Dementia assessment and diagnostic practices of healthcare workers in rural southwestern Uganda: a cross-sectional qualitative study

doi:10.21203/rs.2.12551/v1

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Dementia assessment and diagnostic practices of healthcare workers in rural southwestern Uganda: a cross-sectional qualitative study

https://doi.org/10.21203/rs.2.12551/v1

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Background

An estimated 50 million people worldwide have Alzheimer’s disease and related dementias (ADRD), and this number is projected to increase with the growth of the aging population, with the largest growth occurring in low and middle-income countries. Diagnostic coverage for dementia is estimated to be only 5-10% in low- and middle-income countries. Timely diagnosis of ADRD could prompt early access to information, medical treatments, and support for caregivers. The aim of this study was to assess how healthcare workers in rural southwestern Uganda assess for and diagnose ADRD.

Methods

We used in-depth interviews to investigate the medical knowledge and clinical practices surrounding ADRD diagnoses in healthcare workers working at mid-tier health facilities in southwestern Uganda. Qualitative content analysis was used to identify distinct categories and themes.

Results

In our sample, healthcare workers without specific mental health training assessed and diagnosed dementia based on history and physical examination alone. On the other hand, healthcare workers with some specialized training in mental health were more likely to use neuropsychological tests, blood tests, urine tests, and brain imaging in the diagnosis of dementia. Collateral history from caregivers was noted to be very important in proper assessment and diagnosis of dementia among all categories of healthcare workers. The majority of healthcare workers regarded memory loss as part of the normal aging process and reported that it does not need any specific treatment. Other healthcare workers could recognize signs and symptoms of dementia, but focused on managing other medical problems at the expense of assessing cognitive decline and mental health. Diagnostic practices did not differ based on age, years of experience, or gender of the healthcare workers.

Conclusion

These results indicate that specialized training in mental health among healthcare workers is crucial for the assessment and diagnosis of ADRD in rural southwestern Uganda.

Health Policy

Dementia

Uganda

Assessment

Diagnosis

Healthcare workers

Rural

Alzheimer’s disease and related dementias (ADRD) affect approximately 50 million people worldwide, and this number is currently increasing due to the growth of the aging population, with the global prevalence expected to reach 152 million by 2050 [1]. Most of this increase is projected to occur in low- and middle-income countries (LMIC) [1–3]. Over 58% of people with ADRD currently live in LMIC including Sub-Saharan Africa, where more than 1.69 million people are estimated to be living with dementia [4]. ADRD is the most important independent cause of disability among the elderly in LMIC [5].

Despite availability of numerous dementia diagnostic tools, 62% cases of ADRD worldwide are undiagnosed, while 91% are diagnosed very late [3, 6–8]. Missed or delayed diagnosis magnifies the socioeconomic burden on families and healthcare systems through heavy expenditures on unnecessary investigations, treatments driven by vague symptoms, and lack of counseling of family and caregivers [7, 9–12]. Early diagnosis could prompt early evaluation for reversible dementia syndromes as well as timely access to information, medical treatment, advice and support for caregivers, and targeted community interventions from the time of diagnosis to end of life [10, 13, 14].

Consensus guidelines on the assessment for ADRD includes medical history, physical examination, laboratory tests, cognitive assessment, and brain imaging [15]. Prior case reports have described the assessment and diagnosis of ADRD in sub-Saharan Africa and Uganda [16–18], but little is known about broader trends in dementia assessment and treatment in rural primary care settings in Uganda. The aim of the study was to assess how healthcare workers in health facilities in rural southwestern Uganda assess for and diagnose ADRD.

Study design

This was a cross-sectional qualitative study that used individual in-depth interviews to investigate how healthcare workers in health facilities in rural southwestern Uganda assess for and diagnose ADRD.

Study setting

The study was conducted in the districts of Kabale, Rukungiri, and Mbarara, which are rural regions southwest of the capital city Kampala, Uganda. The districts were purposively selected based on the number of health facilities per district to ensure that the required sample size was achieved. Kabale district had the highest number of healthcare facilities (n=139), followed by Rukungiri (n=88), and Mbarara (n=58) [19].

In Uganda, dementia is regarded as a mental health condition. Provision of mental health services begin at health center III (HC III) which is sub-county level, with subsequent referrals to HC IV at the county level, district hospitals, regional referral hospitals, and finally to Butabika Hospital, the national referral hospital [20–22]. At HC IV level and above, medical facilities are expected to have general doctors (medical officers), clinical officers (diploma level medical assistants), nurses, midwives, and specialized mental health workers (psychiatric nurses, psychiatric clinical officers, and psychiatrists). The HC IIIs do not have general doctors or mental health specialists but have all the other cadres of healthcare providers. In our study, assessments were performed at mid-tier medical facilities: HCs III, HCs IV, general hospitals, and regional referral hospitals.

Study population and sampling

The study participants included nurses, clinical officers, medical doctors and mental health specialists directly involved with assessment of patients in the participating health centers regardless of gender, age, and seniority. From each district, we purposively selected participants from one hospital, 2 HC IVs, and 2 HC IIIs based on their active involvement in patient assessment. Representation from the different categories of healthcare workers was a key consideration in the selection of participants in order to understand how different categories of healthcare workers assess and diagnose dementia.

We recruited participants until saturation was reached and there was no new information from each category of health workers. Saturation was reached at seven for medical officers, at 12 for clinical officers, at 15 for nurses, and at 8 for specialized mental health workers. Overall a total of 42 healthcare workers participated in the study. For the purposes of analysis in this study, a specialized mental health worker was defined as anyone with special training in mental health including a psychiatric nurse, psychiatric clinical officers, psychiatrist, or any other medical professional with extra training in mental health conditions.

Data collection tools

Data collection was done through in-depth face to face interviews with 42 participants using open-ended questions in line with the study objectives. An interview guide (Table 1) was developed by RK together with GZR and SB to assess basic care knowledge and practice expected from a general healthcare worker in a rural setting. The questions in the interview guide were based on literature and the republic of Uganda Ministry of Health Uganda Clinical Guidelines manual [21].

Table 1: Interview Guide

Biographic data: Job title, level of training, Gender, Age, Number of years in post

Approximately how many elderly people, around 60 years and older do you see at this health center per day?

What have you observed about the behavior of your elderly patients? (Probe for difficulty remembering history, “odd” behavior, poor hygiene, inappropriately dressed for the weather.)

How comfortable are you in assessing elderly patients suspected to have dementia? (Probe for how they asses memory loss, difficulty performing familiar tasks, problems with language, disorientation to time and place, poor or decreased judgment, problems with abstract thinking, misplacing things, changes in mood or behavior, changes in personality, loss of initiative.)

Please tell me about the kind of tools used to assess for dementia here at your health facility? (Probe for whether they perform a cognitive examination or neurological examination, and whether they use the MOCA, MMSE, or other standardized assessment tool.)

Tell me about any training you have received about assessing for dementia? (Probe for what sorts of training would they want to get, if they wanted more training for dementia.)

Do you commonly recommend any diagnostic tests for someone suspected of having dementia? (Probe for whether they recommend lumbar puncture; blood work such as HIV, RPR, B12, CBC, LFTs; depression screening; neuroimaging.)

If a patient is suspected of having dementia, do you commonly tell them their diagnosis? Do you tell their family or caregiver the diagnosis?(Probe for whether they integrate family members; prepare anything for disclores meeting; consider the patient’s perspective or prepare for the patient’s or family’s reaction to the diagnosis)

Table 1 Legend: The Interview guide used to get in-depth insight in how health workers assessed and diagnosed dementia is shown. Semi-structured open-ended questions are designated in brackets. MOCA=Montreal-Cognitive Assessment; MMSE=Mini Mental State Examination; HIV=Human Immunodeficience Virus; RPR=Rapid Plasma Reagin; B12=Vitamin B12; CBC=Cell Blood Count; LFTs=Liver Function Tests

Data collection procedure

In-depth interviews were conducted by the lead author and three trained research assistants between January and February 2019. Each interview was conducted until there was no new information generated. Interviews lasted approximately 40 minutes. All interviews were conducted in English, the official national language. They were audio recorded and backed by field notes with participant’s consent. Two research teams were used to collect data concurrently. Each team of two researchers interviewed a maximum of three participants per day. One member conducted the interview while the other was recording the interview with an audio recorder and taking notes. The team members alternated roles with subsequent interviews.

Quality control

The lead author RK and research assistants were trained on study objectives, informed consent, ADRD epidemiology, and data collection procedures. Interview guides were pilot tested at a separate health facility for usability and clarity. There were feedback meetings at the end of each day of data collection to check for completeness of the data. GZR provided oversight during the feedback process and attended some of the interviews to ensure that interviews were conducted properly according to the study objectives.

Data management and analysis

Field data collected from interviews was immediately transcribed verbatim and cleaned by GN, and checked by the lead author RK against the audio recordings for correctness of information before proceeding to the next set of interviews. Processed data were then imported into Atlas.ti (qualitative analysis software for Windows) for coding and analysis. Data were thematically analyzed with Atlas.ti version 7. The coding process was done by RK in consultation with GN, SB, GZR, and CO. Different segments of coded data were retrieved and organized into broad themes which mirrored the study objectives. There was an iterative process during the coding to agree on which responses were relevant to the study objectives. Emerging patterns in the data were described with rich verbatim quotes from participants to illustrate the key issues in the themes. The computer-assisted analysis of data helped to ensure standardized and comparable analysis and interpretation of qualitative data across different levels of training and gender of participants.

Confidentiality was ensured by allocating non-identifiable field codes to each participant in addition to conducting the interviews in private space. We respected individual autonomy to participate in the study and did not include those who declined to participate. All who consented to participate were informed about their freedom to withdraw from the study at any time without any penalties.

The three broad themes emerged from the findings including (a) clinical assessment skills, (b) use of cognitive tests, and (c) use of diagnostic studies. Representative quotes have been included, followed in brackets by gender of participant, level of mental health training and district of the participants.

A total of 42 participants were interviewed; demographic characteristics are summarized in Table 2. Specialized mental health workers included two psychiatric clinical officers, three psychiatric nurses, one general clinical officer, one medical officer, and one general nurse.

Table 2: Summary of demographic characteristics

	Medical Officer	Clinical Officer		Nurse
Level of training	Bachelor of Medicine and Surgery	Diploma in general clinical medicine, Diploma in clinical psychiatry, or Short course in mental health		Diploma in nursing or Diploma in psychiatric nursing
Age range (years)	28-44	26-50		25-58
Years of experience	1-6	1-18		2-13
Gender Male Female	5 3	11 4	2 17
Special training in mental health	1	3		4

Table 2 Legend: Characteristics of participating health workers. A subset of participants in each training category had received specialized training in mental health.

Clinical assessment skills

Participant’s clinical assessment skills in the evaluation of dementia were probed with the question: “What do you do when you receive an elderly patient with the problem of memory loss?” All participants regardless of level of training, gender, and years of experience highlighted the importance of collateral history by caregivers in the assessment of elderly patients presenting with signs and symptoms of dementia.

“Majorly we always ask their (dementia patients’) attendants or care takers for information that can lead to meaningful diagnosis” (Male, Clinical officer, Mbarara District)

Specialized mental health workers reported that their prior training in mental health was crucial for the proper assessment and diagnosis of dementia.

“We used to be so green about them (signs and symptoms of dementia), but last year we had a training about assessing mental health patients and now we are somehow catching up. Actually, that time we never used to do (even) counseling. We could always say this category of people (elderly with dementia signs) is always like that. But now we got some light, now we even see it (dementia) as a condition.” (Female, General Nurse, Mbarara District)

“Me myself am comfortable (assessing elderly patients with signs of dementia) maybe because of my background. I never started as a medical officer. I was an educational therapist so I had worked in the psychiatric setting. But for others who don’t have training in that area (mental health), I think it is more of a challenge.” (Male Medical officer with prior training in mental health, Kabale district).

On the other hand, participants without specialized mental health training reported discomfort and uncertainty of their knowledge and skills in assessing a patient with signs of dementia.

“....to be honest, I don’t like such patients (patients with dementia). I have deficient knowledge of assessment and skills (for people with dementia) but I go on to assess (them) because it a job to do...” (Female Clinical officer, no specialized training in mental health, Rukungiri district)

Some participants without specialized mental health training perceived signs and symptoms of dementia as signs of a normal aging process, and stated that nothing could be done about it.

“… to be honest I usually don’t consider memory loss, in especially that age group you have talked about (the elderly), as something that is worrying. So, I tend to actually give more attention to the physical symptoms and signs that I can pick out because that one (memory loss), I know it’s part of the aging process.” (Female Medical officer, Rukungiri district)

“……No really because sometimes I take it for granted that it’s because of the age and I assume that I can’t help much because old age cannot be treated” (Male Clinical officer, Mbarara district)

Many healthcare workers without mental health training expressed the notion that they observe many elderly people with signs and symptoms of dementia but they feel unable to do anything. These participants reported that they either ignore the signs or look for and treat other comorbidities in these patients.

“I just overlook them (signs of dementia) because even I don’t know what to do with it (dementia)” (Female Clinical officer, no specialized training in mental health, Kabale district)

“……but truth is, we get many clients (elderly patients with signs of dementia) were if someone appreciated the mental state exam, I think he would actually help a number of clients. Because we get them but we always somehow look for other things to manage and not do a lot to address mental state issues even though we actually see that we have people in need.” (Male Medical officer, no specialized training in mental health, Mbarara district)

Differences in gender and years of experience did not have an effect on how participants assessed and diagnosed dementia.

Use of cognitive tests

To assess for which tools were being used by healthcare workers to assess for dementia, participants were asked this question: “which tools do you use when assessing patients suspected to have signs of dementia?”

Specialized mental health workers were more likely to use standardized assessment tools such as Mini Mental Status Exam (MMSE). Many healthcare workers without mental health training reported to have no special tools for assessing dementia in suspected patients apart from the general clinical assessment methods of history and physical examination. These findings held across participants regardless of the level of training, gender, and years of experience.

“I will not lie, we don’t (have any tool). At least if we do, I have never interfaced with it in this hospital. So basically, we do basic general assessments. We do not rely have a protocol well set out or established here that confirms or safe guidelines that we use to assess and determine this condition (dementia)” (Medical officer, no specialized training in mental health, Male, Mbarara district)

Other healthcare workers were aware that the MMSE tool existed but they felt inadequately skilled to apply it in assessing elderly people suspected to have dementia.

“You always don’t tend to think that we might benefit a lot from mental status exam or even then, the expertise to do a mental state exam is actually lacking very significantly.” (Male Medical officer, no specialized training in mental health, Mbarara district)

Apart from the MMSE, there was no other dementia assessment tool mentioned or known to any of the healthcare workers who participated in the study.

Use of diagnostic tests

The responses to the question: “What investigations or tests do you order for elderly patients suspected to have signs and symptoms of dementia?” varied according to level of training of healthcare workers. All of the specialized mental health workers and some of the other healthcare workers were able to mention relevant investigations to rule out other possible causes of dementia. The most common tests mentioned by the participants included tests for malaria, syphilis, human immunodeficiency virus, serum electrolytes, urinalysis, complete blood count, liver function tests, and renal function tests, vitamin B12, blood sugar, and neuroimaging techniques (magnetic resonance imaging and computerized tomography scan). Neuroimaging techniques were mentioned by medical officers and clinical officers, but were not mentioned by nurses. A number of healthcare workers explicitly stressed the idea that it is not necessary to make any investigations for anyone with signs and symptoms of dementia.

“If there is no other condition and I really feel its dementia, maybe it is just a knowledge gap but I don’t know any test. In me I don’t think any test will confirm dementia.” (Male Clinical officer, no specialized training in mental health, Mbarara).

This study investigated how healthcare workers assess for and diagnose ADRD in mid-tier healthcare facilities in southwestern Uganda. Medical history, collateral history, physical examination, and use of Mini Mental Examination (MMSE) screening tool were identified by participants as the basis for diagnosing dementia. There was a notable difference in the assessment and diagnosis of dementia between specialized mental health workers and the other healthcare workers. Participants with specialized training in mental health were more likely to use standardized assessment tools or neuropsychological tests such as MMSE. Some participants believed that memory loss is part of a normal aging process that does not need any treatment. Other healthcare workers could recognize signs and symptoms of ADRD but do not pursue further work up because they are not sure of further steps in diagnosis or management.

In our sample, only healthcare workers with specialized training felt comfortable in making a clinial diagnosis of ADRD using clinical interview, cognitive exam, and ancillary tests. Consensus guidelines recommend that clinical diagnosis of dementia follow established criteria and require a clinical history from the patient and informants, standardized neuropsychological test such as the MMSE, and assessment for reversible causes of dementia and comorbid conditions [3, 23]. Our findings therefore suggest that a significant population of ADRD patients in southwestern Uganda are likely to go undiagnosed due to the fact that there is a small percentage of a healthcare worker with mental health training who have the knowledge and skills to use neuropsychological tests to assess for dementia. This is in line with findings from other LMIC, with estimates showing that up to 62-90% of people with dementia in developing countries are likely to be undiagnosed [7, 24]. Further epidemiological studies measuring the prevalence and diagnostic coverage of dementia in Uganda are needed.

In our sample, most general trained healthcare workers held the view that memory loss is a part of a normal aging process with no effective interventions available. This knowledge gap is likely to lead to delayed and missed diagnosis of dementia and a lost opportunity to offer help and support to patients and caregivers. Specialized mental health workers were unlikely to hold this view, further demonstrating and underlining the importance of mental health training in dementia assessment and diagnosis care. Our observation fits with data worldwide showing that both the general public and healthcare workers often viewed memory loss as a normal part of the aging process [25–28]. Therefore, policymakers and planners seeking to improve early detection and diagnosis of ADRD should offer dementia-focused mental health training for healthcare workers which includes improved professional awareness and understanding of dementia in addition to specific training in clinical diagnostic criteria, cognitive assessment, and use of ancillary tests.

Study limitations

A limitation to this study is that we employed a qualitative study design using individual interviews with limited scope and sample size. Individual interviews are best suited to elicit experiences and beliefs, and qualitative content analysis allows investigators to gain in-depth understanding of the latent contents of conversations of informants [29, 30] . Consequently, we were unable to draw definitive empirical generalizations from these findings [31]. Instead, the data from the current study provides in-depth insights into the challenges of dementia assessment and diagnosis facing healthcare workers in rural southwestern Uganda. Furthermore, our data highlights opportunities for future epidemiological studies to quantify dementia burden in rural Uganda, and lays the foundation for future interventional research projects seeking to improve ADRD assessment and diagnosis in Uganda and other LMIC.

Training in mental health is very crucial for all healthcare workers in order to be able to recognize and respond appropriately to signs of dementia. Our findings point out key gaps in the knowledge and skills of healthcare workers in dementia assessment and diagnosis that should be targeted by future interventions aiming to improve assessment, diagnosis, and management of dementia by healthcare workers in southwestern Uganda and other resource-limited settings.

ADRD Alzheimer’s and Related Dementias

B12 Vitamin B 12

CBC Cell Blood Count

HC Health Center

HIV Human Immunodeficiency Virus

LFTs Liver Function Tests

LMIC Low and Middle Income countries

MADRI Mbarara Alzheimer’s Disease and Related Dementias Initiative

MMSE Mini Mental State Examination

MOCA Montreal-Cognitive Assessment

RPR Rapid Plasma Reagin

Acknowledgements

We wish to thank Prof. Elialilia Okello who contributed invaluable insight in proposal development and data analysis. We also acknowledge the District Health Officers and Health Center administrations in participating districts and all study participants for having made this research possible.

Funding statement

The work was supported by the Fogarty International Center and the National Institute on Aging of the National Institutes of Health [D43TW010128]. This work is part of the project titled Mbarara Alzheimer’s and Related Dementias Research Initiative [3D43TW010128-04S1]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Fogarty International.

Authors’ contributions

RK, CO, EW, SB, and GZR designed the study. GZR, RK and GN participated in data collection. All authors participated in data analysis and manuscript writing. All authors read and approved the final manuscript.

Author information

RK is a lecturer in the Department of Anatomy and a Trainee under the Mbarara Alzheimer’s and Related Dementias Research Initiative (MADRI) program (Grant Number D43TW010128: Celestino Obua).

GZR is a Clinical Psychiatrist and Senior Lecturer in the Department of Psychiatry and Key Person in MADRI program (Grant Number D43TW010128: Celestino Obua).

EW is a Research Administrator/Manager Office of Research Administration at Mbarara University of Science and Technology, and a Key Person on the MADRI program (Grant Number D43TW010128: Celestino Obua)

CO is a Senior Researcher, a Pharmacologist and Vice chancellor, Mbarara University of Science and Technology. He is the Principal Investigator Grant Number D43TW010128: Celestino Obua.

GN is a Graduate Nurse and Lecturer at Bishop Stuart University. She is a research assistant on the MADRI program (Grant Number D43TW010128: Celestino Obua)

Stephanie S. Buss, M.D., 330 Brookline Avenue KS KS258, Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. Telephone +1-617-667-7000 Email [email protected]. She is a mentor on the MADRI program (Grant Number D43TW010128: Celestino Obua)

Ethics approval and consent to participate

The study was approved by the Mbarara University of Science and Technology Research Ethics Committee (Ref.N0. MUREC 1/7) and the Uganda National Council for Science and Technology (Ref.No. HS2223). Relevant local governments and health center authorities gave administrative permission. Prior to data collection, written individual informed consent was obtained from the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflicts of interest regarding the publication of this article.

Data availability

The full dataset generated and analyzed during the current study are not publicly available in order to maintain the privacy of the individuals interviewed during this study. Deidentified data can be made available from the corresponding author on reasonable request.

WHO | Global action plan on the public health response to dementia 2017 - 2025. WHO. http://www.who.int/mental_health/neurology/dementia/action_plan_2017_2025/en/. Accessed 26 Jun 2019.
Prince M, Ali G-C, Guerchet M, Prina AM, Albanese E, Wu Y-T. Recent global trends in the prevalence and incidence of dementia, and survival with dementia. Alzheimers Res Ther. 2016;8:23.
World Alzheimer Report 2016 - Improving healthcare for people living with dementia: Coverage, quality and costs now and in the future. :140.
Mayeux R, Stern Y. Epidemiology of Alzheimer disease. Cold Spring Harb Perspect Med. 2012;2.
Sousa RM, Ferri CP, Acosta D, Albanese E, Guerra M, Huang Y, et al. Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: a 10/66 Dementia Research Group population-based survey. Lancet. 2009;374:1821–30.
Jitapunkul S, Kunanusont C, Phoolcharoen W, Suriyawongpaisal P. Prevalence estimation of dementia among Thai elderly: a national survey. J Med Assoc Thai. 2001;84:461–7.
Lang L, Clifford A, Wei L, Zhang D, Leung D, Augustine G, et al. Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis. BMJ Open. 2017;7:e011146.
Parmar J, Dobbs B, McKay R, Kirwan C, Cooper T, Marin A, et al. Diagnosis and management of dementia in primary care: exploratory study. Can Fam Physician. 2014;60:457–65.
Griffin-Pierce T, Silverberg N, Connor D, Jim M, Peters J, Kaszniak A, et al. Challenges to the recognition and assessment of Alzheimer’s disease in American Indians of the southwestern United States. Alzheimers Dement. 2008;4:291–9.
Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol. 2003;60:1119–22.
Knapp M, Iemmi V, Romeo R. Dementia care costs and outcomes: a systematic review. Int J Geriatr Psychiatry. 2013;28:551–61.
Robinson L, Tang E, Taylor J-P. Dementia: timely diagnosis and early intervention. BMJ. 2015;350:h3029.
Bradford A, Kunik ME, Schulz P, Williams SP, Singh H. Missed and delayed diagnosis of dementia in primary care: prevalence and contributing factors. Alzheimer Dis Assoc Disord. 2009;23:306–14.
Dubois B, Padovani A, Scheltens P, Rossi A, Dell’Agnello G. Timely Diagnosis for Alzheimer’s Disease: A Literature Review on Benefits and Challenges. J Alzheimers Dis. 2016;49:617–31.
McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR, Kawas CH, et al. The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7:263–9.
Namuli JD. A Case of Alzheimer’s Dementia in Uganda. In: Brain Degeneration and Dementia in Sub-Saharan Africa. New York: Springer-Verlag; 2015.
Akinyemi RO, Owolabi MO, Makanjuola VA, Ogunseyinde AO, Ogunniyi A. Frontotemporal dementia in a Nigerian woman: case report and brief review of the literature. Afr J Med Med Sci. 2009;38:71–5.
Ogunnyi A, Akang EEU, Gureje O, Takao M, Piccardo P, Baiyewu O, et al. Dementia with Lewy bodies in a Nigerian: a case report. Int Psychogeriatr. 2002;14:211–8.
Health Facilities Inventory July 2012 | Ministry of Health Knowledge Management Portal. http://library.health.go.ug/publications/health-facility-inventory/health-facilities-inventory-july-2012. Accessed 7 Jul 2019.
Nsereko JR, Kizza D, Kigozi F, Ssebunnya J, Ndyanabangi S, Flisher AJ, et al. Stakeholder’s perceptions of help-seeking behaviour among people with mental health problems in Uganda. Int J Ment Health Syst. 2011;5:5.
Uganda Clinical Guidelines 2016 | Ministry of Health. https://www.health.go.ug/content/uganda-clinical-guidelines-2016. Accessed 7 Jul 2019.
Wakida EK, Obua C, Rukundo GZ, Maling S, Talib ZM, Okello ES. Barriers and facilitators to the integration of mental health services into primary healthcare: a qualitative study among Ugandan primary care providers using the COM-B framework. BMC Health Serv Res. 2018;18:890.
Ngo J, Holroyd-Leduc JM. Systematic review of recent dementia practice guidelines. Age Ageing. 2015;44:25–33.
Dias A, Patel V. Closing the treatment gap for dementia in India. Indian J Psychiatry. 2009;51 Suppl 1:S93-97.
Patel V, Prince M. Ageing and mental health in a developing country: who cares? Qualitative studies from Goa, India. Psychol Med. 2001;31:29–38.
Living well with dementia: A National Dementia Strategy. 2009.
Cations M, Radisic G, Crotty M, Laver KE. What does the general public understand about prevention and treatment of dementia? A systematic review of population-based surveys. PLoS ONE. 2018;13:e0196085.
Judge D, Roberts J, Khandker R, Ambegaonkar B, Black CM. Physician Perceptions about the Barriers to Prompt Diagnosis of Mild Cognitive Impairment and Alzheimer’s Disease. Int J Alzheimers Dis. 2019;2019:3637954.
Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358:483–8.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–12.
Guba EG, Lincoln YS. Competing paradigms in qualitative research. In: Handbook of qualitative research. Thousand Oaks : Sage Publications; 1994.

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Dementia assessment and diagnostic practices of healthcare workers in rural southwestern Uganda: a cross-sectional qualitative study

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