecting qualified (OR 10.32; 95% CI 5.84-18.26) or experienced workers (OR 1.93; 95% CI 1.07-3.48). Caretakers went to private providers when seeking treatment as "first aid" (OR 0.20; 95% CI 0.08-0.52) (III). Discussion: Caretakers should be sensitized on recognition of symptoms for pneumonia, prompt care seeking and use efficacious drugs. CMDs should be able to do some diagnostic investigations and have constant drug supply. Using drug shops and private clinics in community interventions could complement government efforts to deliver timely treatment. Keywords: fever, malaria, pneumonia, community health worker, drug shop, child
Access to improved sanitation among households in peri urban area in Bwaise II Parish, Kawempe Division: A cross sectional study

(Makerere University, 2023) Namusu, Irene

Introduction: Sustainable Development Goal (SDG) target 6.2 aims at achieving universal access to sanitation, leaving no one behind by 2030. To enhance this achievement, SDG target 1.4 aims at basic sanitation for all especially the poor and vulnerable. As such, improved sanitation has now been restricted to at least using improved sanitation facilities which are not shared by other households. This study assessed improved sanitation among households as per the Joint Monitoring Programme indicators to determine the current status of improved sanitation in Kawempe division as previous efforts to improve sanitation and research have been focused on improved technology types regardless of whether they are shared or not. Objective: To determine the proportion of households with access to improved sanitation and associated factors, environmental and policy influencing factors in Bwaise II, Kawempe division. Methods: This was a cross sectional study that utilized both quantitative and qualitative methods of data collection from household heads and key informants respectively. A household based study and key informant interviews were therefore conducted in this regard. Statistical data analysis was by logistic regression in STATA 15 software. Qualitative data were analysed thematically. Coding of data were done manually and themes identified, marched and collated together in tables. Quotes from key informants were identified, summarised and reported. Results: Access to improved sanitation was at 36.2%. Households heads in agegroup above 50 years and those with above secondary level of education were more likely to have improved sanitation (AOR : 4.21, 95% CI: 1.62-10.95) and (AOR: 5.12, 95% CI : 2.00 -13.16) respectively. Households with wife present at home during the week were less likely to have access to improved sanitation (AOR: 0.57, 95% CI 0.33 – 0.99). Ownership of a housing unit (landlord) was positively associated with access to improved sanitation (AOR: 4.04, 95% CI: 2.26 – 7.25). Collapsing soils, high water table, flooding and weak enforcement for Public Health Act (PHA) and sanitation related regulations, unfavourable land system of tenure are environmental and policy related factors respectively that limit improved sanitation in Bwaise II. Conclusion and recommendation: Access to improved sanitation was low with majority of the population using shared sanitation facilities. Access to improved sanitation was significantly higher among those who were in the above 50 years age group, those with above secondary education and those who were landlords. Factors that influenced access to improved sanitation were nature of soils, high water table, and unfavourable land tenure system. Sanitation programmes need to explore low cost and water proof technology options to promote and scale up construction of household sanitation facilities to enhance progress towards realisation of improved sanitation for all.
Access to selected sexual reproductive health services among adolescent refugees in Rhino camp refugee settlement in Arua district.

(Makerere University, 2023-01-17) Kalema, Charles

Introduction: Uganda hosts 1.4 million refugees and conflict-affected people. Widely regarded as the best place in Africa to be a refuge. Adolescents in refugee camps in West Nile Region face challenges that can be mitigated with creating a comprehensive access to Sexual Reproductive Health Services (SRHs). The limited access to SRHs among adolescent refugees is associated with low availability of social services like health education in the context of sexual and reproductive health services like Family Planning Services (FP), Antenatal Care (ANC), Post-Natal and Post Abortion Care (PAC). Access to Sexual Reproductive Health Services is low among adolescents living in the refugee camp settings as compared to counterpart in the normal settings in Uganda. Objectives: The main objective was to investigate the level of access to Sexual Reproductive Health Services (SRHs) and associated factors among adolescent refugees in Rhino Camp Refugee Settlement in Arua District West Nile Region Uganda. Methods: This was a cross sectional study among 310 out of the 427 sample calculated refugee adolescents aged 14-19 years, these were selected using a systematic method with a random start in Rhino camp refugee settlement, Arua District. The (03) FGDs were used to collect qualitative data which were analyzed using t hematic analysis. Quantitative data was obtained using interviewer administered questionnaire and check list (This helped the team to verify and observe the available family planning commodities, PAC medicines etc). Data was analyzed using STATA 15. Modified Poisson regression with robust standard errors was done to assess the association between the independent and dependent variables at the bivariate and multivariate analyses. Variables with P-value of ≤ 0.2 at bivariate were considered for multivariate analysis. Variables with a P-value less than 0.05 were considered to be statistically significant. Results: A total of 310 (73% response rate) adolescents were recruited for quantitative part of the study, 24 adolescents and 14 health workers (Midwives and NGO Officials) total 38 respondents for qualitative part of the study. The mean (SD) age of adolescents at recruitment was 17.3 (±1.5) years. Of the 310 adolescents, 132 (42.6%) were male and 178 (57.4%) were female. The overall level of access to SRHs (FP, ANC and PAC) among the adolescents was 50%. This was measured by the proportion of adolescents who had the need and opportunity to reach and obtain any of the three services: The level of access is still very low SRH interventions must be put in place to increase access. At multivariate analysis, the factors that were independently associated with access to SRHS were lack of awareness of sexual reproductive health services (PR=0.33, 95% CI: 0.16, 0.93) and being single adolescents (PR=0.53, 95% CI: 0.29, 0.98). Qualitative data also revealed that long distance to health facilities, low income earning, health workers’ attitude, stock out of commodities, fear and shyness, parents’ attitude, and long waiting hours in health facilities were some of the factors that deterred access to SRHs by adolescents in refugee camps. Conclusion: The prevalence of access to SRHs among refugee adolescents in Rhino refugee settlement camp is low (50%). This was achieved by summarizing proportions for the considered three components of SRHs (YES/NO) among the adolescent refugees in Rhino camp compared to their counterparts of Ugandan, Tanzanian and Ethiopian nationalities (65%). Factors that were independently associated with access to SRHS among refugee adolescents were awareness of SRHs, level of education (primary level and secondary level), and married adolescents. There is need for effective SRH interventions in order to at least achieve the minimum sphere standards recommended in such situations including mobile clinics, awareness creation, health outreaches, availability of FP commodities, emergency transport services among others. Keywords: Sexual and reproductive health, adolescent, refugee, access to SRHs, availability, acceptability, Arua, Uganda.
Accessibility of essential maternal health related in-vitro point-of-care diagnostic tests at the primary health care level in Luwero district central Uganda

(Makerere University, 2021-03-02) Muniri, Abdul

Background: Poor maternal outcomes at the Primary Health Care (PHC) level of Low-Income Countries such as Uganda are partly attributed to poor maternal health services including inaccessibility of appropriate maternal diagnostics. The use of maternal health related In-Vitro Point-Of-Care Diagnostic Tests (IVPOCDTs) can bridge the gap between the delay in diagnosis and timely evidence-based maternal interventions such as treatment or referral. The clinical impact of IVPOCDTs on maternal outcomes such as safe birth depends on their accessibility. Objective: The study determined the accessibility of maternal health related IVPOCDTs in terms of their availability, utilization capacity and the technical competency of their operators at the PHC level in Luwero district so as to yield information that will inform health policies/programs that can improve accessibility of such diagnostic tests. Method: Between March and May 2020, we conducted a cross-sectional study in the 3 Health Sub Districts of Luwero district. We accessed the Luwero district inventory list of 75 HCs II and III from which we chose 65 as the study sample using probability proportionate to size stratified random sampling. We collected data on the availability and utilization capacity of IVPOCDTs and also the technical competency of their operators using a standardized, structured and WHO adapted survey tool. Data capture was by Microsoft excel and analysis was by SPSS version 23. Results: While the average number of maternal IVPOCDTs available in the HCs was 7.06 (range: 2-12; SD = 3.01), 41.7% (25/60) of the HCs reported a high availability of the diagnostics (9-12 IVPOCDTs). Almost all (83.3%) (10/12) of the IVPOCDTs had low frequency of utilization. The most frequently utilized IVPOCDT was for malaria (100%) (60/60), while the least frequently utilized was for gonorrhea (12%) (7/60). Only 10% (6/60) of the IVPOCDTs’ operators had degrees, while close to half (46.5%) (28/60) had certificates. Majority (65%) (39/60) of the same operators had a high working experience. Conclusions: There was a suboptimal accessibility of the maternal health related IVPOCDTs at the PHC level of Luwero district Central Uganda. Availability of the maternal IVPOCDTs and the technical competency of their operators were average, while the utilization capacity was low. Recommendations: There is need for policy changes to ensure adequate accessibility of the maternal health related IVPOCDTs in Luwero district to the levels recommended by the WHO guidelines for maternal assessment during pregnancy.
Accountability mechanisms in results based financing and their implementation in Lira District Northern Uganda

(Makerere University, 2022-12) Okiror, Nathan

Introduction: Results-based financing has been proposed as an innovative reform to enhance systems performance in Uganda. Lira District is one of the districts implementing the national results-based financing (RBF) scheme under the Uganda Reproductive Maternal and Child Health services Improvement Project (URMCHIP). The diversity of relationships among various actors in RBF implementation underscores the need for mechanisms to ensure accountability among them. This was a case study which aimed at exploring the RBF accountability mechanisms, their implementation and related factors in Lira District. Methods: The study was a descriptive case study employing qualitative methods. The data collection methods included a) focus group discussions with the health workers from RBF facilities, b) key informant interviews with key actors in the RBF program at the MOH as well as in the district including district managers, health facility in charges, verifiers, members of the health facility management committees c) review of RBF documents, annual progress and audit reports. Data were analyzed thematically guided by a framework that explored the relationships and related accountability mechanisms in RBF. Results: Several accountability mechanisms existed among different actors in the RBF program. The accountability mechanisms between MOH and the districts included regulatory approaches such as contracts, while between the district and health facilities mechanisms included reporting, data verifications and financial audits. Public disclosure through display of results on notice boards and feedback through complaint boxes were the mechanisms employed between the facility and the community. Intrinsic health system arrangements such as support supervision, administrative health facility meetings were some of the enablers’ .Challenges hindering accountability mechanisms included infrequent financial support to enable regular support supervision/verification visits by EDHMT and corruption. Conclusion: Implementation of RBF accountability mechanisms in Lira was suboptimal due to the various RBF design and implementation challenges. The factors were likely to constrain RBF from reaching its full potential. More effort needed to be directed towards supporting the EDHMT and facility managers in terms of capacity building and facilitation to do their work. Additionally, efforts need to be undertaken to address the downstream challenges such as delayed disbursement of funds and corruption impeding the implementation of RBF accountability mechanisms in the district.
Adherence among Female Sex Workers taking oral HIV pre-exposure prophylaxis in Kampala, Uganda

(Makerere University, 2019-06-17) Nalukwago, Grace Kakoola

Title: Adherence among female sex workers taking oral HIV pre-exposure prophylaxis in Kampala, Uganda. Background: Globally, Sub-Saharan Africa remains most severely affected with highest HIV prevalence rates. Oral PrEP is a novel HIV prevention intervention that offers hope to decrease HIV incidence in key populations. In Kampala Uganda, female sex workers (FSWs) have high HIV prevalence (33%), and inadvertently form the majority of PrEP users at the Most at Risk Population Initiative (MARPI) PrEP clinic in Kampala. However, studies have shown that with poor adherence, oral PrEP has no efficacy, and therefore adherence to PrEP is critical in realizing the benefits of PrEP for maximum HIV prevention. To date, implementation data on adherence to PrEP among FSWs is limited in Africa. This study therefore sought to assess adherence to PrEP among FSWs. Specifically, we sought to 1) determine the level of adherence to PrEP among FSWs, 2) determine factors associated with PrEP adherence as well as 3) explore factors influencing PrEP adherence among FSWs. Methods: This mixed methods cross-sectional study was conducted from August to December 2018; 126 FSWs using PrEP were interviewed using a questionnaire, and 30 women underwent in-depth interviews. Adherence was categorically defined as high adherence if a FSW takes at least six doses of PrEP in the past week and low adherence if a FSW takes less than 6 doses of PrEP in a week. Logistic regression using STATA version 14 and thematic data analysis were conducted for the quantitative and qualitative objectives respectively. viii Results: The median age of the FSWs was 24.5 years. Forty one percent of the FSWs had attended secondary level education. The median duration of sex work was 3 years. On average, the FSWs had 11 sex partners in the past week. Reported condom use among FSWs was far more consistent with clients (87.9%) compared to 59% among non-paying sexual partners. Self reported proportion with high adherence to PrEP was 71%. Factors associated with high adherence to PrEP at bivariate level were condom use with clients, color of PrEP tablet, and PrEP packaging. In multivariate analysis, not using condoms with clients (OR 0.07, 95% CI: 0.01-0.42) and using long-term contraception methods (OR 0.06, 95% CI: 0.04-0.77) were significantly negatively associated with high PrEP adherence; whereby FSWs who used long-term contraceptive methods (IUD and Implants) were 94% less likely to adhere to PrEP. FSWs adhered to PrEP because they felt at risk; because they experienced condom breaks or because they do not use condoms. Barriers of PrEP adherence include drug side effects, lack of financial resources, food insecurity, stigma, and doubts about PrEP efficacy, travel and health system factors. Conclusion: A high proportion of FSWs had high self-reported adherence to PrEP. FSWs considered PrEP as a reliable method of protection against HIV in cases of condom breaks or sex without a condom. However a number of barriers to PrEP adherence at both personal and systems level need to be addressed for successful PrEP implementation.
Adherence and associated factors with HIV oral Pre-exposure Prophylaxis among high-risk adolescent girls and young women aged (15-24 years) at Luwero Hospital in Luwero District, Uganda

(Makerere University, 2024) Ndyamuhaki, Ella

Introduction Globally, human immunodeficiency virus (HIV)remains a significant global health problem with an estimated 38.4 million people seen to have been infected with HIV in 2021. Evidence has also shown that pre-exposure prophylaxis (PrEP) is a bio-medical intervention that can effectively reduce the incidence of HIV by 25%. With the HIV prevalence among high-risk adolescent girls and young women dramatically increasing in Uganda and the rest of the world, the World Health Organization (WHO) recommends pre-exposure prophylaxis (PrEP) among young women, especially the ones who are sexually active and at high-risk of acquiring HIV. Luwero district registered a high prevalence of PrEP initiations among high-risk adolescent girls and young women in 2021/2022 however, the adherence level remains low. There is limited information about adherence to PrEP among high-risk AGYW in the Luwero District. Therefore, this study aims to understand the determinants of adherence to PrEP among high-risk AGYW at Luwero hospital in Luwero District. Objective To determine the level of adherence to oral PrEP for HIV and associated factors among high-risk adolescent girls and young women 15-24 years at Luwero hospital in Luwero District. Methods This was a cross-sectional study conducted at Luwero Hospital between September and October 2023. Both quantitative and qualitative methods of data collection were used among 123 sexually active high-risk AGYW, five in-depth interviewees and five key informants. The quantitative methods employed simple random sampling for participant selection, while the qualitative methods used purposive sampling for insightful perspectives. A standardized questionnaire was used for the collection of quantitative data which was then cleaned and analyzed using STATA.15 software. Modified Poisson regression was used to obtain prevalence ratios as a measure of association where statistical significance of p<0.05 was used for statistical inference. Qualitative data were obtained from verbatim transcriptions of in-depth interviews (IDIs) and key informant interviews (KIIs) and analyzed thematically using Atlas.ti version 9. Thematic analysis was used to come up with emerging themes relevant to answering adherence to PrEP for HIV. Some of the reported statements were quoted verbatim to give exact meaning. Results The level of adherence to HIV oral PrEP among high-risk adolescent girls and young women was at 24%. The factors associated with adherence to PrEP were; living 2 km to 5kms (aPR=0.44,95% CI:0.22-0.86), and more than 5kms from the health facility (aPR=0.43, 95% CI:0.21-0.86), follow up calls from health workers (aPR=1.36, 95% CI:1.15-1.86), perceived awareness of risk of HIV infection in the presence of PrEP (aPR=11.35, 95% CI: 2.82-45.67). From KIIs and IDIs the factors commonly highlighted by high-risk adolescent girls and young women as facilitators to adherence to PrEP are perceived awareness of risk of HIV infection, health worker attitude towards patients, knowledge about PrEP, follow-up calls, and integration of PrEP with other family planning services. Barriers included attitude towards PrEP and distance to the health facility. Conclusion and Recommendation The study demonstrated that adherence to oral HIV PrEP among high-risk adolescent girls and young women 15-24 years was relatively low in the study area. The most important factors associated with adherence to PrEP are the perceived awareness of risk of HIV infection in the presence of PrEP, health worker attitude toward patients, knowledge about PrEP, follow-up calls from health workers, and integration of PrEP services with family planning services. Based on the results, policymakers need to expand follow up call programs for all users to inform AGYW about HIV risk and the benefits of PrEP when taken with maximum adherence. This can be done through educational programs like community-based education sessions and workshops. Also, the Ministry of health and development partners should consider operationalizing mobile health units to ease accessibility, especially in rural areas.
Adherence levels and associated factors to Pre-exposure prophylaxis among high risk individuals enrolled at public health facilities in Mbale district

(Makerere University, 2019-11) Akello, Doreen

Introduction: HIV, a major disease of public health importance, is responsible for over 35 million deaths worldwide (WHO 2018). HIV prevention strategies have been made available to people at risk of HIV sexual transmission but inspite of all the strategies in place, transmission remains high. Oral pre-exposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV acquisition in high-risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence. Currently PrEP is being made available to populations at high risk for HIV infection. However adherence and retention are developing into a major challenge, with individuals initiating or expressing interest in PrEP choosing not to continue. A number of factors limit the scale-up of PrEP in areas of high HIV burden. In order to maximize the impact of PrEP, it is important to understand the factors that influence uptake of and adherence to PrEP and draw a definitive conclusion about the HIV prevention benefit of PrEP for people at HIV risk. This study aimed at assessing the adherence level and factors influencing adherence to PrEP among these HIV high-risk populations in Mbale District, Eastern Uganda. Methods: This was a cross-sectional study that employed qualitative and quantitative methods and used one-to-one structured interviews for data collection. The study was carried out in 3 public health facilities in Mbale District that offer PrEP. The demographics of the participants were collected from client files and PrEP registrars, and then quantitative and qualitative interviews were conducted with the participants who were enrolled on PrEP from April 2018 to March 2019. The measure used for adherence assessment was 30 day pill count. A total of 6 key informant interviews were conducted with the health facility service providers and 16 in-depth interviews were also conducted with the high-risk populations. Results: A total of 252 respondents were enrolled. The mean (SD) age was 30 years (8.22) while the median (IQR) was 30 years (25, 33.5). Majority of the respondents (78.17%) were aged 16-34 years. and males constituted 60.3%. The categorization of high-risk included female sex workers (33.73%); mobile populations (25.79%)-including long distance truck drivers, boda boda riders and migrant workers; people who use drugs (22.22%); sero-discordant couples (9.13%); adolescents and young adults (5.16%); and men who have sex with men (3.97%). The adherence level among the HIV high-risk populations who reported to have a good adherence was found to be at 62%. Factors significantly associated with poor adherence were younger age (16-34years ) , mobile population category , primary level of education or no education attained, those who reported to have experienced side effects to PrEP, and the use of other HIV prevention tools were significantly associated with poor adherence to PrEP. Older participants were found to be more adherent to PrEP as compared to younger participants; Mobile population category was found to be the category with the least adherence to PrEP as compared to sero-discordants; those who experienced side effects to PrEP were found to have a poor adherence to PrEP as compared to those who did not; the participants who had received primary or no education had a poor adherence to PrEP as compared to those who had attained tertiary level of education. Conclusion: Overall, good adherence among the HIV high-risk population was 62%. Barriers to adherence in this population include side effects to PrEP medication, younger age, no education or only primary level of education attained, being a mobile population and use of other HIV prevention tools. Recommendation: Strategies are needed to address these barriers to adherence. These could include community-based delivery mechanisms that could help to facilitate adherence to PrEP, the Health facilities should develop a plan for managing side effects (e.g. over the counter medications that can mitigate symptoms) should help patients feel more in control and prevent them from stopping their medication. Adequate adherence counselling and care especially among the younger populations should be done to improve adherence among the younger age group. Centralised Health information systems could be put in place to enable the mobile population be able to access healthcare from anywhere in the country and proper monitoring of their drug usage. Use of drugs that are safe for use and have less side effects such as TAF (Tenofovir alafenamide Fumarate) as compared to TDF/3TC that is currently provided for use in Uganda, may improve adherence.
Adherence of health workers to severe Malaria treatment guidelines and associated factors at Gulu Referral and Lacor Hospitals in Gulu District, Uganda

(Makerere university, 2022) Kyambadde, Paul

Introduction: Severe malaria is a life-threatening medical emergency and requires prompt and effective treatment to prevent death. There is a paucity of published information on current adherence of health workers to guidelines for management of severe malaria in sub-Saharan Africa. It is important to know the role of patient, clinical and institutional factors in the adherence of health workers to severe malaria treatment guidelines. Objective: To assess adherence to National treatment guidelines for severe malaria and associated factors at Gulu Regional Referral Hospital and St. Mary’s Lacor hospitals, Gulu District. Methods: This was a cross-sectional study using both quantitative and qualitative methods. The study was conducted at GRRH and St. Mary’s Lacor hospital. We reviewed a total of 468 severe malaria case records for the period January 2019 to December 2020. Fourteen (14) key informant Interviews (KIIs) with the in-charges of outpatient department, medical department and pediatric department and 2 health workers who manage severe malaria cases from each of the wards and six (6) In-depth Interviews (IDIs) were conducted. Categorical variables are presented in tables and charts and reported in frequency and proportions while the continuous variables are summarized using medians and Interquartile ranges (IQR). Factors associated with adherence to the measured parameters contributing to adherence and the overall adherence were determined using modified Poisson regression adjusting for clustering at the two sites. Quantitative data were analyzed using STATA version 16. Qualitative data were analyzed using Atlas ti vr 6.0 software and the results presented under different themes. Results: Of the 468 patient files included, 48.1% (225/468) were from Gulu RRH. About 54.5% (225) of the cases were male. The proportion of patients with severe malaria who were appropriately managed was 60.3% (282/468), (95%CI 55.66 – 64.72) and ranged from 66.7% (150/225) at Gulu hospital to 54.3% (132/243) at Lacor hospital. Adherence was more likely among cases who complained of a fever (cPR = 1.18, 95%CI 1.072 – 1.290) and those who presented with high-grade fever (cPR = 1.18, 95%CI 1.068 – 1.302). Adherence was less likely in cases aged 11 to 15 years (cPR = 0.62, 95%CI 0.561 - 0.682) and 16 to 20 years (cPR = 0.80, 95%CI 0.772 - 0.893). Support supervision and accessibility to the Uganda Clinical Guidelines facilitated adherence to severe malaria treatment guidelines whereas stock-outs of drugs and diagnostics, lack of staff training, unaffordability of drugs, suspected resistance to ACTs, shortage of blood for transfusion, malfunction of the laboratory, inadequate staff and failure of junior doctors to consult their seniors hindered adherence to guidelines. Conclusions: Adherence of health workers to national severe malaria treatment guidelines is still low (60.3%). Patient’s age, complaining of a fever, presentation with a body temperature >39.5°C and having other complaints were associated with appropriate management. Recommendations: There is a need to make standard treatment guidelines available, organize regular staff trainings on the management of severe malaria by the Ministry of Health and malaria implementing partners to enable health workers to correctly treat severe malaria irrespective of the age bracket and when patients don’t present with the common signs of a temperature >39.5°C or any other common complaints.
Adherence to antiretroviral therapy before and after substitution to Dolutegravir and associated factors among pregnant and postpartum mothers at the MUJHU supported facilities in Kampala - Uganda.

(Makerere University, 2023-01-19) Ajambo, Aidah

Introduction: In 2020, the Uganda Ministry of health rolled out the use of dolutegravir based ART regimens as the preferred first line ART for all people living with HIV including the pregnant and postpartum mothers. Despite the proved efficacy and low toxicity profile of DTG, its introduction in Uganda faced great challenges with some women of reproductive age declining substitution to this regimen due to fear of teratogenicity. Although prior studies reported decline in ART adherence levels following regimen changes, there is no publicly available data on adherence following substitution to DTG based ART and factors associated with adherence to DTG in this population remain unknown. This study aimed to compare adherence to ART before and after substitution to dolutegravir based ART and associated factors among pregnant and postpartum mothers at Makerere University Johns Hopkins University research collaboration (MUJHU) and Kawempe ART clinics. Methods: A retrospective cohort design and a cross sectional study design were used to answer the study objectives. Facility records were reviewed for 506 participants to compare the adherence before and after ART change, to answer objective one. Exit interviews using a pretested standardized questionnaire were carried out for 342 participants to assess the factors associated with DTG based adherence, to answer objective 2. Qualitative data from 16 respondents were collected through in-depth interviews using an interview guide. Data were collected between 9th August and 9th September 2022. The Wilcoxon signed rank test was carried out on mean of the last three abstracted adherence data before changing to DTG and mean of the first three adherence levels following change to DTG based ART to compare adherence of the participants on these different regimens. To determine factors associated with DTG based ART adherence, bivariate and multivariable analysis were performed on quantitative data using the robust modified Poisson method while thematic analysis was used to analyze qualitative data. Results: There was a slight (2.1%) improvement in the mean adherence levels following the substitution of non-nucleoside reverse transcriptase inhibitor (NNRTIs) or protease inhibitors (PI) with DTG. 94% of the mothers had optimal adherence to DTG based ART. At multivariable analysis, the following factors had a statistically significant association with optimal adherence to DTG. Primary level education (aPR=1.13, [95%1.12, 1.96]), disclosure of one’s HIV status (aPR: 1.10 [1.04 – 1.19]) particularly to their spouses (aPR: 1.09 [1.04 – 1.19]) and not having experienced DTG related side effects (aPR: 1.09 [1.08 – 1.52]) were positively associated with optimal adherence while swallowing ART in the morning (aPR: 0.93 [0.87 – 0.95] had a negative association. These were supported with findings from the in depth interviews. Conclusion: Finding from this study show a 2.1% improvement in ART adherence among pregnant and postpartum women following their change to DTG based ART. However, the slight improvement seen is too small to confidently conclude that it was as a result of transitioning these mothers to DTG based ART since other time varying co variates were not catered for in this study. Additionally; the results seen could have been as a result of over powering the study due to the very large sample size used. 94% of the pregnant and postpartum women had optimal ART adherence and the key facilitators of optimal adherence to DTG included; disclosure of the spouse, level of maternal education, being free of ART side effects while swallowing of DTG based ART in the morning was identified as a barrier to adherence. Recommendation: Further studies with two comparable groups having similar characteristics are needed in order to cater for the time varying covariates and efficiently attribute the found improvement in adherence to transitioning to DTG based ART. With 94% of the mothers having optimal adherence, there is still need for clinicians to come up with innovate strategies to address the identified barriers in order to attain the UNAIDS goal of zero new HIV infections by 2030.
Adherence to clinical standards of quality HIV/AIDS care and anti-retroviral therapy in health facilities in West Nile Region, Uganda.

(Makerere University, 2011-06) Aldomoro, Burua

Introduction: Almost one quarter of an estimated one million people living with HIV in Uganda are receiving ART, creating unprecedented demand for long term high quality HIV/AIDS care. Objectives: To assess adherence to clinical standards of HIV care at facilities, so as to inform the design of appropriate strategies to improve the quality of HIV care in West Nile. Methods: A descriptive cross sectional study of 9 health facilities including records review for a cohort of 270 ART clients was undertaken. Indicator standards of quality HIV care were analyzed as proportions and the performance of each facility compared to national targets. Results: In all the facilities, national standards were met for CPT (98.5%) and prescribing a standard 1st line ARV regimen (100%). Laboratory monitoring was inadequate especially at general hospitals and HC’s where 42.2% and 36.7% of HIV clients respectively were monitored. Only 51% of HIV clients received ART adherence support, performance reducing with subsequent visits. All facilities had basic lab tests except CD4 and RFT/RFT’s, only available at the regional hospital. Over half of district hospitals and health centres experienced stock outs of 1st line ARV drugs. The KI interviews revealed inadequate trained personnel; irregular supply of ARVs; and inadequate infrastructure as common challenges in provision of ART services. Conclusion: Facilities generally adhered well to standards of HIV care, performance being poorer at the health centres. Challenges in accessing CD4 tests and stock out of ARV’s and OI medicine are still prevalent at lower level facilities. Recommendations: The DHT should target support particularly to lower level facilities by Providing recent HIV care guidelines and job aides to enable observation of the standards of HIV care. They should strengthen laboratory support supervision and revitalize the district therapeutic committees to do regular ARV stock monitoring and advice on re-allocations within districts.
Adherence to community prescribed antimalarial drugs among caregivers of U5 children and factors associated with their treatment seeking behaviour in Nadunget and Rupa sub-counties in Moroto District, Uganda

(Makerere University, 2015-09) Opio, Chono Alex

Background: Malaria is the leading cause of child mortality in Moroto district. Through iCCM, VHTs treat children under five years of age for malaria at community level. Poor adherence to antimalarial drugs can result into development of ACT resistant plasmodium falciparum species. Adherence to community distributed ACTs in Moroto district is not known. Objectives: To determine caregivers’ adherence to ACTs prescribed by VHTs, and to understand health seeking behaviour for fever or suspected malaria among children under five in Moroto district. Methods: A cross sectional study was conducted in two subcounties in Moroto district. A structured questionnaire was used to interview 477 caregivers of children under five who had suffered with fever two weeks preceding the study. Dependent and independent variables were analysed at univariate, bivariate and multivariate levels. In the univariate analysis, categorical variables were summarized using proportions, percentages and presented using tables, bar charts and pie charts. Frequencies were calculated using proportions. In the bivariate analysis, the chi-square test was applied and prevalence ratios (PRs) were used as a measure of association. In the multivariate analysis, the chunk test was applied to generate adjusted prevalence ratios which were used as a measure of association. A 95% CI was used to assess statistical significance. Adherence to ACTs was assessed through caregiver self-reports. Results: Caregiver non-adherence to ACTs prescribed by VHTs was at 50%. Caregivers’ misunderstanding of the dosing instructions (79.7%; 130/163) was the main reason cited for non-adherence to ACTs. From the multivariate analysis, caregivers’ not understanding the dosing instructions given by the VHT (APR=10.752; 95% CI=5.44-21.26) and a child aged 36-47 months (APR=0.480; 95% CI=0.28-0.84) were associated with caregiver non-adherence to ACTs. VHTs (68.3%) and health facilities (26.4%) were the preferred sources of care for children with fever. From the multivariate analysis, availability of VHT at source of care (APR=1.791; 95% CI= 1.36-2.36).if VHT had attained formal education – at least primary level status (APR=0.560; 95% CI=0.463-0.678); and if caregiver had attained formal education – at least primary level status (APR=0.708; 95% CI=0.63- 0.79) were associated with seeking treatment for fever from a VHT. Conclusion: Caregiver adherence to ACTs prescribed by VHTs was 50% (and is lower than expected (>80% is ideal). Non-adherence to community prescribed ACTs in Moroto district can be minimised if caregivers’ understanding of the correct or recommended dosing instructions is enhanced through: improving the quality of pre-treatment counselling given by VHTs; refresher training of VHTs in iCCM; and community sensitisation on the dangers of non-adherence to medication. VHTs are the preferred source of care for treating fever in children in Moroto district. To reduce malaria related morbidity and mortality, the MoH should consider scaling up the iCCM program to additional districts.

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