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The 14-day incidence and risk factors of gastrointestinal anastomotic leak among adult patients in Mulago Hospital, a prospective cohort study

(Makerere University, 2025) Omare, Isaac

Background: Anastomotic leak is one of the most feared complications following gastrointestinal (GI) anastomotic surgery. It increases morbidity and mortality of patients undergoing GI surgery. Globally, the frequency of anastomotic leak varies depending upon the tissue that is being anastomosed. Higher incidences of anastomotic leak up to 36.5% have been reported in Low- and Middle-income countries compared to the lower rates of less than 10% in Higher income countries for small and large bowel anastomoses. Despite the burden, the incidence and risk factors of anastomotic leak following gastrointestinal surgery are not well defined in Uganda. Objective: We aimed to determine the incidence and risk factors of anastomotic leak following gastrointestinal surgery at Mulago National Referral Hospital (MNRH). Methods: In this prospective cohort study, we recruited 85 adult patients admitted to the general surgery wards of MNRH 24 hours following gastrointestinal surgery. Independent variables including preoperative anemia, preoperative albumin level, and ASA status were recorded on entry, while the dependent variable (anastomotic leak) was obtained upon 14 day’s follow- up. Data was analysed using SPSS version 26. Multivariate logistic regression was used to determine the independent risk factors for anastomotic leak, p< 0.05 was considered statistically significant. Results: Out of the 85 participants recruited, 7 (8.2%) developed anastomotic leak during the 14 day follow up. Hemoglobin level less than 10 g/dl (RR, 8.15; 95% C.I, 1.16 - 57.48; p=0.035) was identified as independent risk factor for anastomotic leak after multivariate logistic regression adjusted for confounders. Conclusion: The incidence of anastomotic leak in Mulago National Referral Hospital was low, (8.2%). Low Hb (Hb<10g/dl) was the only statistically significant predictor variable of gastrointestinal anastomotic leak in this study.
The abdominal sonographic features of burkitt's lymphoma in patients seen at Uganda Cancer Institute, Mulago Hospital, Kampala

( 2009-10) Kwitonda, Pascal

INTRODUCTION: Burkitt lymohoma is a B-cell lymphoma presenting in three main clinical variants: the endemic, the sporadic and the immunodeficiency-associated variants. In Uganda, Burkitt’s lymphoma represents 50-70% of childhood cancers presenting mainly as facial tumour. Diagnosis depends on tissue examination. Imaging provides very useful diagnostic and staging information. Characteristically abdominal BL sonographically presents as well defined solid hypoechoic mass with mass effect; they lack calcifications and are a vascular on colour Doppler study. Ultrasound therefore plays an important auxiliary role in early detection and diagnosis of this potentially curable tumour and can be used to predict the prognosis. OBJECTIVES: The major objective of the study was to describe the sonographic features of BL and to relate them with the clinical features and laboratory findings in order to determine the prognostic benefit of abdominal ultrasound in patients with BL at the UCI-Mulago hospital. METHODOLOGY: This case series was conducted In UCI and Department of Radiology-Mulago hospital from march 2009 to September 2009. Sixty (60) patients with confirmed BL had abdominal ultrasonography done before initiation of chemotherapy and at one month after initiation of chemotherapy. RESULTS: Sixty (60) patients participated in the study. The age range was 3-18 years with a mean of 7.2 and standard deviation of 2.98. The peak incidence was between 5-9 years. There were 43 (71.7%) males and 17(28.3%) females. Facial bone tumours remained the commonest clinical finding however, the commonest single presenting compalit was palpable abdominal mass with pain in 31(51.7%) patients. Abdominal ultrasound showed that 40 (66.7%) of all patients had intra abdominal masses. Forty four (73.3%) patients had the tumours involving other parts of the body. Mpst patients presented with stage D disease and therefore had poor prognosis. The commonest ultrasound findings were multiple lobulated heterogeneous hypoechoic abdominal masses in 40 (66.7%) patients. Of these masses 20(33.3%) were in the kidneys. Follow-up abdominal ultrasound showed that 32(80%) patients had tumour regression after one month of induction. CONCLUSION: • Abdominal ultrasound was able to demonstrate greater disease extent than clinical evaluation, thus highlighting the value of imaging in tumour staging and follow-up of patients. • This study showed more cases of abdominal BL involvement than previously seen in our patients, possibly due to better imaging facilities now. • Burkitt’s lymphoma should be strongly suspected in a child presenting with large lobulated hypoechoic intra-abdominal mass and histological diagnosis must be established as soon as possible. • Serum LDH levels were very high in patients with large and multiple tumour sites involvement but decreased as the tumour mass regressed. RECOMMENDATIONS: • Follow up abdominal ultrasound should be done after one month of treatment in order to assess early response to chemotherapy. • A bigger study should be done to comprehensively assess the role of ultrasound and serum LDH levels in follow up and determination of prognosis in BL patients.
Acceptability and perceptions of contraceptives among young HIV positive women in KCCA Art Clinics

( 2019-09) Muzeyi, Wani

Introduction There are about 7000 new HIV infections among young women in Sub Saharan Africa. Forty- three percent of pregnancies among young HIV positive women in Uganda are either unwanted or mistimed and this accounts for 21.3% of neonatal HIV infections. The prevention of unwanted pregnancy among young HIV positive women through the use of effective modern contraceptives is a key component of the WHO’s four-pronged HIV prevention and control strategy. Study objective. To determine the acceptability of contraceptives, its associated factors and perceptions of contraceptives among young HIV positive women in KCCA ART Clinics. Methods We conducted a convergent parallel mixed-methods study from February to May 2019 among 450 participants in three Public Kampala city HIV clinics (Kisenyi HC IV, Kiswa HC III and Komamboga HC III). For quantitative data, participants were systematically recruited into the study and were interviewed using a structured questionnaire. Data was analysed using STATA 13. Acceptability of contraceptives was measured by the proportion of participants that reported contraceptives to be very acceptable or acceptable. Prevalence ratios were determined using modified Poisson regression reporting clustered robust standard errors with a 95% confidence interval (CI) and P values. For qualitative data, six to eight participants were purposively selected from each facility for in-depth interviews. A total of 20 in-depth interviews were conducted from the three facilities. Thematic analysis was used to describe the data. Results The acceptability of contraceptives among young HIV positive women was low at 40.4 %( 95% CI: 26.0-54.9). Age greater than19 years (PR; 6.88, 95%CI; 1.09-46.91, P =0.04), having a friend who uses contraceptive (PR; 1.89, 95CI; 1.12-3.19; P=0.018) and being divorced/separated (PR; 1.31, 95%CI; 1.03-1.67, P=0,027) were found to be significantly associated with acceptability of contraceptives. Regarding perceptions themes that emerged misconceptions on contraceptive use, lived experiences and perceived negative interaction between ARVs and contraceptive. Conclusion Acceptability of contraceptives among young HIV positive in KCCA ART clinics was low and this could have been due to perceptions young women have about contraceptive usage. Young HIV positive women should be given more information on the safety of contraceptives use.
Acceptability of cervical cancer screening using visual inspection with acetic acid and lugol's iodine among women attending the family planning clinic in mulago hospital.

( 2008-05) Busingye, Priscilla

BACKGROUND: Cervical cancer is the commonest malignancy among women in Uganda. Over 80% of patients diagnosed with cervical cancer in Mulago hospital present with advanced disease. Cytology based screening services are not feasible for low resource settings like Uganda. It is proposed that visual inspection with acetic acid and Lugol’s iodine is an alternative method to cytology. There are already programs going on with VIA/VILI but since they are new methods we need to know the acceptability of cervical cancer screening using these methods in Ugandan women. OBJECTIVES: The main objective of the study was to determine acceptability of cervical cancer screening using VIA/VILI among women attending the family planning clinics at mulago hospital. METHODS: It was a cross-sectional study with both quantitative and qualitative approaches. A total of 384 participants were recruited in the study RESULTS: Participants who accepted cervical cancer screening using VIA/VILI were 229. Of these, 209 that is, 91.3% were willing to recommend others for the same service while 223 participants that is 98.7% would return for the same screening if the need arose. 155 participants out of 384 did not accept screening. The reasons for refusal included; fear of undressing, fear of the speculum and fear of results. Findings were similar in the FGD. CONCLUSIONS: Acceptability of cervical cancer screening using VIA/VILI was found to be very high among women attending family planning in Mulago hospital. Some women refuse screening because of fear of instruments, undressing and fear of knowing that they might have cancer.
Acceptability of TeleMental Health and its influencing factors among adolescent patients, caretakers, and mental health professionals at Butabika Hospital

(Makerere University, 2023-11) Segawa, Enock Suubi

Background: Mental disorders are a significant cause of disability worldwide, Uganda inclusive. In 2019, they accounted for 4.92% and 3.94% of the disease burden in the world and Uganda, respectively. Adolescents are at a relatively higher risk of these disorders due to developmental biological and psychological vulnerabilities to environmental stressors. Telemental health (TMH) can be used to increase access to mental health services for adolescents. However, its effectiveness will depend on its acceptability by adolescent patients, their caretakers, and mental health professionals (MHPs). Main objective: To assess the acceptability of TMH for adolescent patients at Butabika Hospital among adolescent patients, their caretakers, and MHPs, and determine the associated factors among the patients and their caretakers. Methods: A concurrent mixed-methods design was used. The quantitative research component was a cross-sectional design among 63 patients and 188 caretakers. Quota sampling was used. Data were collected using a researcher-administered questionnaire. It was managed in EpiData Manager and analysed using Stata software. The qualitative research component was with four mental health professionals, six patients, and eight caretakers. An exploratory descriptive qualitative approach was used. Data were collected through in-depth and key-informant interviews. It was managed in OpenCode and analysed by thematic analysis. Results from the qualitative were triangulated with those from the quantitative research component at the interpretation phase. Results: Most patients were female (61.9%), did not own phones (59.7%), and had no experience with any TMH service (77.4%), while most caretakers were female (72.3%), owned phones (97.9%), and had no experience with any TMH service (81.4%). The prevalence of high acceptability among patients was 77.8% (95% CI: 67.2% - 88.3%), and among caretakers was 93.1% (95% CI: 89.4% - 96.7%). None of the candidate factors was associated with high acceptability among patients, while caretaker acceptability was associated with phone ownership (aPR 0.940, 95% CI: 0.900 - 0.982). There were no confounding or interaction effects in the data. Most participants favoured using or providing the TMH service at Butabika Hospital. Furthermore, while using or providing the service was ethical, it presented difficulties in the case of providing it to minors who were non-emancipated patients. The mental health professionals also anticipated minimal opportunity costs, except if they had to provide it outside working hours. Finally, most participants believed that physical limits hampered the efficiency of the service. Conclusion: Most patients and caretakers expressed high acceptability of the TMH service for adolescent patients at Butabika Hospital. Among caretakers, not owning a phone was associated with a high acceptability of TMH. However, the study was underpowered to detect associations between any candidate predictor and high acceptability. Most participants had favourable opinions about the service. However, they also expressed concerns about its limitations. The management of Butabika Hospital could consider conducting formative research about the TMH service. All TMH providers should endeavour to innovate within prevailing constraints to mitigate the limitations of TMH. Finally, future researchers should use large homogeneous samples from study populations to ensure adequate study power.
ACCURACY OF CHEST ULTRASOUND IN DIAGNOSING PNEUMONIA IN PEDIATRIC PATIENTS AT MULAGO NATIONAL REFERRAL HOSPITAL, KAMPALA, UGANDA.

(Makerere University, 2019-08) KYOMUHANGI, AGNES

ackground. Pneumonia is a major health threat worldwide and a leading infectious cause of death in children under 5 years causing more deaths than AIDS, malaria, and measles. The current guidelines suggest that the diagnosis of pneumonia in pediatric patients can mainly be made clinically using WHO criteria for diagnosing pneumonia with chest X-ray (CXR) reserved for severe or complicated cases of pneumonia. However, it has relatively low accuracy, is associated with delays in diagnosis and exposes children to ionizing radiation. Some studies have shown that chest ultrasonography (CUS) is accurate at diagnosing community acquired pneumonia (CAP) in children. It is also cheaper, more readily available, safer than chest radiography and a good tool for easy bedside use and follow up of patients. However, very few studies have been done in children and none in our settings. Objective of the study. The aim of this study was to establish the accuracy of chest ultrasound in diagnosing pneumonia in pediatric patients at Mulago National Referral Hospital. Method and materials. This was a cross sectional study conducted at acute Care Unit(ACU), MNRH. Children aged 2 months to 12 years admitted with a clinical suspicion of pneumonia were prospectively enrolled for the study and underwent both chest X-ray and chest ultrasound (performed by the principal investigator blinded to CXR findings). Both investigations were performed within 24 hrs. of admission. Chest sonography was carried out using a high frequency (7-12 MHz) linear probe. Different CUS findings including; B-lines, lung consolidation, CXR findings; alveolar process, interstitial process and/or pleural effusion were assessed. The final discharge diagnosis was based on history and physical examination and CXR findings. The final diagnosis was based on overall clinical findings and CXR findings and was used as a reference standard compared with CUS to determine the accuracy of chest ultrasound in diagnosing pneumonia. The bivariate and multivariate analysis were done to determine the association between radiological and clinical findings. Results. Of the 280 patients enrolled, 252 patients had complete data for analysis. The mean age was 21.4 months with more male participants 131(52%).CUS was positive in 164(64.7%) cases; 149(59.0%) consolidation and 62(24.6%) B-lines; 115(46.0%) had at least one patterns; 48(19.0%) 13 had both; 29(12.0%) pleural effusion. CXR was positive in 95(37.7%) cases; 82(32.5%) alveolar process; 18(7.1%); 90(35.7%) had at least one pattern; 5(2.0%) had both patterns; 9(3.6%) pleural effusion. 205(81.3%) had a final clinical diagnosis of pneumonia. CUS sensitivity was 72%(95% CI [65-78]), specificity 67%(95% CI [52-81]), PPV 91%(95% CI [85-95]), NPV 35%(95% CI [25-46]), likelihood ratios, 2.2 (95% CI [1.44-3.37]) for positive and 0.42(95% CI [0.31-0.56], for negative, ROC 0.7(95% CI [0.62-0.77]). When compared to CXR findings alone, CUS sensitivity was 96% [95% CI, 90-99], specificity of 54% [95% CI, 46-62], PPV of 56% [95% CI, 48-64], NPV of 96% [95% CI, 89-99]. Hypoxia (SP 02 <93%) showed a strong association with both CUS and CXR, tachypnea with only CUS and inability to feed with only CXR, with p-values <0.05. The odds of diagnosing pneumonia by CUS in children with cough was 3.9; [95% CI; 1.19-9.62; p-0.022], and those with with hypoxia 1.9; [95% CI; 1.05-3.33; p-0.035]. The odds of diagnosing pneumonia by CXR in children with hypoxia 1.9 [95% CI; 1.07-3.26; p-0.028]. Conclusion CUS was found to have a high sensitivity and therefore be used as a screening tool or add- on tool to CXR to diagnose pneumonia especially when CXR is negative. Hypoxia and tachypnea are the main predictors of pneumonia radiologically using CUS and CXR in children with clinical suspicion of pneumonia
Accuracy of ganga hospital open injury score in predicting amputation of severe open lower limb injuries among adults seen at Mulago Hospital

(Makerere University, 2025) Ibrahim, Abdirahman Hassan

Background: With the recent advent of more motorization in Uganda, severe open lower limb injuries are pretty common. Hence, a frequent ethical and medical-legal dilemma in decision-making by frontline clinicians often occurs on whether to amputate a limb to prevent mortality. There are a variety of injury scores to help guide decisions; unfortunately, most fall short of accuracy. There is a need for a precise score to assist clinicians in providing a tiebreaker to salvage or amputate with the most accuracy. Objective: To assess the accuracy of GHOISS in the clinical prediction of amputation among adult patients with severe open lower limb injuries at Mulago National Referral Hospital. Methods: A three-month hospital-based prospective cohort study was done at Mulago National Referral Hospital’s accident and emergency ward among 92 adult patients with severe open lower limb injuries using the Buderer sample technique. An interviewer-guided questionnaire was used to collect participants' socio-demographic and clinical characteristics. The patients with severe open lower limb injuries were evaluated and scored using GHOISS and MESS scores. Participants were thereafter followed up for up to 5 days to see if any subsequently experienced a delayed amputation. Results: The study included 92 participants, predominantly male (85.87%), with a mean age of 34 years (±11.47). The most common cause of injury was road traffic accidents (90.22%), and the tibia was the most frequently injured site (80.43%). Among the study population, 2.17% underwent primary amputation, 7.61% had delayed amputation, and 90.22% had limb salvage. The predictive accuracy analysis of GHOISS compared to MESS demonstrated superior performance for GHOISS. For primary amputation, both scores had AUC = 1.0, but GHOISS had slightly higher specificity (91.11% vs. 87.78%). For delayed amputation, GHOISS showed AUC = 0.95, sensitivity = 71.43%, specificity = 94.12%, outperforming MESS (AUC = 0.72, sensitivity = 42.86%, specificity = 88.24%). Conclusion: The findings indicate that GHOISS is a highly accurate tool for predicting primary and delayed amputations, significantly outperforming MESS in sensitivity and specificity.
Accuracy of lung ultrasound in diagnosing respiratory distress syndrome in very low birth weight neonates at Kawempe national referral hospital and Mulago specialized women and neonatal hospital

(Makerere Univeristy, 2022-11) Angom, Okello Diana

ABSTRACT Introduction Globally, prematurity and its complications, including low birth weight are a leading cause of death in children under the age of 5 years. In Uganda, neonatal deaths represent 42% of under 5 deaths; 27.9% of which are attributed to Prematurity and its complications, making it the second leading cause of neonatal mortality. The predominant reason for these preterm deaths is respiratory distress syndrome (RDS). Currently diagnosis of RDS is based upon clinical signs and symptoms and confirmed on Chest radiography which exposes the neonates to ionizing radiation. The use of lung ultrasound, a safer modality of imaging for diagnosis of RDS, has not been studied in our setting and thus its applicability to our population remains unknown. Aims; The study aimed to determine the accuracy and incremental detection rate of LUS in diagnosing RDS in very low birth weight neonates. Methodology; This was a cross-sectional study involving 263 neonates of less than 1500grams who were admitted to the neonatal intensive care units at Kawempe national referral hospital and Mulago specialized women and neonatal hospital. Patients with clinical features of RDS at admission had an Antero-posterior chest radiograph done and bedside lung ultrasound scan was done for all participants. Both investigations were done within 72 hours of admission. The chest radiographs were interpreted by two independent radiologists blinded to the lung ultrasound findings, with a tie breaker in cases of non-agreement. The different CXR features included, ground glass opacities, consolidations, atelectasis. The principal investigator performed the bedside ultrasound scans using a high frequency liner probe and was blinded to the chest radiographic findings. The LUS features included pleural line abnormalities, B-lines, consolidations. The final clinical diagnosis based upon clinical history, physical examination and chest radiographic features was used as the reference standard and compared to LUS to determine the accuracy of LUS in diagnosing RDS. Results; Overall 263 participants were enrolled and had complete data for analysis. Majority of the participants were recruited from Kawempe national referral hospital. A slight female predominance 140 (53.2%) was seen with a median birth weight of 1320grams and age of 24 -48 hours. LUS was positive in 237(90.1%) cases; of these, 237 (100%) had pleural irregularities, 233(98.3%) had B-lines, 214(90.3%) had A-line disappearance, 55(23.2%) had consolidations, and no pleural effusions were observed. There were 199 CXR of diagnostic quality, of these, 98(49.3%) were positive. Of the positive cases, 90(91.8%) had ground glass opacities, 18(18.4%) had consolidations but no pleural effusions were depicted. There were 204(77.9%) cases who had a final clinical diagnosis of RDS. LUS had a sensitivity of 96.08% (95%CI; 92.42- 98.29%), specificity of 29.82% (95%CI;18.43% to 43.40%), positive predictive value of 83.05% (95% CI; 80.50% to 85.33%), negative predictive value of 68.00% (95%CI; 49.16% to 82.36%), positive likelihood ratio of 1.37 (95%CI; 1.15 to 1.63) and negative likelihood ratio of 0.13 (95%CI; 0.06 to 0.29). The incremental detection rate of LUS over CXR in diagnosing RDS in VLBW neonates was found to be 49%. Conclusion; LUS was found to have a high sensitivity for the diagnosis of RDS among VLBW neonates and can thus be used as a screening tool to aid in the diagnosis of RDS especially in cases where CXR is negative and the neonate is symptomatic.
Accuracy of rapid tests as compared with field microscopy for the diagnosis of malaria in adolescents and adult patients in mulago hospital.

( 2008-08) Ssekiganda, Luzige Simon

BACKGROUND: Blood smear microscopy is the recommended gold standard test for laboratory confirmation of malaria. However, due to some limitations associated with microscopy such as being labour intensive and time consuming, rapid diagnostic tests (RDTs) are becoming attractive alternatives to microscopy because these tests are fast, easy to perform and do not require electricity or specific equipment. Although their accuracy in a number populations and epidemiological settings has been reviewed, the results are often variable and not easily transferable. This study was therefore performed to evaluate the accuracy of RDTs for the diagnosis of malaria in adolescents and adult patients in Mulago hospital. METHODS: From February to May 2007, we evaluated the accuracy of SD malaria Pldh P.F/Pan, SD malaria HRP-II p.f, Parabank as compared to field microscopy of blood smears in five hundred fifty five (555) adolescent and adult patients clinically suspected to have malaria at mulago hospital. With microscopy as the gold standard, we analyzed for the accuracy of each RTD by computing for sensitivity, specificity, positive and negative predictive values as well as positive and negative predictive values as well as positive and negative diagnostic likelihood ratios (DLRs). RESULTS: The adjusted prevalence of smear confirmed malaria was 20% (111 patients). SD malaria Pldh p.F/Pan and Paracheck had similar sensitivities (89%) meanwhile; SD Bioline-P.f HRP2 and parabank were respectively 87% and 83%. Overall the greater the parasite density the higher was the sensitivity. The PLDH based RDTs SD malaria PLDH P.f/Pan and parabank had a higher specificity (96%) than the HRP2 based tests SD malaria HRP-II p.f (88%) and parabank (91%). The positive predictive values of SD malaria Pldh P.f/Pan and Parabank were respectively 84 and 87 compared to HRP2 based tests SD malaria HRP-II P.f (64%) and paracheck (70%). However, the negative predictive values were similar for all tests (96%-97%). Also, the positive diagnostic likelihood ratios for SD malaria Pldh p.f/pan, parabank, SD Malaria HRP-II P.F and paracheck were respectively 21, 23, 7 and 9 whereas the negative diagnostic likelihood ratios was 0.1 for all RDTs. CONCLUSIONS: The accuracy of rapid tests (SD malaria Pldh p.F/Pan, PARACHECK, SD Bioline-P.f HRP2 and parabank) is comparable to blood smear microscopy in the diagnosis of malaria in adolescents and adult patients in mulago hospital. RECOMMENDATIONS: Rapid diagnostic tests (RDTs) should be considered as alternative methods for supporting or ruling out malaria in adolescents and adult patients suspected to have malaria in Mulago hospital.
Accuracy of Spectral Doppler in evaluation of diastolic dysfunction in hypertensive patients in Mulago Hospital Complex

(MAKERERE UNIVERSITY, 2018) NABIRYE, STELLA

ABSTRACT Background: Hypertension is major risk factor for heart failure, coronary artery disease, kidney injury and stroke worldwide. Uncontrolled hypertension leads to structural changes in the heart which eventually results into interstitial fibrosis, myocardial wall thickness and alteration of function when diastolic dysfunction develops. Hypertension has been observed to be the most predisposing factor for cardiac failure worldwide and a common cause of heart failure on the cardiology ward of Mulago Hospital, accounting for about 40% of all causes of heart failure. Early detection of diastolic dysfunction is likely to halt its progression into overt diastolic heart failure. Spectral Doppler and Tissue Doppler Imaging (TDI) is considered as the most practical and reproducible method for either confirming or excluding diastolic dysfunction in Heart Failure with preserved Ejection Fraction (HFpEF). In Mulago hospital, only spectral Doppler is used to diagnose diastolic dysfunction. Objective: To determine the accuracy of spectral Doppler in diagnosing diastolic dysfunction among hypertensive patients in Mulago Hospital complex. Methods: This was a cross sectional study done in Mulago Hospital Complex. The study was conducted between April 2017 and May 2017. A total of 229 hypertensive patients were enrolled excluding the elderly, those with diabetes mellitus, documented evidence of other heart diseases like pericardial effusion, peripartum cardiomyopathy, valvular heart disease and atrial fibrillation, diabetes mellitus. Data on demographic, clinical characteristics and echocardiographic findings for both systolic and diastolic function was collected using a pretested questionnaire. Spectral Doppler imaging was compared to both spectral and tissue Doppler imaging (gold standard). Sensitivity, specificity, positive and negative predictive values were calculated in comparison to the both spectral and tissue Doppler imaging (gold standard). Results: Of the 229 patients, 146 (63.8%) were females and most of the patients were above 45 years of age. 87 (72.5%) were on antihypertensive treatment with majority of patients on calcium channel blockers and angiotensin converting enzyme inhibitors. Of the 229 enrolled patients, 172 (75%) had diastolic dysfunction using both spectral and tissue Doppler imaging (gold standard). The sensitivity and specificity of spectral Doppler was 60.44% and 51.1% respectively. The negative and positive predictive values were 25% and 82.71% respectively. The accuracy of spectral Doppler in diagnosing diastolic dysfunction was 59%. Conclusions: There was a low level of accuracy in using spectral Doppler to diagnose diastolic dysfunction. The prevalence of diastolic dysfunction was high using the both spectral and tissue Doppler imaging (gold standard). Recommendations: Therefore, it very important for us to emphasize the use the spectral and tissue Doppler imaging (gold standard) in hypertensive patients between 18 and 65 years of age so that we don’t miss out on patients with diastolic dysfunction.
Accuracy of the neutrophil-lymphocyte ratio in predicting thirty-day all-cause mortality among patients hospitalized with community-acquired pneumonia in Uganda a nested cross-sectional study

(Makerere University, 2024) Namiiro, Sharon Mirian

Background: Community acquired pneumonia (CAP) contributes to approximately 3 million deaths globally. The assessment of severity plays a crucial role in effectively managing CAP and accurately predicting mortality outcomes. The neutrophil-lymphocyte ratio (NLR) has shown promise in assessing the risk of mortality for CAP patients, however, its role in predicting CAP mortality has not been extensively evaluated in Sub-Saharan Africa. This study sought to determine the accuracy of the NLR in predicting 30-day all-cause mortality among adults admitted with CAP to Mulago, Kiruddu, and Naguru Referral hospitals in Uganda. Methods: A nested cross-sectional study was conducted among consecutively selected adults with CAP admitted at Mulago, Kiruddu, and Naguru Referral Hospitals in Uganda, between April 2022 and January 2024. This study was nested in the LoRTISA study that seeks to determine the etiology and resistance patterns of clinically diagnosed CAP among hospitalized individuals, using a comprehensive microbiological approach. Data concerning the clinical history, physical examination, and laboratory tests were abstracted from the primary study Research Electronic Data Capture (REDCap) dataset, in February and March 2024. Data on the vital status of the participants at day 30 was also abstracted. Receiver operating characteristic (ROC) curve analysis was employed to determine the optimum cut-off point of the NLR for predicting mortality. Sensitivity, Specificity, Positive and Negative predictive values (PPV &NPV) of the optimum cut-off were then determined. Results: A total of 200 participants were enrolled. The median age and NLR were 41 years (IQR: 32-60years) and 4.0 (IQR:2-8) respectively. Majority of the participants were male (54%, 108/200). Mortality at day 30 was 17.5%. The optimum cut-off point of the NLR for predicting 30-day mortality was 4.23, with a corresponding sensitivity and specificity of 63% and 58%, respectively. The PPV was 24.2% and NPV was 88.1%. The area under the ROC curve (AUC) was 0.63. Conclusion: The NLR cut-off of 4.23 has a modest accuracy in predicting 30-day mortality and identifying high-risk CAP patients needing closer monitoring or treatment. Additional studies are needed to validate and refine NLR cut-off points through prospective studies, which will enhance its clinical utility in CAP management and improve patient outcomes.
Acute chest syndrome in children with sickle cell anaemia at Mulago Hospital: Prevalence, aetiology and clinical characteristics

(Makerere University, 2013-09) Odong, Ochaya

Background: Acute chest syndrome (ACS) is a potentially fatal acute pulmonary complication of sickle cell disease (SCD) defined as presence of an infiltrate on chest x-ray in SCD patient with fever and pulmonary symptoms and signs. In developed countries it is the second most common cause of hospital admissions of children with SCD. Little is known about its burden in sub-Saharan Africa, including Uganda. We set out to determine the prevalence, and to describe the clinical characteristics and bacterial infections associated with acute chest syndrome amongst children with sickle cell anaemia who attend Mulago Hospital Methods: In a cross sectional study, 263 children with SCA and fever from the Sickle Cell Clinic and Acute Care Unit at Mulago Hospital were recruited after informed consent/assent. Chest X-rays, blood cultures, complete blood count, and sputum induction were done. ZN staining, culture and sensitivity and DNA PCR for Chlamydia pneumoniae were done on the sputum. Data was captured using Epidata ver 3.1 and exported to STATA Ver 12 for analysis. Results: Fifty eight (22.7 %) of the 256 children had ACS. Apart from presence of tachypnoea, SpO2 <92% and abnormal chest auscultation, clinical and laboratory findings were essentially not different between children with ACS and those without ACS. Out of the 256 blood culture results, Staphylococcus aureus 11 (4%), Streptococcus pneumoniae 3 (1%), and Group D Salmonella 3 (1%) were the most commonly isolated bacteria. Out of the 83 sputum culture and staining results Streptococcus pneumoniae 10 (12%), Moraxella Spp 7 (8%), Mycobacterium tuberculosis 6 (7%), were the most common organisms identified. Of the 59 sputum DNA-PCR run, Chlamydia pneumoniae was positive in 35 (59%). Twenty five (43.1%) of the CXRs had consolidation and 29 (50.0%) had an interstitial pattern. Conclusion: One in 5 children with SCA and fever had ACS. Tachypnoea, SpO2 <92% and abnormal chest auscultation in a febrile SCA child is associated with ACS. Infections contribute to causative factors of ACS.
Acute pain management and control among children with sickle cell anemia attending the Sickle Cell Clinic - Mulago Hospital

(Makerere University, 2018) Abala, Catherine

Background: Sickle cell disease is the most common hemoglobinopathy worldwide with the greatest burden of the disease occurring in sub-Saharan Africa. Pain is the hallmark of Sickle Cell Anemia. Despite the fact that pain is the most common reason for hospital visit, studies on pain assessment and treatment are scarce. Those available have documented that children with Sickle Cell Anaemia often suffer both under treatment and over treatment of their pain in hospital. The Sickle Cell Clinic Day Care Centre is an innovation for treating children with SCA with acute pain and no medical complications as outpatients. Although Day Care Clinic based management of acute painful episodes has been in existence for years, adequate information on treatment outcomes and associated factors that could be used to improve acute pain management for children with SCA is not available in Sickle Cell Clinic at Mulago Hospital. Objectives: This study aimed to evaluate pain management, describe the treatment outcomes and associated factors among children with sickle cell disease who present with acute pain at the Sickle Cell Clinic. Methods: A prospective cohort study with qualitative and quantitative components was done at the Mulago hospital Sickle Cell Clinic. Children with SCA aged 6 months to 12 years old with an acute painful episode were enrolled. History, examination and pain severity was scored using age appropriate pain assessment tools. Children were re assessed at discharge from the Day Care Centre and followed up at 72 hours to determine the treatment outcomes. Key informant interviews and focused group discussions with health workers at the clinic were conducted. Data was entered into Epi data version 3.1, exported to and analysed using STATA version 12.0. The proportion of children with adequate and inadequate pain control was done using descriptive statistics. The factors associated with the outcomes by logistic regression. Qualitative data was analyzed manually using the content thematic approach. Results: A total of 317 children of ages between 6 months and 12 years were enrolled with mean age of 6(±3.4) years. At discharge from the day care clinic 65.6% of children had inadequate pain control and 34.4% were adequately controlled. After 72 hours, 270(85.4%) had adequate pain control and 46(14.6%) inadequate pain control. The factors that were significantly associated with inadequate pain control both at discharge from day care and at 72 hours were having lower limb pain OR=11.9, 95%CI: (0.8-17.5), p=0.020, having shortness of breath OR=5. 95%CI: (1.4-18.7), p =0.05 and receiving an under dose of morphine OR=9.1, 95%CI: (1.8-44.9), p=0.007.Inconsistent drug supply, inadequate pain assessment, attitude of health workers and lack of knowledge on pain treatment guidelines were also associated with sub optimal pain management. Conclusion: Two thirds of children receive suboptimal pain management from the DCC. The significantly associated factors being under dose of morphine, lower limb pain, and shortness of breath, inconsistent supply of drugs, inadequate training and assessment of pain, health worker attitude and lack of knowledge of pain treatment guidelines. Training in pain assessment and treatment should be done for all health workers involved in care of children with sickle cell anemia.
Adaptation and validation of the Luganda version of the Edinburgh Postnatal Depression Scale for screening prenatal depression among mothers attending the Antenatal Clinic at Kawempe National Referral Hospital

(Makerere University, 2023) Mukasa, David Christopher

Introduction: Depression affects approximately 364 million people, globally. 7.8% of mothers in USA suffer from ante partum depression, 27.5% in Turkey while between 26.3 and 32.9% suffer from the debilitating condition in Africa. Opportunities for screening during the several ante natal contacts are missed. This may be attributed to the higher technical and requirements to use the known gold standard diagnostic tool, the DSM-5 criteria for Major Depressive Disorder (MDD). There is still a paucity of information on locally adapted and validated user-friendly screening tools for prenatal depression in Uganda. Untreated prenatal mental illness is associated with poor outcomes. In this study, we proposed to adapt and validate the Luganda version of the Edinburgh Postnatal Depression (EPDS-L) Scale for screening prenatal depression among mothers attending the antenatal care (ANC) clinic at Kawempe National Referral hospital (KNRH). Methods: This was a cross-sectional facility-based study in KNRH using International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines for the adapting the EPDS-L and quantitative approaches for the validation phase. Consecutive sampling was done until the desired sample size of 100 participants was achieved. The EPDS-L was administered by research assistants, and then the DSM-5 diagnostic criteria for Major depressive disorder was administered by trained Psychiatric nurse to all participants. Quantitative data was analyzed using STATA version 15. Reliability was demonstrated by the Cronbach’s alpha coefficient while validity was demonstrated by sensitivity, specificity, Negative Predictive Value, Positive Predictive Value and Area Under the Receiver Operator Characteristic curve. Results: The EPDS-L was adapted following the ISPOR taskforce recommendation (Appendix 5). The tool had a Cronbach’s Alpha coefficient of 0.8515 hence considered reliable. Using a cut off of 13 or more, sensitivity was 65%, specificity was 100%, Positive Predictive Value of 100% and Negative Predictive Value of 83.3%. The Area Under the Receiver Operator Curve was 0.99. Hence the EPDS-L can be used reliably at a cut off of 13. Additionally, the tool can even perform better at a cut off of 10, with sensitivity of 97.14% and specificity of 98.46%. Conclusion: The EPDS-L was adapted following the ISPOR taskforce recommendations and can be used reliably at a cut off of 13. The tool can even perform better at a cut off of 10.
Adapting and evaluating a mindfulness and acceptance-based intervention supporting mental health and adherence to anti-retroviral therapy among older adolescents in Kampala

(Makerere University, 2023-01-23) Musanje, Khamisi

Background Adolescents living with HIV in sub-Saharan Africa have a higher mental health burden, lower care engagement, and poor medication adherence. To improve treatment outcomes, support interventions that are tailored to the dynamic social and cognitive needs of adolescents as they pass through life-stages need to be developed/adapted, tested and promoted. Mindfulness and acceptance-based interventions are slowly gaining traction as appropriate for adolescents but have not been used in resource constrained settings with young people living with HIV. Purpose The aim of the study was to adapt a mindfulness and acceptance-based intervention for young people in Uganda who are living with HIV, with a focus on cultural saliency and contextual relevance and to evaluate the effectiveness of the adapted intervention in reducing symptoms of depression, anxiety, and internalized HIV stigma as well as improving adherence to antiretroviral therapy among adolescents recruited from two public health centres in Kampala, Uganda. Methods A sequential multi-methods design was used to achieve the study objectives; combining adaptation models, qualitative inquiries and a quantitative parallel group trial. The study was divided into two phases. Phase One encompassed cultural adaptation and qualitative inquiries while Phase Two involved the randomized trial. In phase one, adaption was guided by two adaptation frameworks (the Formative Method for Adapting Psychotherapy and the Ecological Validity Model) which worked as blueprints that guided engagement of n=30 stakeholders to modify the intervention manual for cultural salience and contextual relevance, while exploratory qualitative approach guided by the Theoretical Framework of Acceptability was used to generate qualitative data among n=9 users and n=10 providers on retrospective and prospective acceptability of the adapted intervention. Qualitative data was abductively analysed and organized under a priori themes from the Theoretical Framework of Acceptability. Finally, the study tested the effectiveness of the adapted intervention on reducing symptoms of depression, anxiety and stigma and self-reported adherence to antiretroviral therapy among n=122 adolescents with HIV through an open label randomized trial (ClinicalTrials.gov: NCT05010317). Data was analyzed using mixed effects regression. Results Key adaptations to the intervention included simplifying the language of the training manual into plain English (British level A2 or basic level), adding local practices, integrating locally relevant slang and stories into therapy, introducing culturally relevant visuals and cards representing emotions, and adjusting therapy materials for use in resource-constrained settings. The acceptability assessment indicated that users perceived the intervention to be acceptable, with many stating that it helped them overcome fears, increased their self-acceptance, and gave them the confidence to make careful health-enhancing decisions. Providers also found the intervention to be acceptable and appropriate for use with adolescents, citing benefits such as; the intervention offering support beyond a focus on adherence to drugs, refocusing adolescents on aspects of their lives that matter most, and being easy to integrate into their work processes. They however expressed concern about the time the intervention requires and the possibility of increasing their workload. Results from the trial showed that the intervention was associated with statistically significant reductions in symptoms of depression (β=-10.54, 95 %CI: -8.03 to -0.56; p <.001), anxiety (β=-7.310, 95 %CI: -11.869 to -2.751; p =.002) and stigma (β=-1.484, 95 %CI: -2.172 to -0.797; p =<0.001) over time, while no significant effect was observed on adherence to ART (β=.02, 95 %CI: -.27, .33; p =.85). Furthermore, being in school was a strong predictor of reductions in depression symptoms and anxiety over time while age and sex were not significant. Conclusion The adapted intervention was perceived to be acceptable by both providers and users, resulted in reduction in symptoms of depression, internalized stigma and anxiety but it had no impact on self-reported adherence to ART among adolescents with HIV in Uganda. It can be deduced from the study that adherence to ART remains a considerable challenge among AWH and may not be addressed by a single approach but rather a comprehensive strategy that incorporates various components of care
Adenotonsillar hypertrophy and frequency of Vaso-occlusive crisis in patients with sickle cell disease at Mulago Hospital

(Makerere University, 2023-08-14) Muhereza, Brian

Sickle cell disease is a multisystem disease with episodes of acute illnesses associated with progressive organ damage. The commonest manifestation of sickle cell disease is a vaso-occlusive painful crisis. Complications of adenotonsillar hypertrophy such as obstructive sleep apnea and recurrent infections are more prevalent in children with sickle cell disease compared to the general paediatric population. However, there is limited information regarding the effect of tonsillar hypertrophy on the frequency of vaso-occlusive crises in patients with sickle cell disease. This study sought to determine the factors associated with adenotonsillar hypertrophy and its variation with the frequency of vaso-occlusive painful crises among patients with sickle cell disease. Objectives: To determine the factors associated with adenotonsillar hypertrophy, and to compare the frequency of vaso-occlusive crisis among sickle cell disease patients with and without adenotonsillar hypertrophy at Mulago Hospital. Methods: This was an unmatched case-control study conducted at Mulago National referral Hospital Sickle Cell Clinic. Of the 401 children and adolescents aged 2-17 years enrolled in the study, 123(30.7%) cases of adenotonsillar hypertrophy were compared to 278(69.3%) controls. Tonsillar hypertrophy was diagnosed using direct visual examination using illumination light and, a post-nasal space x-ray was used to diagnose adenoid hypertrophy. An interviewer-administered questionnaire was used to obtain social demographic information and medical history. Data were collected and managed using an open data kit (ODK) and analyzed using STATA version 16.Results: There was a significant difference in the mean frequency of painful vaso-occlusive crises suffered in the previous 6 months between cases and controls (p value= 0.018). Age of 15-18 years (OR: p=0.047, females (OR: 2.35; p=0.003), Snoring (OR: p< 0.0001), and children who predominately breathed through the mouth (OR=5.14, p=0.001) were all associated with increased odds of adenotonsillar hypertrophy. Among disease-modifying factors, patients who were taking hydroxyurea (OR: 2.33; p=0.027) had higher odds of adenotonsillar hypertrophy. Conclusion. Children with sickle cell disease and adenotonsillar hypertrophy are at risk of suffering more pain vaso-occlusive crises compared to their counterparts. The presence of obstructive adenotonsillar hypertrophy in children with sickle cell disease increases sickle cell morbidity, more attention to these children through routine screening, diagnosis, and timely therapeutic intervention could reduce the morbidity.
Adherence and associated factors to postnatal follow up in the program for the prevention of mother to child transimission of HIV at Mulago hospital

( 2007-08) Nassali, Mercy

TITTLE: Adherence and associated factors to postnatal follow up in the program for the prevention of mother to child transmission of HIV at mulago hospital. BACKGROUND: The scale up of the diagnosis of HIV in pregnancy through routine antenatal and intrapartum testing has gone along way in facilitating perinatal PMTCT interventions. Despite this, postnatal follow up of the mother and child for evaluation and ongoing HIV/AIDS care remains a challenge in developing countries. This study was designed to identify the level of adherence and factors associated with postnatal follow up in the PMTCT program at mulago hospital. METHODS: This was a cross-sectional study in which 289 HIV positive mothers were enrolled following discharge from mulago hospital postnatal wards. They were then followed up to six weeks postpartum. They were interviewed concerning socio-demographic characteristics and some possible factors that could be associated with adherence to postnatal follow up using a standardised questionnaire. The level of adherence to postnatal follow up was determined at six weeks postpartum. Four focus group discussions for qualitative analysis were conducted at the end of the follow up period to qualitatively assess the factors that motivate or hinder adherence. RESULTS: The level of adherence to postnatal follow up in the PMTCT program was found to be 38% (110/289) by the end of six weeks. At bivariate analysis, the following factors were associated with adherence to postnatal follow up: living with a partner, maternal age greater than 25 years, belonging to the Christian faith, multiparity, antenatal attendance, previous postnatal clinic attendance and knowledge of venue were to return, having one or no living child, being or having a close contact on HAART, having tested before labour, being already registered into an HIV/AIDS care program and having access to a cell phone. After adjusting for confounding factors, previous postnatal clinic attendance (OR 3.5, P 0.003, Christian faith (or 3.1, p 0.018) and having access to a phone (OR 3.1, P 0.003) remained significantly associated with adherence to postnatal follow up. These results were stratified for age to cater for interaction between maternal age and previous postnatal attendance. In the focus group discussions, lack of funds for transport and inability of the mothers to disclose their HIV positive serostatus to their spouses were identified as the major hindrances to adherence to postnatal follow up in the PMTCT program. CONCLUSIONS: In view of slightly over a third of the mothers who adhered to postnatal follow up, there is still a great need for more emphasis on the value of postnatal follow up and timely linkage to comprehensive care for mother and child beyond the better known peri partum PMTCT interventions. Mothers at increased risk for non adherence like the young prime para and those who have never attended PNC review require closer attention.
Adherence to anti-diabetic medication and associated factors among Type 2 Diabetic patients in Nsambya, Lubaga and Mengo Hospitals in Kampala

(Makerere University, 2024) Bulafu, Douglas

Introduction: Over 4.6 % of the Ugandan population aged 20-70 is living with diabetes with majority living in urban areas like Kampala. Type 2 Diabetes (T2D) is associated with complications like heart disease, stroke, kidney problems, and cancers if not managed or treated. Preventing these complications and having better treatment outcomes requires good adherence to treatment. However, there is limited information on adherence to anti-diabetic treatment among patients in private health facilities yet majority of the patients in urban areas access treatment in private facilities. Main Objective: To assess adherence to anti-diabetic treatment and associated factors among diabetic patients in Mengo, Lubaga and Nsambya hospitals in Kampala, Uganda. Methods: The study employed a cross sectional quantitative study design. Data was collected among 459 consecutively sampled type 2 diabetic patients receiving care in Mengo, Lubaga and Nsambya hospitals using semi structured questionnaires embedded on the kobo collect app on android phones. The collected data was cleaned in excel 2016, and analyzed in STATA version 15 statistical software. Descriptive analyses were conducted and presented as percentages in tables. Association between the adherence to anti-diabetic medication and independent factors was determined using modified Poisson regression at bivariate and multivariate analysis. Results: About 54.5% (95% CI: 26.7-79.7) of the patients adhered to antidiabetic treatment. Using insulin as type of medication (PR-0.53, 95%CI: 0.45-0.81), being reminded by family to take medicines (PR-0.67, 95%CI: 0.48-0.94), was negatively associated with adherence to anti diabetic medication. Additionally, not experiencing side effects while using anti diabetic medication (PR-1.34, 95%CI: 1.03-2.05), was associated to anti-diabetic medication. Conclusion: The study revealed that adherence to antidiabetic medication was suboptimal in private health facilities in Kampala. This low adherence level is associated to insulin use, experiencing side effects, drug unavailability, having a family member with diabetes and reliance on a family member for reminders. Therefore, strategies such as improved stock taking in health facilities and health education of both patients and caretakers on diabetes should be strengthened at these facilities to improve adherence.
Adherence to antiepeleptic drugs among children with epilepsy attending the Paediatric Neurology Clinic at Mulago Hospital

(Makerere University, 2011) Nazziwa, Rose

INTRODUCTION: Epilepsy is one of the neglected and highly stigmatised diseases, yet it is very common affecting about 50 million people worldwide. In Uganda, the estimated prevalence of epilepsy is 13% with about 156 new cases per 100,000 people per year. Adherence to antiepileptic drugs is crucial in achieving seizure control yet in Uganda, there is lack of information on adherence to antiepileptic drugs among children with epilepsy. In addition the factors that affect adherence and the association between adherence and seizure control are not well documented, yet this information is crucial for improving management of children with epilepsy. OBJECTIVES: To determine the level of adherence to antiepileptic drugs and the factors that affect this among children with epilepsy attending the paediatric neurology clinic of Mulago Hospital. METHODS: Using a cross sectional study design, 122 children who met the inclusion criteria were enrolled and interviewed using a pretested questionnaire. Assessment of adherence to antiepileptic drugs was done by self report and assay of serum drug levels of the antiepileptic drugs using Florescence immunopolarisation assay method. Focus group discussions were held to further evaluate the factors that affect adherence to antiepileptic drugs. DATA MANAGEMENT AND ANALYSIS: Data was entered into Epidata version 3.1 and Stata version 9.0 software used for analysis. The proportion of children who adhered to their drugs was computed and reported as percentage of children who were adherent and non adherent. Variables with a p value < 0.2 at bivariate analysis were subjected to logistic regression to assess for factors that were independently associated with non-adherence to AEDs. A P-value < 0.05 was considered statistically significant. Direct quotations from focus group discussions were used in presentation of qualitative data. RESULTS: A total of 122 children were enrolled, age range 6 month - 16 years with a male to female ratio of 1.3:1 and majority had generalised seizures 76 (62.3%). Adherence to antiepileptic drugs by self report was 79.5% and 22.1% by drug levels. Majority of the children in both adherent and non adherent groups by self report had inadequate drug doses (95/122). Children were found to be more non-adherent if the caregiver had an occupation (p-value 0.030, 95%CI 1.18-28.78). The common reasons for missing drugs were: lack of drugs due to their high cost 36 (48.7%) and forgetting 22 (29.7%). Children who were adherent by self report were more likely to have good seizure control compared to the non adherent (p-value 0.63, 95%CI 0.29-8.78). All children with poor seizure control had poor adherence by drug levels. CONCLUSIONS: The level of adherence to antiepileptic drugs was 80% by self report and 22% by drug levels. The caregiver having an occupation was found to increase the likelihood of non adherence in a child. RECOMMENDATIONS: Drugs should be availed at the hospital pharmacy to reduce on the missed doses due to high cost of drugs.
Adherence to benzathine penicilline for secondary prophylaxis among patients affected with rheumatic heart disease ( RHD) at Mulago Hospital

(Makerere University, 2012-05) Musoke, Charles

Background: Rheumatic Heart Disease (RHD) frequently occurs following recurrent episodes of acute rheumatic fever (ARF). It continues to cause gross distortions of the heart which is avoidable in this age of highly efficacious medications. Benzathine penicillin is the most efficacious method for secondary prophylaxis. The efficacy of this treatment is largely determined by adherence to treatment. Various factors determine adherence to therapy. To date, there is no data regarding current use of Benzathine penicillin for secondary prophylaxis in patients with RHD attending Mulago hospital. However, it is known that patients with RHD should receive at least 80% of their monthly injections in a given period. Objective: To determine the levels of adherence to benzathine penicillin prophylaxis, identify patient factors associated with adherence and the reasons for non adherence among Rheumatic heart disease patients in Mulago hospital. Study Methods: This was a longitudinal observational study carried out in Mulago Hospital cardiac clinics over a period of 10 months (June 2011-March 2012). Ninety five consecutive patients who satisfied the inclusion criteria were recruited over a period of 4 months from June to September 2011. All patients consented or assented and data on demographic characteristics and disease status was collected by means of a standardized questionnaire. A card was given to each participant to document the injections of benzathine penicillin received from their health care providers. All patients received education on the importance of monthly benzathine penicillin before being placed back under the care of their primary clinicians. Follow up was done at the end of six months and information retrieved from the cards as regards the monthly benzathine penicillin. Another questionnaire to determine the reasons for non adherence was administered at follow up time. The outcome measures included the number of penicillin injections received to that prescribed over the six months period, the proportion of adherent and non adherent patients, the different patient factors associated with adherence to Benzathine penicillin prophylaxis and the reasons for non adherence among RHD patients in Mulago hospital. Results: Patient Characteristics: The majority of patients were females 75 (78.9%). The patient’s age ranged from 5-55years, with a mean age of 28.1 years (SD ± 12.2) and median age was 28 years. The highest education level was primary school for most patients, 44 (46.3%) with 8 (8.4%) of the patients being illiterate. Most of the patients were either NYHA classification II 39 (41.1%) or III 32 (33.7%). Level of adherence to monthly benzathine penicillin: Forty four patients (54%) adhered to the monthly benzathine penicillin prophylaxis with adherence rates ≥ 80%. Thirty eight (46%) of the patients were classified as non adherent to the monthly benzathine penicillin with rates less than 80%. The mean adherence was 70.12% (SD ± 29.25) and the median was 83.30% with a range of 0 to100%. Twenty seven (33%) of the patients had extremely poor adherence rates of ≤ 60%. Patient factors associated with adherence: Although statistically significant associations with adherence were not found, trends towards adherence were demonstrated among patients who resided in a town/city [OR 1.73; CI 0.64-4.72] and those with at least secondary level of education. [OR 2.21; CI 0.83-5.93] The painful nature of the benzathine penicillin injections and lack of transport money to travel to the health center were the main reasons for non adherence among RHD patients in Mulago hospital. Conclusion1. Although the level of adherence was fairly good (54%), the level of non adherence among these rheumatic heart disease was considerably high (46%) which places a significant proportion of patients at risk of recurrent episodes of ARF and worsening heart lesions. 2. Although no particular patient factor was found to be significantly associated with adherence, we determined that residing in a town/city and having at least secondary level of education was associated with a trend towards adherence. 3. The painful nature of the benzathine penicillin injections and lack of transport money to travel to the health center are the main reasons for non adherence among RHD patients in Mulago.

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