The role of outer setting health system factors in the use of hydroxyurea for Ugandan children with sickle cell anemia

Outer setting factors impacting hydroxyurea use included medication access and cost, laboratory monitoring, and hospital support for use. Respondents endorsed a national plan for scale-up including regional clinic selection based on demonstrated readiness. Sickle cell anemia (SCA) causes childhood morbidity and mortality in Uganda and other countries in sub-Saharan Africa. Hydroxyurea is safe and effective, but not currently widely used in Uganda. We piloted a toolkit to support hydroxyurea use in two public health clinics: a regional referral hospital in a peri-urban area and a district hospital in a rural area. Implementation supports included a manual, expert training, and coaching over 2 years. We conducted key informant interviews and focus groups with national stakeholders, hospital leaders, healthcare workers, patient caregivers, and patients early in Year 1 and later in Year 2. Embedded research assistants at each clinic recorded observational data at least weekly throughout the study. Using rapid deductive qualitative analyses, the study team coded responses and observations according to constructs from the Consolidated Framework for Implementation Research (CFIR). Several key health system factors were critical for implementing hydroxyurea use: access to medication, laboratory monitoring capacity, and personnel and systems to support treatment. For the latter, executing the clinical registry and performing outreach was critical, so caregivers and patients return to clinic at proper intervals for laboratory monitoring, medication evaluation, and continued access to hydroxyurea. Several respondents requested a comprehensive national plan to address SCA, including effective medications. Supportive outer setting factors for hydroxyurea use in public health settings should include a national plan to improve hydroxyurea and laboratory monitoring access and costs, as well as staged roll-out of hydroxyurea to hospitals ready to provide personnel and system supports.