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Background: The One Health approach is key in implementing International Health Regulations (IHR, 2005) and the Global Health Security Agenda (GHSA). Uganda is signatory to the IHR 2005 and in 2017, the country conducted a Joint External Evaluation (JEE) that guided development of the National Action Plan for Health Security (NAPHS) 2019-2023., Aim: This study assessed the contribution of the One Health approach to strengthening health security in Uganda., Methods: A process evaluation between 25th September and 5th October 2020, using a mixed-methods case study. Participants were Subject Matter Experts (SMEs) from government ministries, departments, agencies and implementing partners. Focus group discussions were conducted for five technical areas (workforce development, real-time surveillance, zoonotic diseases, national laboratory systems and emergency response operations), spanning 18 indicators and 96 activities. Funding and implementation status from the NAPHS launch in August 2019 to October 2020 was assessed with a One Health lens., Results: Full funding was available for 36.5% of activities while 40.6% were partially funded and 22.9% were not funded at all. Majority (65%) of the activities were still in progress, whereas 8.6% were fully implemented and14.2% were not yet done. In workforce development, several multisectoral trainings were conducted including the frontline public health fellowship program, the One Health fellowship and residency program, advanced field epidemiology training program, in-service veterinary trainings and 21 district One Health teams' trainings. Real Time Surveillance was achieved through incorporating animal health events reporting in the electronic integrated disease surveillance and response platform. The national and ten regional veterinary laboratories were assessed for capacity to conduct zoonotic disease diagnostics, two of which were integrated into the national specimen referral and transportation network. Multisectoral planning for emergency response and the actual response to prioritized zoonotic disease outbreaks was done jointly., Conclusions: This study demonstrates the contribution of 'One Health' implementation in strengthening Uganda's health security. Investment in the funding gaps will reinforce Uganda's health security to achieve the IHR 2005. Future studies could examine the impacts and cost-effectiveness of One Health in curbing prioritized zoonotic disease outbreaks., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction: Diseases addressed by surgical, obstetric, trauma and anaesthesia (SOTA) care are rising globally due to an anticipated rise in the burden of non-communicable diseases and road traffic accidents. Low- and middle-income countries (LMICs) disproportionately bear the brunt. Evidence-based policies and political commitment are required to reverse this trend. The Lancet Commission of Global Surgery proposed National Surgical and Obstetric and Anaesthesia Plans (NSOAPs) to alleviate the respective SOTA burdens in LMICs. NSOAPs success leverages comprehensive stakeholder engagement and appropriate health policy analyses and recommendations. As Uganda embarks on its NSOAP development, policy prioritisation in Uganda remains unexplored. We, therefore, seek to determine the priority given to SOTA care in Uganda's healthcare policy and systems-relevant documents., Methods and Analysis: We will conduct a scoping review of SOTA health policy and system-relevant documents produced between 2000 and 2022 using the Arksey and O'Malley methodological framework and additional guidance from the Joanna Briggs Institute Reviewer's manual. These documents will be sought from the websites of SOTA stakeholders by hand searching. We shall also search from Google Scholar and PubMed using well-defined search strategies. The Knowledge Management Portal for the Ugandan Ministry of Health, which was created to provide evidence-based decision-making data, is the primary source. The rest of the sources will include the following: other repositories like websites of relevant government institutions, international and national non-governmental organisations, professional associations and councils, and religious and medical bureaus. Data retrieved from the eligible policy and decision-making documents will include the year of publication, the global surgery specialty mentioned, the NSOAP surgical system domain, the national priority area involved and funding. The data will be collected in a preformed extraction sheet. Two independent reviewers will screen the collected data, and results will be presented as counts and their respective proportions. The findings will be reported narratively using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews., Ethics and Dissemination: This study will generate evidence-based information on the state of SOTA care in Uganda's health policy, which will inform NSOAP development in this nation. The review's findings will be presented to the Ministry of Health planning task force. The study will also be disseminated through a peer-reviewed publication; oral and poster presentations at local, regional, national and international conferences and over social media., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Despite the discovery of vaccines, the control, and prevention of Coronavirus disease 2019 (COVID-19) relied on non-pharmaceutical interventions (NPIs). This article describes the development and application of the Public Health Act to implement NPIs for COVID-19 pandemic control in Uganda., Methods: This is a case study of Uganda's experience with enacting COVID-19 Rules under the Public Health Act Cap. 281. The study assessed how and what Rules were developed, their influence on the outbreak progress, and litigation. The data sources reviewed were applicable laws and policies, Presidential speeches, Cabinet resolutions, statutory instruments, COVID-19 situation reports, and the registry of court cases that contributed to a triangulated analysis., Results: Uganda applied four COVID-19 broad Rules for the period March 2020 to October 2021. The Minister of Health enacted the Rules, which response teams, enforcement agencies, and the general population followed. The Presidential speeches, their expiry period and progress of the pandemic curve led to amendment of the Rules twenty one (21) times. The Uganda Peoples Defense Forces Act No. 7 of 2005, the Public Finance Management Act No. 3 of 2015, and the National Policy for Disaster Preparedness and Management supplemented the enacted COVID-19 Rules. However, these Rules attracted specific litigation due to perceived infringement on certain human rights provisions., Conclusions: Countries can enact supportive legislation within the course of an outbreak. The balance of enforcing public health interventions and human rights infringements is an important consideration in future. We recommend public sensitization about legislative provisions and reforms to guide public health responses in future outbreaks or pandemics., (© 2023. The Author(s).)

Background: A large proportion of postgraduate students the world over complete a research thesis in partial fulfilment of their degree requirements. This study identified and evaluated support mechanisms for research generation and utilization for masters' students in health institutions of higher learning in Uganda., Methods: This was a self-administered cross-sectional survey using a modified self-assessment tool for research institutes (m-SATORI). Postgraduate students were randomly selected from four medical or public health Ugandan universities at Makerere, Mbarara, Nkozi and Mukono and asked to circle the most appropriate response on a Likert scale from 1, where the "situation was unfavourable and/or there was a need for an intervention", to 5, where the "situation was good or needed no intervention". These questions were asked under four domains: the research question; knowledge production, knowledge transfer and promoting use of evidence. Mean scores of individual questions and aggregate means under the four domains were computed and then compared to identify areas of strengths and gaps that required action., Results: Most of the respondents returned their questionnaires, 185 of 258 (71.7%), and only 79 of these (42.7%) had their theses submitted for examination. The majority of the respondents were male (57.3%), married or cohabiting (58.4%), and were medical doctors (71.9%) from Makerere University (50.3%). The domain proposal development for postgraduate research project had the highest mean score of 3.53 out of the maximum 5. Three of the four domains scored below the mid-level domain score of 3, that is, the situation is neither favourable nor unfavourable. Areas requiring substantial improvements included priority-setting during research question identification, which had the lowest mean score of 2.12. This was followed by promoting use of postgraduate research products, tying at mean scores of 2.28 each. The domain knowledge transfer of postgraduate research products had an above-average mean score of 2.75., Conclusions: This study reports that existing research support mechanisms for postgraduate students in Uganda encourage access to supervisors and mentors during proposal development. Postgraduate students' engagement with research users was limited in priority-setting and knowledge transfer. Since supervisors and mentors views were not captured, future follow-on research could tackle this aspect., (© 2021. The Author(s).)

Background: While several individual studies addressing research productivity of post-graduate students are available, a synthesis of effective strategies to increase productivity and the determinants of productivity in low-income countries has not been undertaken. Further, whether or not this research from post-graduate students' projects was applied in evidence-informed decision-making was unknown. Therefore, we conducted a systematic review of literature to identify and assess the effectiveness of approaches that increase productivity (proportion published) or the application (proportion cited) of post-graduate students' research, as well as to assess the determinants of post-graduate students' research productivity and use., Methods: We conducted a systematic review as per our a priori published protocol, also registered in PROSPERO (CRD42016042819). We searched for published articles in PubMed/MEDLINE and the ERIC databases through to July 2017. We performed duplicate assessments for included primary studies and resolved discrepancies by consensus. Thereafter, we completed a structured narrative synthesis and, for a subset of studies, we performed a meta-analysis of the findings using both fixed and random effects approaches. We aligned our results to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement., Results: We found 5080 articles in the PubMed (n = 3848) and ERIC (n = 1232) databases. After excluding duplicates (n = 33), we screened 5047 articles, of which 5012 were excluded. We then retrieved 44 full texts and synthesised 14, of which 4 had a high risk of bias. We did not find any studies assessing effectiveness of strategies for increasing publication nor citations of post-graduate research projects. We found an average publication proportion of 7% (95% CI 7-8%, Higgins I-squared 0.0% and Cochran's Q p < 0.01) and 23% (95% CI 17-29%, Higgins I-squared of 98.4% and Cochran's Q, p < 0.01) using fixed effects and random effects models, respectively. Two studies reported on the citation of post-graduate students' studies, at 17% (95% CI 15-19%) in Uganda and a median citation of 1 study in Turkey (IQR 0.6-2.3). Only one included study reported on the determinants of productivity or use of post-graduate students' research, suggesting that younger students were more likely to publish and cohort studies were more likely to be published., Conclusions: We report on the low productivity of post-graduate students' research in low- and middle-income countries, including the citation of post-graduate students' research in evidence-informed health policy in low- and middle-income countries. Secondly, we did not find a single study that assessed strategies to increase productivity and use of post-graduate students' research in evidence-informed health policy, a subject for future research.

Background: Research is a core business of universities globally, and is crucial in the scientific process as a precursor for knowledge uptake and use. We aimed to assess the academic productivity of post-graduate students in a university located in a low-income country., Methods: This is an observational retrospective documentary analysis using hand searching archives, Google Scholar and PubMed electronic databases. The setting is Makerere University College of Health Sciences, Uganda. Records of post-graduate students (Masters) enrolled from 1996 to 2010, and followed to 2016 for outcomes were analysed. The outcome measures were publications (primary), citations, electronic dissertations found online or conference abstracts (secondary). Descriptive and multivariable logistic regression analyses were performed using Stata 14.1., Results: We found dissertations of 1172 Masters students over the 20-year period of study. While half (590, 50%) had completed clinical graduate disciplines (surgery, internal medicine, paediatrics, obstetrics and gynaecology), Master of Public Health was the single most popular course, with 393 students (31%). Manuscripts from 209 dissertations (18%; 95% CI, 16-20%) were published and approximately the same proportion was cited (196, 17%; 95% CI, 15-19%). Very few (4%) policy-related documents (technical reports and guidelines) cited these dissertations. Variables that remained statistically significant in the multivariable model were students' age at enrolment into the Masters programme (adjusted coefficient -0.12; 95% CI, -0.18 to -0.06; P < 0.001) and type of research design (adjusted coefficient 0.22; 0.03 to 0.40; P = 0.024). Cohort studies were more likely to be published compared to cross-sectional designs (adjusted coefficient 0.78; 95% CI, 0.2 to 1.36; P = 0.008)., Conclusions: The productivity and use of post-graduate students' research conducted at the College of Health Sciences Makerere University is considerably low in terms of peer-reviewed publications and citations in policy-related documents. The need for effective strategies to reverse this 'waste' is urgent if the College, decision-makers, funders and the Ugandan public are to enjoy the 'return on investment' from post-graduate students research.

Background: WHO recommends regular viral load (VL) monitoring of patients on antiretroviral therapy (ART) for timely detection of virological failure, prevention of acquired HIV drug resistance (HIVDR) and avoiding unnecessary switching to second-line ART. However, the cost and complexity of routine VL testing remains prohibitive in most resource limited settings (RLS). We evaluated a simple, low-cost, qualitative viral-failure assay (VFA) on dried blood spots (DBS) in three clinical settings in Uganda., Methods: We conducted a cross-sectional diagnostic accuracy study in three HIV/AIDS treatment centres at the Joint Clinical Research Centre in Uganda. The VFA employs semi-quantitative detection of HIV-1 RNA amplified from the LTR gene. We used paired dry blood spot (DBS) and plasma with the COBASAmpliPrep/COBASTaqMan, Roche version 2 (VLref) as the reference assay. We used the VFA at two thresholds of viral load, (>5,000 or >1,000 copies/ml)., Results: 496 paired VFA and VLref results were available for comparative analysis. Overall, VFA demonstrated 78.4% sensitivity, (95% CI: 69.7%-87.1%), 93% specificity (95% CI: 89.7%-96.4%), 89.3% accuracy (95% CI: 85%-92%) and an agreement kappa = 0.72 as compared to the VLref. The predictive values of positivity and negativity among patients on ART for >12 months were 72.7% and 99.3%, respectively., Conclusions: VFA allowed 89% of correct classification of VF. Only 11% of the patients were misclassified with the potential of unnecessary or late switch to second-line ART. Our findings present an opportunity to roll out simple and affordable VL monitoring for HIV-1 treatment in RLS.

Background: Despite 10 to% of persons living with HIV in sub-Saharan Africa having clinical depression, and the consequences of depression for key public health outcomes (HIV treatment adherence and condom use), depression treatment is rarely integrated into HIV care programs. Task-shifting, protocolized approaches to depression care have been used to overcome severe shortages of mental health specialists in developing countries, but not in sub-Saharan Africa and not with HIV clients. The aims of this trial are to evaluate the implementation outcomes and cost-effectiveness of a task-shifting, protocolized model of antidepressant care for HIV clinics in Uganda., Methods/design: INDEPTH-Uganda is a cluster randomized controlled trial that compares two task-shifting models of depression care--a protocolized model versus a model that relies on the clinical acumen of trained providers to provide depression care in ten public health HIV clinics in Uganda. In addition to data abstracted from routine data collection mechanisms and supervision logs, survey data will be collected from patient and provider longitudinal cohorts; at each site, a random sample of 150 medically stable patients who are depressed according to the PHQ-2 screening will be followed for 12 months, and providers involved in depression care implementation will be followed over 24 months. These data will be used to assess whether the two models differ on implementation outcomes (proportion screened, diagnosed, treated; provider fidelity to model of care), provider adoption of treatment care knowledge and practices, and depression alleviation. A cost-effectiveness analysis will be conducted to compare the relative use of resources by each model., Discussion: If effective and resource-efficient, the task-shifting, protocolized model will provide an approach to building the capacity for sustainable integration of depression treatment in HIV care settings across sub-Saharan Africa and improving key public health outcomes., Trial Registration: INDEPTH-Uganda has been registered with the National Institutes of Health sponsored clinical trials registry (3 February 2013) and has been assigned the identifier NCT02056106.

Objective: Clinical and immunological data about HIV in older adults from low and middle income countries is scarce. We aimed to describe differences between younger and older adults with HIV starting antiretroviral therapy in two low-income African countries., Setting: HIV clinics in Uganda and Zimbabwe., Design: Secondary exploratory cross-sectional analysis of the DART randomized controlled trial., Outcome Measures: Clinical and laboratory characteristics were compared between adults aged 18-49 years (younger) and ≥ 50 years (older), using two exploratory multivariable logistic regression models, one with HIV viral load (measured in a subset pre-ART) and one without., Results: A total of 3316 eligible participants enrolled in DART were available for analysis; 219 (7%) were ≥ 50 years and 1160 (35%) were male. Across the two adjusted regression models, older adults had significantly higher systolic blood pressure, lower creatinine clearance and were consistently less likely to be females compared to younger adults with HIV. Paradoxically, the models separately suggested that older adults had statistically significant (but not clinically important) higher CD4+ cell counts and higher plasma HIV-1 viral copies at initiation. Crude associations between older age and higher baseline hemoglobin, body mass index, diastolic blood pressure and lower WHO clinical stage were not sustained in the adjusted analysis., Conclusions: Our study found clinical and immunological differences between younger and older adults, in a cohort of Africans starting antiretroviral therapy. Further investigations should explore how these differences could be used to ensure equity in service delivery and affect outcomes of antiretroviral therapy.

Objective: The HIV/AIDS epidemic has evolved with an increasing burden in older adults. We assessed for knowledge about aging and HIV/AIDS, among clinicians in Kampala district, Uganda., Methods: A cross-sectional survey of 301 clinicians complemented by 9 key-informant interviews between May and October 2011. Data was analyzed by multivariable logistic regression for potential determinants of clinician knowledge about HIV/AIDS in older adults, estimating their adjusted Odds Ratios (aOR) and 95% confidence intervals (95% CI) using Stata 11.2 software., Results: Two-hundred and sixty-two questionnaires (87.7%) were returned. Respondents had a median age of 30 years (IQR 27-34) and 57.8% were general medical doctors. The mean knowledge score was 49% (range 8.8%-79.4%). Questions related to co-morbidities in HIV/AIDS (non-AIDS related cancers and systemic diseases) and chronic antiretroviral treatment toxicities (metabolic disorders) accounted for significantly lower scores (mean, 41.7%, 95% CI: 39.3%-44%) compared to HIV/AIDS epidemiology and prevention (mean, 65.7%, 95% CI: 63.7%-67.7%). Determinants of clinician knowledge in the multivariable analysis included (category, aOR, 95% CI): clinician age (30-39 years; 3.28∶1.65-9.75), number of persons with HIV/AIDS seen in the past year (less than 50; 0.34∶0.14-0.86) and clinical profession (clinical nurse practitioner; 0.31∶0.11-0.83). Having diploma level education had a marginal association with lower knowledge about HIV and aging (p = 0.09)., Conclusion: Our study identified gaps and determinants of knowledge about HIV/AIDS in older adults among clinicians in Kampala district, Uganda. Clinicians in low and middle income countries could benefit from targeted training in chronic care for older adults with HIV/AIDS and long-term complications of antiretroviral treatment.

Depressive disorders are highly prevalent in Africa where diseases such as HIV/AIDS are common. The aim of this study was to assess the validity of commonly used depression screening instruments in a setting characterized by low literacy, where patients may not be able to self-administer depression scales. We explored the validity of the Patient Health Questionaire-9 (PHQ-9), Centre for Epidemiological Surveys for Depression (CES-D), and the Kessler-10 (K-10), using the Mini International Neuropsychiatric Instrument (MINI) as a gold standard in 368 persons living with HIV/AIDS (PLWHA) in Uganda. The shorter versions of the K-10 and PHQ-9 were extracted to assess their performance in comparison to the longer versions. We used STATA 11.2 to analyze the data. The prevalence of a MINI defined depression in this patient sample was 17.4%. The three instruments all performed well, with areas under the curve (AUC) ranging from 0.82 to 0.96. The PHQ-9 showed the best performance characteristics with an AUC of 0.96, a sensitivity of 91.6%, and specificity 81.2%. The extracted versions performed more modestly. All three instruments showed good properties as screening tools; the PHQ-9 has particularly high sensitivity and specificity, and so can be considered useful for screening HIV-positive patients for depression.

Background: Knowledge of tuberculosis has been shown to influence health seeking behaviour; and urban slum dwellers are at a higher risk of acquiring tuberculosis than the general population. The study aim was to assess knowledge of tuberculosis and identify the associated socio-demographic determinants, in order to inform tailored interventions for advocacy, communication and social mobilisation in three urban-slum communities of Uganda., Methods: A cross-sectional survey of 1361 adults between April and October 2011. Data was analyzed by descriptive statistics. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) of potential determinants of tuberculosis (TB) knowledge were estimated by multivariable ordinal logistic regression using Stata 11.2 software., Results: We found low knowledge of TB cause (26.7%); symptoms (46.8%), transmission (54.3%), prevention (34%) and free treatment (35%). Knowledge about TB treatment (69.4) and cure (85.1) was relatively high. Independent determinants of poor knowledge of TB in the multivariable analysis included (aOR, 95% CI) lack of formal education (0.56; 0.38 - 0.83, P = 0.004), unemployment (0.67; 0.49 - 0.90, P = 0.010) and never testing for HIV (0.69; 0.51 - 0.92, P < 0.012). Whilst, older age (1.73; 1.30 - 2.29, P < 0.001) and residing in Lira (2.02; 1.50 - 2.72, P < 0.001) were independent determinants of higher knowledge of TB., Conclusion: This study revealed deficiencies in the public health knowledge about TB symptoms, diagnosis and treatment among urban-slum dwellers in Uganda. Tuberculosis control programmes in similar settings should consider innovative strategies for TB education, advocacy, communication and social mobilisation to reach the youth, unemployed and less-educated; as well as those who have never tested for HIV.