Background: Despite the investments made in veterinary diagnostic laboratory service delivery in Uganda, the scope and level of utilization remains low. This study aimed to determine the priority livestock diseases for which farmers and animal health professionals require veterinary diagnostic laboratory services, document the perceptions and opinions of key stakeholders on veterinary diagnostic laboratory services, and determine the factors that influence the delivery and utilization of animal disease diagnostic services in Uganda.Methods: A qualitative study approach involving a survey and key informant interviews was used to collect relevant data from four stakeholder groups: animal health workers, laboratory technologists and technicians, farmers, and key informants. The survey data were exported to excel, and descriptive statistics performed. The key informant interview recordings were transcribed, and thematic analysis performed.Results: The most reported diseases and conditions for which diagnostic services were needed were hemoparasites , viral , bacteria  and protozoa diseases (coccidiosis), endoparasites (helminths), and mastitis. The most common diagnostic laboratory tests requested by clients, but laboratories were unable to provide included: rapid tests for contagious bovine pleuropneumonia, Foot and mouth disease, Newcastle disease, acaricide analysis, culture and antimicrobial sensitivity test, serology, and complete blood count. The most frequently reported challenges to providing diagnostic laboratory services were poor or lack of relevant equipment, insufficient or lack of supplies and reagents, high cost of reagents, inadequate or lack of laboratory staff to perform tests, and inadequate training of laboratory staff.Conclusions: This study highlighted the need to improve provision of laboratory diagnostic services to meet the prioritized diagnostic needs of farmers and animal health professionals. Increased intersectoral engagement and funding support from the private, industry, and government sectors is necessary to help address the observed challenges to provision of diagnostic laboratory services, including equipping of the laboratories, provision of supplies, and hiring and training of laboratory staff. Finally, the findings also suggest that the education of farmers and animal health workers on the value and benefits of laboratory diagnostic services may contribute to increase in sample submission and subsequent demand for diagnostic laboratory services. Livestock are sources of income, food security and livelihood to over 70% of the households in Uganda. With a rising demand for livestock products in both domestic and regional markets, there is a growing need to support farmers to produce and get more income from the various livestock value chains. However, livestock disease outbreaks continue to affect the productivity of the livestock sector in Uganda. The most reported disease problems in ruminants include East Coast fever (ECF), anaplasmosis, babesiosis, trypanososmosis, Foot and mouth disease (FMD), contagious bovine pleuropneumonia (CBPP), brucellosis, helminth infections, and blackquarter –4. In poAlthough the government of Uganda and development partners have over the last 2 decades invested in supporting disease control and strengthening animal disease diagnostics through establishment of veterinary laboratories, most laboratories continue to struggle to provide diagnostic services while other laboratories have collapsed or are dormant. In Uganda, the importance of veterinary laboratories in disease control is well-enshrined in the Animal Disease Control Act . Over 6 Veterinary diagnostic laboratory service is one of the critical competences the World Organization for Animal Health (OIE) designates in evaluation of the quality of veterinary services at a country level . DiagnosThe specific objectives of this study were to: (i) determine the priority livestock diseases for which farmers and animal health professionals require veterinary diagnostic laboratory services, (ii) document the perceptions and opinions of key stakeholders on veterinary diagnostic laboratory services, (iii) determine the factors that influence the delivery and utilization of veterinary diagnostic laboratory services in Uganda, and (iv) identify ways how preexisting and emerging veterinary diagnostic laboratories can be strengthened to provide sustainable diagnostic services that meet the needs of the growing livestock value chains in Uganda.The mid-Central and Southwest regions of the country were purposively selected based on the predominant livestock species reared in these two regions and on the available budget to implement the study. The mid-Central region is among the regions with high poultry and piggery farming in Uganda. The districts surveyed in the mid-Central region included Wakiso, Mukono, Kampala and Nakaseke. The Southwest region, located farther from the capital city, Kampala, is among the regions with the highest number of commercial beef and dairy cattle farms and small ruminant production in the country. The districts surveyed in the Southwest region included Mbarara and Ssembabule; only two districts in this region were targeted due to limited funding . A total of 6 districts were targeted in this study ; a tableA qualitative study approach was used to collect relevant data from four stakeholder groups: animal health workers, laboratory technologists and technicians, farmers, and key informants. The study sought to collect data on the opinions of these four participant groups; the use of a survey for animal health workers, laboratory technologists and technicians, and farmers, and key informant interviews for key informants were deemed appropriate in this study.Four key stakeholder groups were targeted in this study and were selected based on their role in the veterinary diagnostic service value chain: animal health workers , laboratory technologists and technicians, commercial farmers , and key informants. A total of 160 participants from the four stakeholder groups  was estimated to participate in the study. The number of selected participants was determined based on available participants that met the inclusion criteria. Details of the number of participants from each stakeholder group and from each study region are presented in Supplementary Table 2 of The lists of prospective study participants  were compiled with the support of the District Veterinary Officers (DVOs). A list of DVOs in the six selected districts was obtained from the office of the Uganda Veterinary Association. The list of all active animal health workers obtained from the DVO's office was categorized according to type of practice, for example, ruminant, swine, small animal/companion, poultry, and mixed practice (multiple species). Key informants were purposively selected from each study district based on their experience and local knowledge of the veterinary clinical and diagnostic service industry.This participant group consisted of veterinary officers who were holders of a Bachelor of Veterinary Medicine degree, animal production officers who held a degree in animal production and management, and assistant animal health officers who were diploma holders in animal health and/or production. These three categories of veterinary human resource were purposively selected from across the study areas based on their level of involvement in clinical veterinary practice. Animal health workers who were not fully involved in clinical practice were excluded from the study.Only laboratory personnel that were duly qualified and were from recognized laboratory human resource training institutions were selected for the study. To be eligible the participant was either a laboratory technician with a certificate or held a diploma in laboratory science or was a laboratory technologist with a degree in laboratory sciences and worked in either a public or privately-owned veterinary laboratory.Consisted of commercial dairy, beef, poultry, and piggery farmers. The livestock enterprise selected varied between districts depending on the predominant livestock species that exist in each district. For instance, cattle are predominant in the Southwestern districts whereas poultry and piggery are the major livestock in Central Uganda. Emphasis was placed on selecting commercial farmers because demand for diagnostic services is expected to be highest for this category of farmers. We postulated that commercial farmers were more likely to have more extensive prior experiences (both negative and positive) regarding veterinary diagnostic services and as such capturing their responses would provide valuable information regarding the needs, challenges and diagnostic expectations of large-scale farmers.The key informants included experienced managers of veterinary diagnostic laboratories, senior veterinary diagnosticians/clinicians, government officials working with MAAIF, farmers with experience in utilizing veterinary diagnostic services, and DVOs who provide oversight and supervision of veterinary laboratories.A questionnaire was designed and used to collect data from animal health workers, laboratory technologists and technicians, and farmers  were contacted via telephone and notified of the date when the study team would meet them and conduct the survey. On the visit date, the purpose of the study was explained to each respondent and those who willing to participate were requested to provide informed consent electronically. To obtain the informed consent, each respondent was requested to read the purpose of the study on a tablet and asked to select his or her choice (agree or disagree). For respondents who did not read nor understand English, a study team member or local district veterinarian familiar with the local language helped in translation of the study background and the questionnaire. By clicking the agree button and giving consent, a respondent confirmed that: they had read and fully understood the purpose of the study; they voluntarily consent to participate in the study; and they belong to any of the following category of respondents: veterinarian, animal production officer, animal husbandry officer, laboratory technician/technologist or farmer. Upon consenting, the respondents were given the option to either proceed with answering the questionnaire on a tablet provided (self-administered) or get assistance from the research team to complete entry of responses on to the tablet. The completed surveys were saved and uploaded. Efforts were made to adhere to the standard operating procedures for COVID-19 prevention measures during survey administration; social distancing (standing or seating 2 meters apart) was observed, and masks and sanitizer were provided and used by the study team and study participants.The DVOs were contacted by one of the study investigators A key informant interview guide was designed and used to collect data from the selected key informants  was different from that targeted (n = 148) as shown in Supplementary Table 2 of A total of 165 participants attempted the survey that was administered to laboratory technologists/technicians, animal health workers and farmers. Six of the 165 participants completed only the first question of the survey and were excluded from analysis, leaving a total of 159 respondents that were considered in the analyses. Farmers accounted for most of the respondents  followed by animal health workers  and laboratory technologists/technicians were the least represented  . The totMost of the respondents were male  and aged between 26 and 45 years old . The respondents worked mainly in the following districts: Wakiso , Mukono , Mbarara , Ssembabule , and Kampala  .The 16 laboratory personnel that participated in the study were employed in academia (Makerere University), government  and privately-owned laboratories as shown in Supplementary Table 3 of Most of the animal health workers that participated in the study were employed by the government  while the rest worked in academic institutions and private practice. Ruminants, mixed practice and poultry were the most common type of veterinary practice for the participating animal health workers , cattle , and pig  farmers, and more than half of all farmers reported keeping cattle and chicken at the time of survey. Over 70% (64/86) of the farmers had between 6 to over 20 years of experience in farming  and farmers  appreciate the value of laboratory diagnostic services. When asked whether farmers are willing to pay for diagnostic services, 79% (11/14) of laboratory personnel reported that farmers are willing to pay. A similar proportion (79%) of respondents also believed veterinary diagnostic services can be run profitably  had attended continuous professional development (CPD) courses in the last 2 years on various topics shown in Supplementary Table 6 of To understand the capability of laboratories to provide diagnostic services, laboratory personnel were asked to indicate: the common diagnostic tests requested by clients, diagnostic tests requested but the laboratories were unable to provide, diagnostic tests they would like to have in their laboratories to improve the range of services offered to clients, commonly tested diseases, and the diseases or conditions laboratories would like to test but are currently unable to test.The most common diagnostic tests requested were microbial culture and antimicrobial sensitivity tests , followed by serology , blood smear , post-mortem examination , complete blood count , and other tests as shown in The diagnostic tests that laboratories would like to have to improve the range of services offered to clients were ELISA for Brucella and Gumboro , culture and sensitivity , serology for Black quarter, anthrax and viral diseases , rapid tests for viral diseases such as Newcastle disease  and PCR. The other tests mentioned are shown in The most frequently tested diseases were theileriosis (East coast fever) , brucellosis , helminthiasis and anaplasmosis each at 44% (9/16), colibacillosis, coccidiosis and babesiosis each at 19% (3/16) . Other dAnimal health workers were asked the type of tests they commonly requested when submitting samples to the laboratory in the last 6 months. Serology test was the most frequently reported , followed by blood smear and post-mortem examination each reported by 44% (25/57) and other tests as shown in farmers, commercial farmers, veterinarians, investors and researchers, co-operative societies, non-governmental organizations (NGOs), and community-based organizations (CBOs) like Mercy Corps, FAO, and pharmaceutical companies.” The participants were then asked, “what are the diagnostic services which clients demand?” The direct quotations of various diseases and conditions listed by the eight key informants are shown in One of the three themes identified from the key informant data was “clientele for veterinary diagnostic services.” The participating eight key informants were asked to “list the key clients which use laboratory animal diagnostic services” in Uganda and the most frequent responses were: “Box 1To assess the available functioning equipment, the laboratory personnel were asked to list the instruments or equipment most often used in their laboratories and the calibration status of the equipment where appropriate. The most frequently used equipment included microscope , fridges/freezer , pipettes, incubator, centrifuge each at 44% (7/16), autoclave , biosafety cabinet and weighing balance each at 25% (4/16). Other equipment included ELISA reader for serology (2/16), PCR machine (2/16) for gene amplification, HPLC for chemical analysis (1/16), auto-tissue processor (1/16), and microtome (1/16) for histopathological slide processing  of the respondents reported that some equipment had been calibrated in the last 2 years. However, 36% (5/14) of laboratory personnel noted that equipment in their laboratories were not calibrated. Eight laboratory personnel further noted that service of the equipment in their laboratories was not performed, and two of the eight respondents reported that equipment service was not considered a priority in their laboratories. Other reported reasons for lack of equipment service were lack of finances (2/8), lack of equipment service policy (1/8) and servicing of equipment was postponed because of COVID-19 (1/8). Two respondents noted that the equipment was not due for service.The laboratory technicians were asked to list and briefly explain the challenges to providing diagnostic services by their laboratories. The top five challenges reported by 81.3% (13/16) of the respondents included: lack of laboratory equipment, lack of human capacity to perform tests, poor sample quality, high cost of diagnostic services coupled with insufficient funding to run the laboratories, lack of or insufficient laboratory supplies, and lack of political support for veterinary laboratory diagnostic development .One of the three themes identified from the key informant data was “perspectives on challenges affecting veterinary laboratories.” The response of the key informants on challenges affecting veterinary diagnostic laboratories generated 4 codes (Codes 1–4). The codes within this theme provide an overview of factors which impact client access and the quality of diagnostic services provided. Code 1: access to laboratories, included “inadequate or lack of laboratory facilities,” “long distances to laboratories” and “poor access to laboratories.” Code 2: self-treatment on farms, included “treatment without diagnosis,” “animal losses,” and “preventative treatment.” Code 3: laboratory human resources, included “inadequate or lack of laboratory staff” and “inadequately trained staff.” The most common code in this theme was “access to laboratories,” participants referenced more about “access to laboratories” than the other two codes. Code 4: related to challenges of laboratory equipment and supplies and this included “poor equipping of laboratories,” “lack of relevant equipment,” “lack of reagents,” and “high cost of reagents,” all of which affect veterinary diagnostic service delivery. The direct quotations from the key informants are shown in Box 2Given the experience of the laboratory personnel in veterinary diagnostic services, they were asked their opinion on the factors that influence clients to submit samples to a laboratory and to rank the factors by importance. The most frequently reported factors included: sample turn-around time , professionalism (skillfulness exhibited) , respect and appreciation of laboratory staff toward clients , laboratory staff availability , available diagnostic tests , guidance and communication , and other factors.The top five ranked factors based on importance included: professionalism, respect and appreciation of laboratory staff toward clients , availability of laboratory staff during working hours and beyond , location and accessibility , turn-around time for tests performed and results given , and range of diagnostic tests available to clients  .About 86% (49/57) of the animal health workers reported submitting samples to the laboratory at least once in the 6 months prior to the survey. Only 21% (12/57) of the respondents submitted samples over three times a month to the laboratory. Samples from cattle , goats  and chicken  were the most frequently submitted by animal health workers (Supplementary Table 4 of Although up to 62% (53/86) of the farmers had never submitted samples to the laboratory, 21% (18/86) submitted samples either 1–2 or 3–6 times in past 6 months. Like the animal health workers, farmers also mainly submitted samples obtained from cattle, goats, and chicken , location and accessibility , affordability of services , professionalism, respect and appreciation of laboratory staff toward clients , and turn-around time for tests   (7/14), sensitization of farmers to promote use of laboratories for disease diagnosis (6/14), increase access to the laboratory (6/14), provision of laboratory equipment, test kits and supplies to veterinary laboratories (5/14), training (laboratory staff and vets on sample collection) (4/14) and improve turn-around time for test results (4/14) . Others One of the three themes identified from the key informant data was “solutions suggested by key informants in the veterinary sector.” The key informants were asked to give their opinion on how pre-existing and emerging veterinary diagnostic laboratories can be strengthened to provide sustainable diagnostic services across the livestock and poultry value chains. Their response generated a variety of recommendations for improvements of current and emerging veterinary diagnostic laboratories. Three codes emerged from the responses namely, education and training (code 1), funding and investment (code 2), and by-laws and policies (code 3). Code 1: Education and training, included the education of farmers on the benefits of performing laboratory diagnostics on animal health and welfare, on farmer income and farmer health, the sensitization of farmers on the dangers of self-treatment without a proper diagnosis, sensitizing farmers on benefits of laboratory diagnostics and the reasons for paying for services. Code 2: funding and investment, included the funds to run laboratory business on daily basis for example, to maintain power and cold chain, encourage farmers to pay for services to ensure sustainability, support farmers to get better value for their animal produce so that they can afford to pay for diagnostic services, reduce dependence on donor funding and find alternative sources of funding for laboratory diagnostic services to promote sustainability and improve pay for laboratory personnel to encourage more to enroll in laboratory training courses to become laboratory professionals. Lastly, code 3: by-laws and policies, included the regulation to restrict access to drugs to only qualified professionals. The most frequently referenced code in this theme was, “education and training.” The direct quotations from the key informants are shown in Box 3The animal health workers were asked to rate their level of satisfaction with various aspects of veterinary diagnostic services including laboratory facilities, laboratory staff, and the tests carried out plus post-test services. Regarding laboratory facilities, most of the animal health workers expressed that they were either slightly or very satisfied with the location, organization, cleanliness, and reception area of the laboratories in their area , community-based organizations (CBOs), FAO, and pharmaceutical companies. Although farmers often seek diagnostic services directly from animal health professionals, they also seek diagnostic services through their cooperatives or associations. This is common with cattle farmers, especially dairy and beef cooperatives who tend to be well-organized with clear leadership structure and strategic goals . VeterinFindings from the survey of laboratory personnel revealed that the diseases most tested for were theileriosis (East coast fever), brucellosis, helminthiasis, anaplasmosis, colibacillosis, coccidiosis and babesiosis. Additionally, findings from the key informant interviews also reported the common diseases and conditions for which diagnostic services were needed. The reported cattle diseases included hemoparasites (tickborne diseases and trypanosomosis), viral diseases , bacteria diseases , parasites (helminths), reproductive diseases or conditions  and mastitis. The current study findings agree with the reports on the commonly diagnosed cattle diseases by Byaruhanga et al.  and NakaOn the other hand, the most frequently reported diseases the laboratories were unable to test included avian influenza, CBPP, FMD, PPR, Rift valley fever, Swine fever, brucellosis, and tick-borne diseases such as heart water. Some of these diseases were also reported among the most tested diseases including FMD, RVF, brucellosis and tick-borne diseases. Even though the reasons why the laboratories were unable to test for these diseases were not investigated in the current study, this finding suggests that the demand for diagnostic testing of these diseases  may be high, but provision is inadequate. Therefore, improving the provision of diagnostic services for these diseases as well as the other diseases previously mentioned above may contribute to veterinary diagnostic service delivery.The most common tests requested by clients as reported by laboratory technologists/technicians included microbial culture and antimicrobial sensitivity tests, serology, blood smear, post-mortem examination, and complete blood count. While the most common diagnostic tests requested by clients, but laboratories were unable to provide included rapid tests for CBPP, FMD, NDV and mycoplasma infection, toxicological tests especially acaricide analysis, general gram staining, culture and antimicrobial sensitivity test, serology, and complete blood count. Some of the diagnostic tests that laboratories were unable to provide were also reported among the most requested tests including, culture and antimicrobial sensitivity test, serology, and complete blood count. The reasons why the laboratories were unable to provide the tests were not investigated in the current study. The findings nevertheless also suggest that the demand for these diagnostic tests  may be high, but provision is inadequate. Subsequently, there is a need to improve provision of these diagnostic tests as well as the provision of other tests mentioned above at the laboratory level.The current study findings suggest there is low capacity of veterinary laboratories to perform the requested diagnostic tests. Although microbial culture and antimicrobial sensitivity testing was the most common test requested by clients and reported as one of the tests that laboratories were unable to provide, only a few laboratories have the capacity to perform microbial culture. The regional veterinary laboratory in Mbarara district has the capacity to carryout microbial culture but is constrained by lack of budgetary support and inadequate laboratory supplies. The only participating laboratories that reported conducting microbial culture and antimicrobial sensitivity testing in this study were the microbiology laboratories at COVAB and NADDEC. Therefore, to promote antimicrobial stewardship, it's critical that regional veterinary laboratories are strengthened with the necessary equipment, biosafety containments, and human resource to be able to carry out culture and antimicrobial sensitivity testing. The availability and use of culture and antimicrobial sensitivity testing will help promote prudent antimicrobial use and prescription by animal health workers, thereby minimizing the risk of emergence of antimicrobial resistance.Brucella spp. screening using Rose Bengal test (RBT) as opposed to ELISA. Of the participating laboratories only RTC laboratory and NADDEC laboratory perform routine ELISA testing for vaccination monitoring and disease surveillance, respectively. Laboratories offering specialized serological tests for routine diagnosis and vaccine monitoring may benefit from expanding the scope of serological services offered to include endemic diseases for which laboratory diagnostic testing is needed such as FMD  was also reported as one of the tests that laboratories were unable to provide yet was in demand. To address this need, veterinary laboratories need to consider introducing traditional CBC techniques but also evaluate the market feasibility of introducing automated hemo-analyzers. Considering the high initial cost of investment, automated hemo-analyzers could be introduced especially in large or regional laboratories. For other tests that laboratories were unable to provide such as toxicological tests, the laboratories should target clients who intend to carryout residue analysis for animal product sanitary certification.This study found contrasting responses between farmers and animal health workers on the level of satisfaction of clients with veterinary laboratory diagnostic services. Whereas, animal health workers were slightly, or very satisfied, farmers were neither satisfied nor dissatisfied or not sure with the various aspects of veterinary diagnostic services including laboratory facilities , laboratory staff , and tests carried out . These findings could be explained by the fact that sample submission to veterinary laboratories is mostly performed by animal health workers. Animal health workers interact more frequently with veterinary laboratories thus putting them in a better position to make fair assessment regarding laboratory services than farmers. The fact that animal health workers showed some level of satisfaction with veterinary laboratory services is a positive indicator for the laboratory service providers. However, the findings suggest there is a need to engage farmers to understand the value of laboratories in relation to disease diagnosis, so that farmers can fully support animal health workers to make laboratory diagnosis a priority before medication.The perceptions of animal health workers, farmers and laboratory technologists and technicians on the most important factors that determine whether clients will submit samples to a laboratory were assessed. Both animal health workers and farmers indicated that the most important factors that determine whether they will submit samples to veterinary laboratories were sample test results turn-around time and location and accessibility (proximity of laboratory to farm premises). The findings in this study agree with a European study that investigated the opinions of veterinary practitioners in Northern Ireland . The stuLocation and accessibility of veterinary laboratories was reported by both animal health workers and farmers as an important factor that influences their decision to submit samples to a laboratory. The proximity of a laboratory to those submitting the samples, whether it is animal health workers or farmers can play a big role; a longer distance or difficult access to the laboratory is likely to discourage sample submissions. Strategies aimed at increasing availability of laboratory facilities and improving access to laboratories are likely to contribute to increased sample submission to veterinary laboratories. To remain attractive to farmers, veterinary laboratories should also strive to make their services affordable. Most farmers ranked affordability of services among the most important determinants of sample submission. Equally, for veterinary laboratories to attract animal health workers to submit samples, they should continuously carryout market analysis to know the diagnostic needs of the clinicians and strive to improve the range of diagnostic tests offered. Whereas, laboratory accreditation was ranked least, it is important that veterinary laboratories develop quality management systems and aim to get accredited, in alignment with OIE quality standards for conducting tests for animal diseases . AccrediThere were similarities in the challenges to providing diagnostic services reported by laboratory personnel and the key informant interview respondents. Both groups reported that the most frequent challenges to providing diagnostic services were poor equipment or lack of relevant equipment, insufficient or lack of supplies and reagents, high cost of reagents, inadequate or lack of laboratory staff to perform tests, and inadequate training of laboratory staff. A previous study that surveyed animal health workers reported similar challenges including inadequate laboratory space, lack of trained laboratory personnel, lack of equipment, lack of funds to purchase supplies, lack of motivation of veterinary staff to perform laboratory diagnosis, farmers not motivated to support laboratory diagnosis, and lack of required tests .The lack of laboratory equipment, laboratory supplies and human capacity to perform tests were mentioned in all the study districts. It should be noted that at the district level, veterinary diagnostic services are not fully supported with recurrent budgets at both central and local governments. Considering that veterinary laboratories are mainly government owned, there is need for both central and local governments to take full responsibility for renovating, equipping, and employing laboratory staff at both district and regional/national laboratories. To encourage financial independence and promote sustainability, the government laboratories should be allowed to charge modest cost-recovery fees for diagnostic services offered. This is the strategy currently used by laboratories in Makerere University and the private laboratories established with support from Zoetis under the ALPHA initiative. Other strategies that may help achieve sustainability include investment in improving laboratory environments, purchase of laboratory equipment and supplies, and appropriate payment of laboratory human resources.Laboratory technologists/technicians and key informants proposed ways veterinary diagnostic services can attract more clients and improve client satisfaction, including education of farmers on the benefits of performing laboratory diagnostics , and provision of laboratory equipment, test kits, and supplies to veterinary laboratories. The key informants also proposed ways veterinary diagnostic services can attract more clients and improve client satisfaction, including sensitization of farmers on dangers of self-treatment without proper diagnosis, encouraging farmers to pay for services to ensure sustainability, supporting farmers to get better value for their animal produce so can afford to pay for diagnostic services, reduce dependence on donor funding and find alternative sources of funding for laboratory diagnostic services to promote sustainability, improve pay for laboratory personnel to encourage more to enroll in laboratory training courses to become laboratory professionals.Demonstrating how useful the diagnostic approach is, showing its benefits. For example, A cow with subclinical mastitis giving 12 liters after treatment, the cow gives another 4 liters, such a farmer will never stop.” Therefore, it is important for all veterinary laboratories in the country to reach out to animal health professionals and farmers, promote the diagnostic solutions to their clients, demonstrate the value added by diagnostics to the client's business and use the revenues generated to improve laboratory facilities, supplies, and other operational costs if they are to run sustainably.The current study agrees with Nakayima et al.  that vetFor the district and regional government laboratories, there is a need for more government commitment to provide budget and other support for operationalizing diagnostic laboratories. There should be a deliberate effort to expand the human resource at district and regional veterinary departments to include positions for laboratory technicians and technologists. With recurrent financial support, the districts, and regional laboratories will help to reduce pressure on the national animal diagnostic laboratory (NADDEC) in both active and passive surveillance as well as outbreak investigations. Part of the investment in the laboratories should also cover installation of power backup systems to avoid service interruptions due to power outage. It is worth noting that the proximity of district veterinary laboratories to farmers is an incentive for sample submission and evidence-based drug prescription. Therefore, government support to increase access to laboratories will contribute toward veterinary diagnostic service delivery and to efforts that promote appropriate antimicrobial drug use.Clearly veterinary diagnostic laboratories would benefit from the support of the government, farmers and the livestock industry. Support for veterinary diagnostic laboratories in Uganda will improve the quality of veterinary services delivered to livestock farming communities, and as a consequence the high burden of livestock diseases in farms will be mitigated. These actions will create positive influences on the economy of farming communities, which currently are hampered by the rampant livestock diseases, while numerous investment opportunities would also be identified along the livestock value chains and hence boosting the general economy of the nation.Overall, the management of the various veterinary laboratories need to develop quality management system that must be implemented, reviewed, and improved. This will ensure that human resources in the laboratory are well-trained and competent and provide quality customer care, laboratory equipment are maintained and calibrated, scope of tests offered is progressively increased to respond to market demands, and that laboratories develop strategic plans and work toward accreditation.This study has identified the priority livestock diseases for which diagnostic services were needed, and revealed that some common endemic viral, bacterial, and tick-borne diseases are not tested due to lack of test capacity at laboratories. The study findings suggest that there is a need to improve provision of culture and antimicrobial sensitivity testing, serology and complete blood count testing because current provision of these tests is inadequate yet there is demand. To improve sample submission rate, strategies must be developed at the government and local laboratory levels to ensure that the most important determinants of sample submission are addressed appropriately, including increasing availability of laboratory facilities, improving access to laboratories, reducing sample test results turn-around time, increasing range of diagnostic tests available to clients, making diagnostic services affordable, improving professionalism of laboratory staff, respect and appreciation of laboratory staff toward clients, and quality of laboratory reports. Study findings also revealed that veterinary diagnostic services in Uganda are financially constrained, and improved funding and budgeting within the services provided by government and private sector may help address the reported challenges such as poor equipment or lack of relevant equipment, insufficient or lack of supplies and reagents, high cost of reagents, and inadequate or lack of laboratory staff to perform tests. Finally, the education of farmers and animal health workers on the value and benefits of performing laboratory diagnostics may help contribute to increase in sample submission and subsequent demand for diagnostic services. And the improvement in quality management systems at the laboratory level through attainment of accreditation may increase the confidence of clients in laboratory results and contribute to overall strengthening of the veterinary laboratory diagnostic services in the country.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Makerere University, School of Veterinary Medicine and Animal Resources Institutional Animal care and Use Committee (Protocol number: SVAR-IACUC/46/2020) and the Uganda National Council for Science and Technology (Ref number: A84ES). The participants provided their written informed consent to participate in this study.AE and PV conceived the study. AE, PV, JB, IE, RA, and AC developed study protocol—including data collection strategy and instruments. PV, JB, AE, and IE were involved in data collection activities. SW, NG, IE, AE, and PV conducted data analysis and interpretation. AE, SW, NG, JB, and PV were involved in preparation of the manuscript. AE, PV, SW, NG, JB, IE, RA, EM, GV, and AC contributed to the final version of the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the African Livestock Productivity and Health Advancement (ALPHA) Initiative, co-funded by the Bill and Melinda Gates Foundation (BMGF) and Zoetis. Funding from Zoetis was an unrestricted grant. BMGF Grant number: OPP1165393.The views and opinions expressed in this article are those of the authors and do not necessarily reflect the policy or position of any affiliated agency or institution of the authors.EM and GV are employed by Zoetis and contributed to conception and report writing. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To investigate the feasibility of establishing hospital-based antimicrobial stewardship (AMS) programmes comprising action-planning, educational interventions and data feedback in two provincial-level hospitals in Viet Nam.This was an implementation research using participatory action process and existing resources from the Duke Antimicrobial Stewardship Outreach Network with local adjustments. A national stakeholder meeting and Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis were conducted to identify gaps and potential interventions.Hospital AMS staff implemented activities throughout the study phases. Routinely collected patient data were analysed to support planning, implementation and evaluation.Hospitals were considered as a complex adaptive system and leveraged their unique characteristics and interconnections to develop 1-year plans containing core interventions  and evaluations).We assessed feasibility using outputs from stakeholder meeting, SWOT analysis, baseline data, planning process and implementation.The stakeholder meeting identified three gaps for AMS at national level: supportive policies, AMS training and core competencies and collaboration. At the hospitals, AMS programmes took 1 year for planning due to lack of hospital-specific procedures and relevant staff competencies. Baseline data (January–December 2019) showed variations in antibiotic consumption: 951 days of therapy (DOT) per 1000 days present in the control and 496 in the intervention wards in hospital 1, and 737 and 714 in hospital 2, respectively. During 1-year implementation, clinical pharmacists audited 1890 antibiotic prescriptions in hospital 1 (June 2020–May 2021) and 1628 in hospital 2 (July 2020–July 2021), and will continue PAF in their daily work.Our data confirmed the need to contextualise AMS programmes in low-income and middle-income countries (LMICs) and demonstrated the usefulness of implementation research design in assessing programme feasibility. Developing staff competencies, using local data to stimulate actions and integrating programme activities in routine hospital work are key to success in LMICs. Our study used a participatory and teamwork approach involving hospitals as a complex adaptive system with unique characteristics and interconnections that can be leveraged to develop locally tailored interventions.We employed intervention strategies that were conducted using locally available staff and resources, specifically clinical pharmacists and routinely collected data.In the process of setting up antimicrobial stewardship programmes, we incorporated perspectives and expertise from both policy makers and hospitals at different levels and from international and local partners.Contextualisation and tailoring is a strength, but this also affects the study’s external validity, and the results cannot be generalised to all healthcare settings as this implementation study targeted community hospitals with medium levels of resources and staff available.Despite fast-growing literature on the effectiveness and potential economic impact of antimicrobial stewardship (AMS) in healthcare facilities around the world,11The Ministry of Health (MoH) in Vietnam developed a National Action Plan on AMR in 2013 for 2013–2020. Surveillance and AMS programmes were two of the six listed priorities of the plans. A nation-wide AMR hospital surveillance network and a reference laboratory have been established.15In a previous qualitative study about AMS implementation in seven hospitals in the national AMR surveillance network,17In this study, we aim to investigate the feasibility of establishing hospital-based AMS programmes comprising action-planning, educational interventions and data feedback in two provincial-level hospitals in Vietnam. We describe the process of preparation, planning and implementation and identify the factors that are important in setting up such a programme in hospital settings in the country.In this implementation research study, we employed a participatory action process to establish AMS programmes at two provincial-level hospitals in Vietnam. In this process, hospitals were considered a complex adaptive system consisting of evolving inter-related individuals and non-linear interactions, and the study was conducted under the assumption that interventions cannot be applied in different hospitals with predictable results.Our planning process began at a national AMS stakeholder meeting organised by the Medical Services Administration of the MoH, WHO and Oxford University Clinical Research Unit (OUCRU), during which we reviewed the current status of AMS implementation in the country. Based on our pre-existing understanding and network with local hospitals, on this meeting, and on subsequent discussions with MoH, we invited two provincial hospitals to join this implementation study: Viet Tiep Hospital in Hai Phong, a large port city with 2 million inhabitants, in the north  and Dong Thap General Hospital in Cao Lanh, Dong Thap in the Mekong Delta in the south . Hereinafter, these two study hospitals will be intentionally referred to as hospital 1 and hospital 2 (in no particular order) to avoid identification of the hospital name in the data presented.The process of setting up an AMS programme at each hospital went through cycles of planning, implementing and evaluating phases . During Each hospital selected eight clinical wards to participate in the study: four for AMS intervention and four as control wards (the number of wards was determined by the funding availability). The selection of intervention and control wards was based on discussions within the hospital AMS team with two selection criteria: (1) the amount of antibiotic used was greater than average of all wards in the hospital based on pharmacy reported data and (2) the head of ward was willing to participate in the study intervention or control group. The control wards were included to support evaluation of overall AMS outcome indicators  using trend analysis over 12 months before and after the start of intervention. For practical reasons, there was no strict requirement to identify control wards that were similar to the intervention wards. After eight wards were identified, the decision on the wards to be in the intervention group and control group was left at the discretion of the director board and the AMS team in each hospital. At both hospitals, the directors and the AMS teams decided to select the wards that were more likely to accept the AMS interventions based on their judgement and internal relationships. The allocation of the wards to each study group was as follows:At hospital 1:Intervention group included surgical intensive care unit, traumatology, respiratory/musculoskelectal system, and infectious diseases (ID) ward.Control group included internal intensive care unit, surgical nephro-urology, paediatrics and general internal medicine ward.At hospital 2:Intervention group included surgical intensive care unit, general internal medicine, traumatology and high-quality-serviced ward .Control group included internal intensive care unit, oncology, ID and surgical gastroenterology ward.The preparation and implementation process started with the training and mentoring component, which was then integrated throughout the study life cycle. Training, technical support and mentoring activities were modelled to international AMS models and developed with experts from DASON, and included sharing experiences and identifying opportunities for local changes and interventions to improve antibiotic use and patient outcomes. DASON is community hospital network that supports the implementation of local AMS programmes and collaborative network participation has shown reductions in antibiotic use in these hospitals.19 20Training and mentoring by local experts on ID, clinical pharmacists and clinical microbiologists to support AMS implementation were also integrated into the programmes. These experts were from National Hospital for Tropical Diseases, Hanoi (NHTD); Hospital for Tropical Diseases, Ho Chi Minh City (HTD), Vietnam National Children’s Hospital, Hanoi and Hanoi University of Pharmacy, Hanoi.The following training events were organised throughout the planning and implementation phases, with topics discussed and agreed on by all partners involved and timing decided based on practical considerations, including the impact of COVID-19 on routine care in each location:A study tour to Duke University was organised for AMS staff of two study hospitals and local AMS experts from NHTD and HTD in July–August 2019. Participants attended lectures presented by DASON experts on AMS principles and practical guidance and experiences on specific AMS interventions. Participants also visited four DASON community hospitals to learn about the AMS models implemented at these sites. Participants also discussed about the feasibility and applicability of the interventions to the Vietnamese context.Visits by DASON experts and OUCRU staff at each study hospital in Vietnam were organised in December 2019 to provide on-site training and technical support in assessing the needs and planning of activities.Training courses by local experts on antibiotic treatment, clinical pharmacy and clinical microbiology were organised in a class-room style for doctors, pharmacists and microbiologists. These courses were provided at two time points: one initial course in June 2020 to cover the broad concepts and one follow-up course in October 2020 focusing on the specific needs and knowledge gaps of each hospital.One-week training and shadowing for clinical pharmacists on prospective audit and feedback at HTD was organised in December 2020.Training course on microbiological specimen sampling was organised at hospital 1 for nurses in April 2021.Training and on-going technical support were provided by OUCRU for AMS staff on specific skills in planning and implementation of AMS activities.Local meetings were organised in each hospital with the participation of AMS team members and participating intervention wards to assess the current gaps and needs and develop plans for implementation. Mid-term meetings and project monitoring meetings were also organised by OUCRU to review on the progress and upcoming activities with the AMS team at each hospital.Evaluation was integrated throughout starting with the first round of data collection and analysis before the AMS intervention and every 3 months after programme implementation. The data were used to design and tailor the intervention activities towards the goal in reducing unnecessary antibiotic use in each hospital. Following baseline indicators were evaluated in each hospital :10.1136/bmjopen-2021-053343.supp1Supplementary dataAntibiotic use in total and from targeted agent groups.Knowledge and perceptions of doctors.Proportions of antibiotic prescriptions which had an indication documented, had review/stop date documented, were used as surgical prophylaxis for greater than 24 hours, were not compliant with guidelines currently endorsed at the hospital, and were inappropriate.Proportion of resistant isolates for priority antibiotic-organism combinations.Cost of antibiotic treatment and hospitalisation.In-hospital mortality.Hospital length of stay.Data were collected from the existing routine hospital information systems for 12 months baseline period, knowledge-attitude-practice (KAP) surveys of all doctors in eight study wards and relevant AMS staff (pharmacists and microbiologists), and reviews of medical charts in the four intervention wards by the doctors at each of the wards.The key process indicators of the project were: (1) a functioning AMS team was formed and was able to lead the AMS activities; (2) a 1-year implementation plan for AMS programme was developed and carried out and (3) baseline data and subsequent data from evaluation rounds were used to inform planning and implementation. We recorded implementation data to monitor the intervention activities, specifically prospective audit and feedback (PAF) implemented by the clinical pharmacists. Other data about trainings and meetings  and resources required for the activities  were also recorded for monitoring the process of programme implementation and support parallel economic evaluation.We reviewed contextual information collected from the national meeting and the baseline needs assessment at the two hospitals and performed an analysis of strengths, weaknesses, opportunities and threats (SWOT) of AMS implementation to support the AMS team in initial planning of the activities at each hospital. We used the following DASON recommendations for the key AMS components to guide our analysis, which include the core elements described by the US CDC22An individual who is qualified through education, training or experience in ID and/or antibiotic stewardship as leader of AMS programme; committee structures for oversight and executive authority for AMS activities; formal policy outlining AMS programmeAutomated systems ; pharmacy-based dose optimisation activities; regular antibiotic use evaluations; antibiotic formulary; pharmacy staffing with clinical pharmacist with specialised training and interest in IDLaboratory reporting system; cumulative antibiogram; microbiology personnel; testing and incidence of multi-drug resistant organisms.ID clinician presenceWe performed descriptive data analysis for each hospital on baseline data and data from the subsequent evaluation rounds to identify issues that required attention and opportunities for intervention in the AMS programme. Results were summarised and presented to provide feedback to the hospital management board, AMS team and intervention wards through reports and project progress meetings and to use as evidence for identifying further actions. We characterised antibiotic use by subgroups, types of clinical wards and international classification of diseases (ICD-10) code groups. Hospital-wide antibiotic susceptibility testing results entered into WHONET were extracted and analysed following the same analysis protocols performed in previous studies for AMR surveillance data from VINARES hospital network.et alResistance results were expressed as proportions of resistant isolates out of the number of tested isolates. We classified multidrug resistance (MDR) and carbapenem resistance based on the criteria proposed by Magiorakos Acinetobacter baumannii and Acinetobacter spp.: MDR is defined as resistant to at least three of the following: cephalosporin (ceftriaxone or cefepime), aminoglycosides , ciprofloxacin and carbapenem (imipenem or meropenem); carbapenem resistance is defined as resistant to imipenem or meropenem.For Escherichia coli, Klebsiella pneumoniae and Klebsiella spp.: MDR is defined as resistant to at least three of the following: carbapenem , cephalosporin (ceftriaxone or cefepime), aminoglycosides  and ciprofloxacin; carbapenem resistance is defined as resistant to ertapenem, imipenem or meropenem.For Pseudomonas aeruginosa: MDR is defined as resistant to at least three of the following four agents: imipenem, ceftazidime, ciprofloxacin and tobramycin; carbapenem resistance is resistant to imipenem or meropenem.For Patient and public involvement was not included in this study as this is a new aspect in the local hospital settings and requires additional research to explore its feasibility and the most appropriate approaches. Initial efforts are being undertaken in parallel to this research for involving patients and the public in AMS in the local hospitals.Here we present the results of the initial steps in setting up the programme and describe the baseline summary indicators from the routine data of the two hospitals. This paper was reported following the StaRI checklist ‘Standards for Reporting Implementation Studies: the StaRI checklist for completion’.25The meeting was organised in March 2019 to review the current state of AMS implementation nation-wide with participation of a wide range of stakeholders representative for both public and private sectors, and governmental and international partners working or interested in AMS implementation . The meeData on existing processes and structures were reviewed to provide input for initial planning of AMS intervention. In Both hospitals provide care and treatment to all types of clinical conditions and diseases in the catchment areas. Each hospital has a department of ID, providing care and treatment to patients who are admitted to this department, and provide consultation in managing patients with signs of infection in other clinical wards if required. Each hospital also has a department of pharmacy and a microbiology laboratory. In both hospitals, pharmacists were mostly involved in drug inventory and bidding, and some support to doctors in dose adjustment in special cases, and microbiologists’ main roles were to inform doctors of test results. Engagement of microbiology, pharmacy and ID departments in antibiotic treatment was generally passive, mostly through hospital-wide consultation meetings on an ad-hoc basis when there were difficult cases. Local AMR surveillance data were not readily available for use to inform treatment guidelines or updating drug formularies.From the gaps and needs identified, specific strategies were developed within the first-year plan for interventions targeting each of the key components . These sEstablishing leadership commitment and forming an AMS coordinating team that can connect all relevant wards and units within each hospital. At both hospitals, the planning department plays a key and coordinating role with a linkage to the specific clinical and functional departments and reporting responsibility to the hospital management board;.Using data to inform planning and evaluating AMS activities and stimulate the actions among leaders and staff through regular AMS meetings organised at each hospital. Data were from the KAP surveys, review of patient medical charts and routine data on antimicrobial treatment, clinical diseases, antimicrobial susceptibility data and denominator data (days present at each study ward);Training/mentoring activities to update the knowledge and skill gaps for doctors in the intervention wards based on the findings from quarterly KAP surveys and retrospective reviews of patients charts for antibiotic prescribing practices. These trainings were delivered by national experts on ID, clinical microbiology and clinical pharmacy; technical training for AMS staff on specific skills including setting up an AMS programme, using data for planning and monitoring, PAF, communication skills and developing guidelines provided by DASON experts and local experts;Implementing PAF at the intervention wards by clinical pharmacists with support from the AMS doctor and team members. On-site training and shadowing experienced clinical pharmacists in HTD during their PAF activities were organised to develop the capacity for these new teams. By the end of the implementation period, 1890 antibiotic prescriptions were audited in hospital 1  and 1628 in hospital 2 . Recommendations were made in 82/1890 (4.3%) of the audited cases in hospital 1 and 128/1628 (7.9%) in hospital 2. The hospitals planned to continue PAF in the daily work of the clinical pharmacists.Some strategies differed by site. At hospital 1, due to limited microbiology data available for developing treatment guidelines the hospital decided to focus first on increasing the quantity and quality of specimen cultures through updating the current SOPs and organising trainings for technicians and nurses at each clinical ward. At hospital two where there are more surgical wards, the hospital AMS team put more focus on surgical prophylaxis with an initial aim to reduce the number of two-drug combination orders.Total number of patients admitted at the intervention and control wards at the two hospitals in 2019 and the proportions with antibiotic treatment during the whole hospital admission are summarised in Control group in hospital 1: genitourinary diseases (1057), respiratory diseases (1028) and certain infectious/parasitic diseases (927).Intervention group in hospital 1: respiratory diseases (897), certain infectious/parasitic diseases (863) and injury, poisoning and certain other consequences of external causes (729).Control group in hospital 2: digestive diseases (800), certain infectious/parasitic diseases (797) and neoplasms (553).Intervention group in hospital 2: respiratory diseases (888), injury, poisoning and certain other consequences of external causes (736) and digestive (707).There were 2430 isolates reported from culture of 10 784 specimens  in hospital 1, with 289 isolates from 3583 blood specimens (8.1% positivity rate) in 2019. Hospital 2 reported 5463 isolates recovered from 23 731 specimens  and 1642 isolates recovered from 14 539 blood specimens (11.3% positive rate) in 2019.Among the study wards, there were 1392 isolates (5.5 isolates per 1000 days present) reported for eight study wards in hospital 1  in 2019. Slightly more isolates were from male patients (56.6%) and from older age range  in the eight wards of this hospital. Hospital 2 reported 2433 isolates (13.4 isolates per 1000 days present) for eight study wards in 2019, of which 802 (33.0%) were blood isolates. These isolates were also mainly from male patients (64.3%) and older age range .E. coli was the most commonly isolated bacterium in the study wards in both hospitals  and MDR . For hospital 1, Klebsiella spp. showed lower carbapenem resistance (26.3% n=167) and MDR (39.5% n=167) in all specimens.ospitals , and harospitals . K. pneuA. baumannii in hospital 2 and Acinetobacter spp. in hospital 1 .High levels of carbapenem resistance in all specimens (80.0% n=325) and in blood (57.9% n=19) and MDR  in all specimens (62.6% n=265) and in blood (47.1% n=17) were reported for P. aeruginosa in all specimens, the proportions were 25.3% n=253, 35.0% n=254% and 24.3% n=272 for ceftazidime resistance, carbapenem resistance and MDR , respectively, in hospital 2, lower than those in hospital 1 .For Staphylococcus aureus were 79.0% (n=210) in hospital 1 and 76.7% (n=103) in hospital 2 based on the cefoxitin test.Proportions of methicillin-resistant We used an implementation research approach to evaluate the feasibility and understand the process of AMS implementation in two pilot hospitals in Vietnam. First, this study showed that building a functioning multidisciplinary AMS team is an important factor for the success of the programme. In Vietnam, AMS committees have been formed in 334 out of 655 hospitals (51%) in a recent MoH report in 2019; however, the majority of these committees had irregular activity (72%).Second, the partnership approach combining local and international partners in our study demonstrated an effective synergy of experience, expertise and resources to ensure the appropriate selection of strategies and methods in setting up AMS programmes in LMICs. This approach has been advocated in a recent call for international collaborations in AMS implementation in LMICs, which can be achieved through the dissemination of high-quality research and educational resources recognising the needs to contextualise to the local conditions.Across a number of AMS programmes worldwide, pharmacists are often included to manage the prescription-based strategies including preauthorisation formularies and postprescription audits and feedback (PAF). This was reflected in the national guideline on AMS implementation originally issued in 2016 and updated in 2020.29AMS programmes in LMICs generally encounter challenges of limited financial and physical resources available for implementation including substandard lab practices, lack of well-trained staff, insufficient opportunities for continuing professional development and difficulties in deploying prescription-based stewardship strategies.Among these considerations, capacity building and training for the AMS team in programme planning and evaluation and hospital pharmacists to conduct PAF activities were identified as the key components. As recommended in a recent review of AMS programme designs, practically integrating the planned changes into the normal routine clinical practices is the best way to achieve sustainability apart from securing long-term resources.AMS programmes have been traditionally ‘pharmacy-centric’ with minimal or no input from microbiology; participation of clinical microbiologists in AMS teams varied widely around the globe .37The strengths of our study include the participatory approach in AMS implementation where hospitals were considered as a complex adaptive system with unique characteristics and interconnections between players that could be leveraged to develop locally tailored interventions for maximal results.Our study, however, shares the common limitation of implementation research, which is the ability to generalise the obtained knowledge of AMS implementation to different healthcare settings. Our evidence in two provincial hospitals in Vietnam will be generalisable to the community hospitals with medium levels of resources and staff available for implementation but lack of staff training and capacity in carrying out AMS activities. Nevertheless, the nature of implementation research in recognising and tailoring activities to the local contexts is an important aspect in bridging the gap in our understanding of what is known to be effective and what works in the actual patient care settings.In conclusion, AMS implementation requires an in-depth understanding of the local conditions and practices and the contextualisation of the intervention strategies in Vietnam and similar LMIC settings. We showed that using implementation research design is an effective approach in assessing the feasibility and evaluation of the AMS programme. It also helps local hospitals understand their needs and start prioritising AMS in the local agenda, paving the solid steps for a long-term institutionalisation and improvement of the programme. As evident in our process, it is important to develop the skills and capacity of the multidisciplinary AMS team and identify creative combinations of strategies that could be carried out with locally available resources for maximal and sustainable outcomes.


Background: Only limited Sexual Health and Relationships Education (SHRE) is provided in Iranian schools and universities while research has highlighted demand and need for improved SHRE among young adults. We explored health-care professionals' (HCPs) assessments of, and recommendations for, SHRE and service provision for young people in Tehran.Design and Methods: Semi-structured interviews were conducted with a sample of 17 HCPs based in Tehran and verbatim transcripts were analyzed using thematic analysis.Results: Participants confirmed the need for improved SHRE and service provision for young adults. HCPs described how a lack of reliable educational resources for young adults, taboo and cultural barriers, and a lack of trust and confidentiality prevented young people from accessing information and services. They unanimously supported education and services to be augmented, and provided recommendations on how this could be achieved.Conclusions: A number of positive suggestions for the improvement of SHRE and Iranian sexual health services in Iran were identified. Health care professionals (HCPs) in Iran, as in other countries, face cultural barriers to implementing evidence-based, sexual-health education and training . OptimalTehran is the most populous city in Iran with a population of 8.5 million (in a country of 81 m) , includiSHRE has never been included in Iranian school curricula but many Iranian universities, including those in Tehran, offer a single module (“Science of Family and Population”) which is a 20-h course taught by a lecturer specializing in religious and spiritual studies . The modAccording to the World Health Organization (WHO), SHRE should promote “a state of physical, mental and social well-being in relation to sexuality … requiring a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” . SHRE isThe demand for comprehensive SHRE in Iran has been documented. Shahhosseini and Hamzegardeshi  conducteDespite public health need and clear demand from young people there are socio-cultural barriers to the delivery of comprehensive SHRE in Iran. Latifnejad Roudsari et al.  reportedSo, given the potential effectiveness of SHRE and the lack of negative consequences observed across studies , the pubWe investigated the views of Tehran-based HCPs regarding sexual-health education and services for 18-25 year-old (young) Tehranians, We also explored the potential utility of new workshops to augment current provision. Discussion focused on five topics  was obtained from every interviewee to protect anonymity. All participants consented to interviews being recorded and for quotations to be reported anonymously.N = 7) and social workers and community health consultants (10) of whom seven were policy makers or had a high level of influence on policy development and implementation in relation to sexual health.Twenty-nine HCPs were contacted. Twelve declined or were unavailable during the data collection period. Seventeen Iranian, Persian-speaking HCPs working in Greater Tehran were interviewed (5 men and 12 women). These included HCPs with and without medical qualifications and those in clinical contact with patients and clients . A few participants also highlighted concerns about unintended pregnancy, emphasizing that these concerns were often more important to young people than those relating to STIs because of the social visibility of pregnancy and the socio-cultural context (1b).Participants highlighted a range of socio-cultural barriers, including the lack of legal and service support for individual sexual choices (2a). Participants noted that the illegality of sexual relations outside marriage and of abortion, created fear and repressed open discussion of safer sexual practices and service use among unmarried people (2b). This prevents the normalization of sexual healthcare for unmarried people.Participants also discussed gender power inequalities, highlighting disempowerment of women in heterosexual relationships and the implications for contraceptive use and STI-preventive practices. The challenge here is to provide support for young women to take responsibility and skillfully manage their sexual health (2c).Some participants highlighted 2013 changes in national policy and their healthcare implications. They explained that a successful national family planning program had been in place between 1998–2006, which involved free and unlimited access to condoms and contraception methods including tubectomy and vasectomy. This was largely withdrawn in 2013 as national policies focused on increasing Iran's population (2d).Participants commented on current provision, including HIV-awareness courses delivered in high schools and STI-awareness courses delivered in universities. Participants were, unsurprisingly better informed about educational initiatives run by their own organizations but these various programs are not officially evaluated and the number of users/recipients is unknown. Overall, HPCs painted a picture of a patchy educational service with some centers of excellence but poor provision for the general population of young people.Almost all interviewees agreed that sexual-health knowledge was poor among their young patients/clients. A concerning lack of understanding of sex, contraception, and STIs was reported. Interviewees attributed this to a lack of reliable information sources, including official sexual-health education (4a). This was combined with poor self and relationship management skills among young Tehranians due to limited interpersonal communication skills-training during their education (4b).Participants were critical of existing pre-marriage classes in terms of SHRE delivery, including content range, delivery methods, timing of the intervention, and lack of evaluation (4c) and supported more comprehensive, more accessible SHRE including workshops. However, they also recognized that cultural constraints render such developments problematic, including parental objections, and policy-makers lack of understanding of the sexual-health needs of young people (4d). Participants also highlighted a gap between what policy-makers and legislators deem necessary and the education that front-line HCPs view as essential to protect health and promote wellbeing and noted that current provision is not usually evaluated in terms of reach, use, or impact (4e).Two clear sources of sexual-health information for young Tehranians were identified; friends (5a) and the internet (5b). Both were considered to be popular but were acknowledged as sources of unreliable information that could engender potentially wide-spread misinformation and sub-optimal sexual practices .Sexual healthcare services offered by “Centers for Behavioral Diseases” (CBDs) (6a) were discussed by interviewees. In Iran, general health centers resemble a GP office or clinics for family medicine where general health and well-being concerns are addressed, while CBDs provide specialized STI services. Participants noted the lack of preventive services and one-stop-shop services . The lack of preventive services was lamented and generally attributed to limited funding (6b).Almost all participants noted the lack of publicity for government-funded sexual healthcare, including CBDs (7a) and that cost was a major barrier (7b), especially since healthcare is mostly privatized in Iran, highlighting socioeconomic inequalities in health care access (7c), especially for young Tehranians many of whom do not have secure incomes.Participants also noted that young people distrust official sexual health services (7d) fearing that confidentiality will not be respected and that doctors may be judgmental.There was consensus for two important changes needed to improve SHRE education and services for young people. First, participants recommended that, in the absence of comprehensive SHRE, officials recognize young people's use of the internet as an educational resource and offer endorsement and recommendation of reliable online educational resources (8a). Second, participants recommended development of comprehensive SHRE in secondary schools and university across Iran (8b). Although, there was pessimism about this being accepted as future policy.Participants believed that a new SHRE workshop or day-course would be beneficial. All HCPs unanimously supported such new SHRE workshop and 12 of them provided longer quotes, which are included in the Anatomy of sexual organs was considered essential by many participants as this subject is not fully covered in human biology courses in schools (10a). STIs prevention, use of condoms and other contraceptives for pregnancy prevention was suggested by all participants (10b). In addition, wider publicity for existing services (10c), and relationship management skills (10d) were highlighted as important content.Participants were divided on the merits of same vs. mixed gender classes (11a). Some believed mixed classes would facilitate breaking taboos while others felt that same-gender classes would provide a more relaxed learning environment, especially for young women. Participants supported group discussions and Q&A opportunities (11b).To our knowledge, this is the first qualitative investigation of HCPs' views of sexual health education, training, and service provision for young Tehranians. Together with previous studies of young Iranians' views of SHRE and sexual-health services in Iran, our findings highlight a serious public health need and a potentially culturally acceptable way forward. In particular, (i) official endorsement of selected online resources and (ii) provision of new culturally-tailored, government-endorsed workshops for young Iranians focusing on knowledge transfer, STIs and pregnancy prevention and relationship management skills are recommended.Confirming previous research, HCPs suggested that a lack of SHRE in Iran contributes to increasing STIs and illegal abortions . InterviDespite the availability of a small number of government-funded sexual healthcare clinics, HCPs believed that (i) most young Tehranians are unaware of these facilities and, perhaps more importantly, (ii) these services do not provide preventative content. Interviewees also noted the high cost of medical consultations which exaggerates existing socioeconomic (SES) inequalities. This is particularly problematic as the majority of the population cannot afford private healthcare. Furthermore, HCPs were aware of a lack of trust among many young people; suggesting that many fear breaches of confidentiality; which would ultimately damage their social image, even in conversations with doctors. HCPs highlighted the need for improved, well-publicized, accessible, confidential and affordable sexual healthcare in combination with a comprehensive SHRE program.HCPs made a series of recommendations for future services. In particular, SHRE that clearly explains the physiology and function of sexual organs and the mechanism underlying STIs transmission and pregnancy. In addition, they emphasized the importance of training young people in skills such as relationship management, condom-acquisition, condom-use negotiation, and consistent condom use. Participants also recommended training materials specifically addressing support for women to manage sexual relationships more confidently and to control their sexual health including instructions on how to best negotiate condom use, confirming findings of Mirzaii Najmabadi et al. .HCPs noted that young people depend on unreliable educational sources, including their friends and social media, and are consequently largely uninformed and unskilled, confirming previous findings , 28. ParInterviewees noted that existing educational initiatives focus predominantly on HIV awareness, and do not include content on contraception or relationship management skills. They highlighted organizational constraints including limited funding for sexual health educational programs and lack of cooperation between various ministries and organizations responsible for such programs. The lack of evaluation of existing programs was also discussed. This casts doubt on the efficacy and reach. There was a sense of pessimism among our HCPs because they, themselves, cannot transform the sexual health services. Improvements will require operational and political decisions by national level managers and policymakers. Nonetheless, an understanding of the views of HPCs provides guidance on priorities for improvement to SHRE and sexual health services in Iran.Moreover, HCPs considered the quality and content of existing programs, including courses tailored to marrying couples, to be ineffective and provided recommendations for how the current provision should be improved or augmented. This indicated their perceived need and demand for provision of comprehensive SHRE cf. , 30]..30)].In spite of limited government-funded sexual healthcare clinics, HCPs believed that young Tehranians are unaware of these facilities and viewed visits to private doctors as limited by cost. They therefore recommended publicizing such services to all social groups including young adults. Interviewees mentioned lack of trust in available services and believed that young Tehranians doubt their confidentiality and fear the potential damage to their social standing, even in conversations with doctors.In general, the results suggest a need for improved, well-publicized, accessible, confidential, and fairly priced sexual healthcare. Additionally, co-creation and testing of comprehensive SHRE modules was strongly supported.We recruited a unique mix of private and public sector HCPs from different managerial and client-serving backgrounds. Their opinions help to draw a robust evidence-based picture of sexual health knowledge and practices among young Iranians. Our findings provide a novel needs assessment with helpful recommendations to improve sexual health services and education. Nevertheless, there are limitations to this research. A small sample was used and the views of important stakeholders  were absent from this study. Nonetheless, our findings support those of Akbari et al. , who incIn conclusion, HCPs judged young Tehranians' sexual health knowledge to be poor and believed that existing government-funded sexual healthcare is lacking and inaccessible. They strongly suggested that available sexual health provision should be augmented and recommended development of non-judgmental, accessible, confidential and fairly-priced sexual healthcare, availability of publicized sexual health clinics, as well as provision of culturally-tailored, government-endorsed reliable online training materials in Persian. These recommendations complement and correspond to suggestions made by young Iranians, across studies. Collectively this body of research recommends action to develop new culturally acceptable SHRE for young Iranians.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by The University of Exeter Medical School and Iran University of Medical Sciences. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.NS and CA collaboratively designed the study. NS collected and analyzed the data. CA and SD advised on data analysis, participated in drafting the article, and critically revised the final version. All authors have read and approved the final version of the article for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder common from childhood to adulthood, affecting 5% to 12% among the general population in developed countries. Potential etiological factors have been identified, including genetic causes, environmental elements and epigenetic components. Nutrition is currently considered an influencing factor, and several studies have explored the contribution of restriction and dietary supplements in ADHD treatments. Iron is an essential cofactor required for a number of functions, such as transport of oxygen, immune function, cellular respiration, neurotransmitter metabolism (dopamine production), and DNA synthesis. Zinc is also an essential trace element, required for cellular functions related to the metabolism of neurotransmitters, melatonin, and prostaglandins. Epidemiological studies have found that iron and zinc deficiencies are common nutritional deficits worldwide, with important roles on neurologic functions , finicky appetite, and mood changes (sadness and irritability). Altered levels of iron and zinc have been related with the aggravation and progression of ADHD. Objective: This is a systematic review focused on the contribution of iron and zinc in the progression of ADHD among children and adolescents, and how therapies including these elements are tolerated along with its effectiveness (according to PRISMA guidelines). Method: The scientific literature was screened for randomized controlled trials published between January 2000 to July 2021. The databases consulted were Medline, PsycINFO, Web of Science, and Google Scholar. Two independent reviewers screened studies, extracted data, and assessed quality and risk of bias . Conclusion: Nine studies met the eligibility criteria and were selected. Evidence was obtained regarding the contribution of iron-zinc supplementation in the treatment of ADHD among young individuals. The discussion was focused on how the deficits of these elements contribute to affectation on multiple ADHD correlates, and potential mechanisms explaining the mediational pathways. Evidence also suggested that treating ADHD with diet interventions might be particularly useful for specific subgroups of children and adolescents, but further investigations of the effects of these diet interventions are needed. Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder, usually beginning in early childhood and with a chronic progression to adulthood with several negative consequences, such as low self-esteem, difficulties in interpersonal relationships, and problems in school learning . SubtypeEtiological research outlines that ADHD constitutes a complex condition with multiple interactive factors . SpecifiDiverse treatment plans have demonstrated to improve the symptoms of ADHD, usually combining medication (stimulants and non-stimulants have proved efficacy) with behavioral therapy ,34. EmpiOn the other hand, despite growing pharmacological discoveries, mental disorders (such as ADHD) have shown a gradual rise during the last few decades, and rates are expected to continue increasing in the coming years ,43,44. IDietary models have proved to be relevant to both metabolic performance and individuals’ behavior. Restriction and elimination diets have been tested in ADHD treatments , and supSome studies have analyzed the contribution of zinc and iron on ADHD occurrence, but conflicting findings have been obtained . As a trOn the basis of the controversial results published regarding the role of dietary nutrients with zinc and iron for the treatment of ADHD ,60, we pPreferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) . The next filters were employed: (a) type of publication:  and ; and (b) Date of publication: (From 1 January 2000–31 July 2021).PsycINFO: search = [((zinc OR iron) AND (ADHD)) AND ((treatment or therapy))]. The next filters were defined: (a) Type of publication: [Peer Reviewed Journal]; and (b) Date of publication: [1 January 2000–31 July 2021];Web of Science: search = [(((zinc OR iron OR ferritin) AND (ADHD)) AND ((treatment or therapy))))]. The next filters were defined: (a) Document Types: [Clinical Trial], and (b) Publication years: [1 January 2000–31 July 2021];Google Scholar: search = [(zinc OR iron) AND (supplement) AND (ADHD) AND (treatment or therapy) AND  AND (children or adolescent) AND ].The research was conducted on 20 July 2021. The strategy research (keywords and search sequence) for each database was:Two authors of this systematic review independently analyzed the title and abstract of each record, according to the inclusion/exclusion criteria. Only studies meeting the eligibility criteria were then extracted. Data validation was discussed by the same authors, and disagreements were resolved by discussion and if needed by consulting a third team member until a consensus was reached.The authors also extracted data of the identified screening records to be described and evaluated in the results section. The information considered for applying the eligibility criteria was: the date and location of publication, type of publication, sample size, participants’ sex and age range, study design, type and duration of the treatment, and measures and outcomes .Consolidated Standards of Reporting Trials guidelines were employed (CONSORT-2010) , obtaining the precision of the estimates  and carrying out a cost-effectiveness analysis cost). p = 0.02), but no differences between the groups were found in the other measures for the hyperactivity and impulsivity scales. The lack of differences in the total ADHD score in this study suggested that augmentation with zinc could only partially improve ADHD severity levels. The authors of the study also noticed that the difference between the two groups regarding the gender ratio compromised the generalization capacity, and that the use of the Connors Parent’s Questionnaire as the only measure for ADHD was a significant limitation .The study of Noorazar and colleagues used the next intervention : (a) a dn = 40 pediatric children, and obtained an improvement in ADHD signs associated to the experimental group in the questionnaires answered by teachers (no differences emerged from the parents’ reports) [The study of Zamora and colleagues also valued the effect of zinc supplementation (10 mg/day) as an adjuvant therapy  for ADHD in reports) . These an = 52 ADHD children treated with d-amphetamine (weight-standardized) and zinc complementation (15 mg/day or 30 mg/day) or d-amphetamine and a placebo, a similar improvement in ADHD was observed in all the conditions  [In the research by Arnold et al. with placebo) . InteresThe study carried out by Akhondzadeh et al. aimed to compare two groups of patients with ADHD  and both conditions treated with methylphenidate (1 mg/kg/day), and the experimental group obtained more improvement according to parents’ and teachers’ ratings at 6 weeks of the intervention . Trend an = 400 children with ADHD observed that the group receiving the zinc supplement (approximate dose of 40 mg/day) compared with the control group (receiving placebo) obtained greater improvements in multiple measures  but results were similar for attention deficiency [The study by Bilici and colleagues among a large sample of ficiency . The gren = 23 children who met the criteria for ADHD, which showed that the experimental group reported more improvement than the control group in different treatment outcomes [The study by Konofal and colleagues aimed to examine the contribution of iron supplementation  in a sample of outcomes : ADHD syn = 42 children with ADHD also obtained benefits for the use of ferrous sulfate (5 mg/kg/day) plus methylphenidate (1 mg/kg/day), in the inattentiveness, hyperactivity, and impulsive symptom levels reported by parents at 2 months of treatment [The study of Panahandeh et al. in a sample of reatment . In the reatment ,78.Some randomized clinical studies have also valued the contribution of multimineral-vitamin supplements which include zinc and iron for ADHD treatment in children. The rationale for selecting trails with multi-supplements therapy plans for ADHD was the low number of trails using simultaneously zinc and iron, and those identified used preparations with vitamins, dietary minerals and other nutritional elements. Therefore, considering these studies facilitates generalizability of the results related with the use of zinc–iron supplements. n = 93 patients used Daily Essential Nutrients , which contains a comprehensive range of micronutrients . The participants were instructed to titrate the dose up to over a week, starting with 3 capsules per day and increasing it to up to 12 capsules per day  is consistent with other non-randomized studies that explored the contribution of these micronutrients within clinical- and population-based samples. For example, a longitudinal study with a large sample with p period . A positchildren . The potential explanations about the paths between the zinc–iron levels and the various ADHD manifestations are discussed in a number of studies, which showed that lower levels of these elements in childhood  could be related to a dopaminergic impairment, which could be the origin of the high inattentiveness–hyperactivity levels and the other correlates of the ADHD disease (like the presence of restless leg syndrome and other multiple sleep problems) ,84,85. Nn = 810 monitored children aged 5–12 years old showed that consumption of omega-3 and omega-6 with complementation of zinc improved ADHD symptoms, as well as other emotional problems, and sleeping disease  after 12 weeks [The link between iron and zinc supplementation and the observed decrease in ADHD symptoms in the controlled clinical trials selected for this systematic review also makes sense with regard to the role of zinc and iron as dopamine reuptake inhibitors, which was precisely the core target of the stimulant medications used in the combined treatment plans for the disease. Other non-randomized studies using a combination of polyunsaturated fatty acids with zinc supplementation also showed benefits for the treatment of ADHD. For example, the observational study of Huss et al. in a large sample of 12 weeks . The rat12 weeks ,93.n = 18 children by comparing d-amphetamine with Efamol, assessed the moderate role of zinc [The studies included in this review support the existence of subgroups  that could be particularly benefitted from treatments including dietary zinc and iron supplements, such as the results of Bilici and colleagues : the ass of zinc , categor of zinc  analyzed of zinc . This st of zinc . HoweverBased on the results obtained in this systematic review, the specific role of dietary nutrients with zinc and iron still seems controversial for the treatment of ADHD, being most consistent with the evidence for zinc. Moreover, although the reviewed studies found a relationship between the use of dietary supplements containing these elements with the improvement of ADHD symptoms, neither the mono-causal role of a concrete specific nutritional deficiency among ADHD children nor the role of a concrete dietary nutrient in the management of this disorder were proven (as was reported quite recently ). FutureThe results obtained in this systematic review should be considered for combining these multi-facet interventions with additional precise interventions, specifically focused on the nutritional state and clinical profile of each patient. The ultimate objective of these treatments, including medical, psychological, and diet plans, should be to decrease the levels of ADHD, but also its multiple negative correlates, in order to achieve better performance in vigilance and sustained attention tasks, executive functioning tasks (like planning and organization), set shifting and response monitoring, and complex problem-solving.Finally, this study should be interpreted in consideration of certain limitations. First, a meta-analysis was not conducted. Systematic reviews of treatment plans often include statistical methods to summarize the results of independent research by combining the information of selected studies  with the aim to provide more precise estimates of the effects of health care. However, it must be outlined that not all topics allow a meta-analysis to be conducted, and these concrete systematic reviews use alternative methods of synthesis described as “narrative synthesis”. This was the case of our study: we did not employ meta-analyses because of the clinical heterogeneity of individual studies, with different intervention characteristics , diverse outcome/effects measurement, different research settings, and differences in participants’ features . Since current studies have proven that this heterogeneity could cause significant inaccurate summary effects and associated conclusions, and thus misleading decision-markers , we opte