Evaluating a Mobile Phone-Delivered Text Message Reminder Intervention to Reduce Infant Vaccination Dropout in Arua, Uganda: Protocol for a Randomized Controlled Trial

Background

Globally, suboptimal vaccine coverage is a public health concern. According to Uganda’s 2016 Demographic and Health Survey, only 49% of 12- to 23-month-old children received all recommended vaccinations by 12 months of age. Innovative ways are needed to increase coverage, reduce dropout, and increase awareness among caregivers to bring children for timely vaccination.

Objective

This study evaluates a personalized, automated caregiver mobile phone–delivered text message reminder intervention to reduce the proportion of children who start but do not complete the vaccination series for children aged 12 months and younger in select health facilities in Arua district.

Methods

A two-arm, multicenter, parallel group randomized controlled trial was conducted in four health facilities providing vaccination services in and around the town of Arua. Caregivers of children between 6 weeks and 6 months of age at the time of their first dose of pentavalent vaccine (Penta1; containing diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b antigens) were recruited and interviewed. All participants received the standard of care, defined as the health worker providing child vaccination home-based records to caregivers as available and providing verbal instruction of when to return for the next visit. At the end of each day, caregivers and their children were randomized by computer either to receive or not receive personalized, automated text message reminders for their subsequent vaccination visits according to the national schedule. Text message reminders for Penta2 were sent 2 days before, on the day of, and 2 days after the scheduled vaccination visit. Reminders for Penta3 and the measles-containing vaccine were sent on the scheduled day of vaccination and 5 and 7 days after the scheduled day. Study personnel conducted postintervention follow-up interviews with participants at the health facilities during the children’s measles-containing vaccine visit. In addition, focus group discussions were conducted to assess caregiver acceptability of the intervention, economic data were collected to evaluate the incremental costs and cost-effectiveness of the intervention, and health facility record review forms were completed to capture service delivery process indicators.

Results

Of the 3485 screened participants, 1961 were enrolled from a sample size of 1962. Enrollment concluded in August 2016. Follow-up interviews of study participants, including data extraction from the children’s vaccination cards, data extraction from the health facility immunization registers, completion of the health facility record review forms, and focus group discussions were completed by December 2017. The results are expected to be released in 2021.

Conclusions

Prompting health-seeking behavior with reminders has been shown to improve health intervention uptake. Mobile phone ownership continues to grow in Uganda, so their use in vaccination interventions such as this study is logical and should be evaluated with scientifically rigorous study designs.

Trial Registration

ClinicalTrials.gov NCT04177485; https://clinicaltrials.gov/ct2/show/NCT04177485

International Registered Report Identifier (IRRID)

DERR1-10.2196/17262

Effectiveness of a mobile antiretroviral pharmacy and HIV care intervention on the continuum of HIV care in rural Uganda

Adherence to antiretroviral therapy (ART) is critical in order to achieve viral suppression. We designed an intervention, Mobile Antiretroviral Therapy and HIV care (MAP-HC) in rural southwestern Uganda aimed to reduce travel distance and hypothesized that MAP-HC would improve ART adherence and rates of viral load suppression. The study was conducted at two district hospitals, among patients who lived >5 km from the hospital. For each hospital, we identified 4 health centers in the catchment area to serve as site for the mobile pharmacy. Each site was visited once a month to provide ART refills and adherence counseling. We measured patient waiting time, adherence and viral load suppression before and after the intervention. The proportion of patients who missed an ART dose in the last 30 days dropped from 20% to 8.5% at 12 months post-intervention (p = 0.009) and those with detectable viral load dropped from 19.9% to 7.4% (p = 0.001), however, mean waiting time increased from 4.48 to 4.76 h (p = 0.13). Mobile pharmacy intervention in rural Uganda is feasible and resulted in improvement in adherence and viral load suppression. Although it did not reduce patient waiting time at the clinic, we recommend scale-up in rural areas where patients face transportation challenges.

Building health workforce capacity for planning and monitoring through the Strengthening Technical Assistance for routine immunization training (START) approach in Uganda

INTRODUCTION

The Global Vaccine Action Plan identifies workforce capacity building as a key strategy to achieve strong immunization programs. The Strengthening Technical Assistance for Routine Immunization Training (START) approach aimed to utilize practical training methods to build capacity of district and health center staff to implement routine immunization (RI) planning and monitoring activities, as well as build supportive supervision skills of district staff.

METHODS

First implemented in Uganda, the START approach was executed by trained external consultants who used existing tools, resources, and experiences to mentor district-level counterparts and, with them, conducted on-the-job training and mentorship of health center staff over several site visits. Implementation was routinely monitored using daily activity reports, pre and post surveys of resources and systems at districts and health centers and interviews with START consultants.

RESULTS

From July 2013 through December 2014 three START teams of four consultants per team, worked 6 months each across 50 districts in Uganda including the five divisions of Kampala district (45% of all districts). They conducted on-the-job training in 444 selected under-performing health centers, with a median of two visits to each (range 1-7, IQR: 1-3). More than half of these visits were conducted in collaboration with the district immunization officer, providing the opportunity for mentorship of district immunization officers. Changes in staff motivation and awareness of challenges; availability and completion of RI planning and monitoring tools and systems were observed. However, the START consultants felt that potential durability of these changes may be limited by contextual factors, including external accountability, availability of resources, and individual staff attitude.

CONCLUSIONS

Mentoring and on-the-job training offer promising alternatives to traditional classroom training and audit-focused supervision for building health workforce capacity. Further evidence regarding comparative effectiveness of these strategies and durability of observed positive change is needed.

Comparison of PCR Methods for Onchocerca volvulus Detection in Skin Snip Biopsies from the Tshopo Province, Democratic Republic of the Congo

Defining the optimal diagnostic tools for evaluating onchocerciasis elimination efforts in areas co-endemic for other filarial nematodes is imperative. This study compared three published polymerase chain reaction (PCR) methods: the Onchocerca volvulus-specific qPCR-O150, the pan-filarial qPCR melt curve analysis (MCA), and the O150-PCR enzyme-linked immunosorbent assay (ELISA) currently used for vector surveillance in skin snip biopsies (skin snips) collected from the Democratic Republic of the Congo. The pan-filarial qPCR-MCA was compared with species-specific qPCRs for Loa loa and Mansonella perstans. Among the 471 skin snips, 47.5%, 43.5%, and 27.0% were O. volvulus positive by qPCR-O150, qPCR-MCA, and O150-PCR ELISA, respectively. Using qPCR-O150 as the comparator, the sensitivity and specificity of qPCR-MCA were 89.3% and 98.0%, respectively, whereas for O150-PCR ELISA, they were 56.7% and 100%, respectively. Although qPCR-MCA identified the presence of L. loa and Mansonella spp. in skin snips, species-specific qPCRs had greater sensitivity and were needed to identify M. perstans. Most of the qPCR-MCA misclassifications occurred in mixed infections. The reduced sensitivity of O150-PCR ELISA was associated with lower microfilaria burden and with lower amounts of O. volvulus DNA. Although qPCR-MCA identified most of the O. volvulus-positive skin snips, it is not sufficiently robust to be used for stop-mass drug administration (MDA) evaluations in areas co-endemic for other filariae. Because O150-PCR ELISA missed 43.3% of qPCR-O150-positive skin snips, the qPCR-O150 assay is more appropriate for evaluating skin snips of OV-16 + children in stop-MDA assessments. Although improving the sensitivity of the O150-PCR ELISA as an alternative to qPCR might be possible, qPCR-O150 offers distinct advantages aside from increased sensitivity.

Changes in prevalence of tobacco use and the factors that may affect use among Uganda youth: the Global Youth Tobacco Survey (GYTS) 2007-2011

INTRODUCTION

To assess changes from 2007 to 2011 in the prevalence of tobacco use and tobacco-related indicators in Uganda by examining results from the Global Youth Tobacco Survey (GYTS).

METHODS

Both the 2007 (n=2,251) and 2011 (n=2,026) Uganda GYTS were conducted among students in primary seven, secondary one, two, and three. A two-stage cluster sample design was used to generate a representative sample of students for the surveys. Stata 12 software was used to provide weighted prevalence estimates and logistic regression models were developed to examine the relationship between factors that influence tobacco use and current tobacco use.

RESULTS

The percentage of students who had ever smoked a cigarette, even just one or two puffs, declined from 15.6% in 2007 to 10.9% in 2011 (p=0.03). From 2007 to 2011, neither the percentage of current use of any tobacco (16.6% to 17.3%, p=0.75), nor the percentage of current (past 30 day) cigarette smoking (5.5% to 4.8%,p=0.59) changed significantly. Following adjustment, having parents [Adjusted Odds Ratio (AOR):1.9, 95% Confidence Interval (CI):1.3-2.8] and friends [AOR 2.5, 95% CI: 1.5-4.0)] who smoke, and having seen tobacco advertisements in print media [AOR 1.8(1.3-2.4)], were associated with greater odds of current tobacco use among students in 2007.Having parents who smoke [AOR;1.8, 95% CI: 1.1-3.0] was associated with greater odds of current tobacco use among students in 2011.

CONCLUSION

From 2007 to 2011, no significant change occurred in the prevalence of current tobacco use or cigarette smoking among youth in Uganda. These findings underscore the importance of implementing effective population-level public health interventions, as outlined in the articles of the World Health Organization's Framework Convention on Tobacco Control, to prevent and reduce the use of tobacco among youth in Uganda.

Routines, Hope, and Antiretroviral Treatment among Men and Women in Uganda

Antiretroviral treatment programs, despite biomedical emphases, require social understanding and transformations to be successful. In this article, we draw from a qualitative study of HIV treatment seeking to examine the drug-taking routines and health-related subjectivities of men and women on antiretroviral treatment (ART) at two sites in Uganda. We show that while not all participants in ART programs understand clinical protocols in biomedical terms, they adopt treatment-taking strategies to integrate medication into daily practices and social spaces. In turn, these embedded practices and understandings shape long-term hopes and fears for living with HIV, including the possibility of a cure. More significant than new forms of citizenship or sociality, we suggest that quotidian dimensions of treatment normalization shape the long-term experience of medication and outlook for the future.

Early HIV disclosure and nondisclosure among men and women on antiretroviral treatment in Uganda

Efforts to expand access to HIV care and treatment often stress the importance of disclosure of HIV status to aid adherence, social support, and continued resource mobilization. We argue that an examination of disclosure processes early in the process of seeking testing and treatment can illuminate individual decisions and motivations, offering insight into potentially improving engagement in care and adherence. We report on baseline data of early HIV disclosure and nondisclosure, including reasons for and responses to disclosure from a cohort of men and women (n=949) currently accessing antiretroviral treatment in two regions of Uganda. We found early disclosures at the time of suspicion or testing positive for HIV by men and women to be largely for the purposes of emotional support and friendship. Responses to these selected disclosures were overwhelmingly positive and supportive, including assistance in accessing treatment. Nonetheless, some negative responses of worry, fear, or social ostracism did occur. Individuals deliberately chose to not disclose their status to partners, relatives, and others in their network, for reasons of privacy or not wanting to cause worry from the other person. These data demonstrate the strategic choices that individuals make early in the course of suspicion, testing, and treatment for HIV to mobilize resources and gain emotional or material support, and similarly their decisions and ability to maintain privacy regarding their status.

Improving influenza surveillance in sub-Saharan Africa

PROBLEM

Little is known about the burden of influenza in sub-Saharan Africa. Routine influenza surveillance is key to getting a better understanding of the impact of acute respiratory infections on sub-Saharan African populations.

APPROACH

A project known as Strengthening Influenza Sentinel Surveillance in Africa (SISA) was launched in Angola, Cameroon, Ghana, Nigeria, Rwanda, Senegal, Sierra Leone and Zambia to help improve influenza sentinel surveillance, including both epidemiological and virological data collection, and to develop routine national, regional and international reporting mechanisms. These countries received technical support through remote supervision and onsite visits. Consultants worked closely with health ministries, the World Health Organization, national influenza laboratories and other stakeholders involved in influenza surveillance.

LOCAL SETTING

Influenza surveillance systems in the target countries were in different stages of development when SISA was launched. Senegal, for instance, had conducted virological surveillance for years, whereas Sierra Leone had no surveillance activity at all.

RELEVANT CHANGES

Working documents such as national surveillance protocols and procedures were developed or updated and training for sentinel site staff and data managers was organized.

LESSONS LEARNT

Targeted support to countries can help them strengthen national influenza surveillance, but long-term sustainability can only be achieved with external funding and strong national government leadership.

Two decades of post-graduate training in applied public health: the experience and challenges of the Uganda Public Health School Without Walls

The objective of this work is to describe the experience of the Uganda Public Health School Without Walls (PHSWOW) in training public health professionals at post-graduate level to offer leadership in planning, delivery of health services and research within a decentralized health system. As one of the constituents of the Makerere University College of Health Sciences, the Uganda PHSWOW has the vision of becoming a Centre of Excellence, providing leadership in public health and the mission of promoting the attainment of better health of the people in Uganda and beyond through public health training, research and community service. Key to the successes of the program are the 238 program graduates, most of whom have remained in-country to serve at district and national levels of service delivery. Collaborations have been established with government, private, non-governmental and international institutions leading to increased health service provision and research for the improvement of health status of populations and influence on public policy. There is still a lot to do in diversifying the skills mix of graduates and contributing to an ambitious increment from 0.4 to 4.7 public health professionals per 10,000 population; as is currently the case in high-middle income countries. Currently, the Uganda PHSWOW has exceeded the proposed output for FETPs of training 3 to 5 graduates per 1 million population suggested by some authors, however the output is still inadequate. More also needs to be done to promote a culture of publication in an effort to translate public health evidence into policy and practice.

The Rwanda Field Epidemiology and Laboratory Training Program: training skilled disease detectives

Rwanda still suffers from communicable diseases which frequently lead to epidemics. In addition to other health workforce needs, Rwanda also lacks a public health workforce that can operate multi-disease surveillance and response systems at the national and sub-national levels.In 2009 and 2010 the Rwanda Ministry of Health and its partners from the Government of Rwanda (GOR) as well as the United States (US) Centers for Disease Control and Prevention, the African Field Epidemiology Network, and other partners embarked on a series of activities to develop a public health workforce that would be trained to operate disease surveillance and response systems at the national and district levels. The Rwanda Field Epidemiology and Laboratory Training Program (RFELTP) is a 2-year public health leadership development training program that provides applied epidemiology and public health laboratory training while the trainees provide public health service to the Ministry of Health. RFELTP is hosted at the National University of Rwanda School of Public Health for the didactic training. RFELTP is funded by GOR, the US Presidents Emergency Plan for AIDS Relief and the World Bank; it is managed by a multi-sectoral steering committee headed by the Minister of Health. The first RFELTP cohort has 15 residents who were recruited from key health programs in GOR. Over the first year of implementation, these 15 residents have conducted a variety of field investigations and responded to several outbreaks. RFELTP has also trained 145 frontline health workers through its two-week applied short courses. In the future, RFELTP plans to develop a veterinary track to address public health issues at the animal-human interface.