Acceptability of donated breast milk among pregnant women in selected hospitals in central Uganda: a cross-sectional study

BACKGROUND

Donated breast milk is considered beneficial to vulnerable infants. Thus, Uganda launched its first human milk bank in November 2021 to provide breast milk to preterm, low birthweight and sick babies. However, there is a scarcity of information on the acceptability of donated breast milk in Uganda. The study sought to assess the acceptability of using donated breast milk and associated factors among pregnant women at a private and a public hospital in central Uganda.

METHODS

This cross-sectional study enrolled pregnant women attending antenatal care at the selected hospitals between July and October 2020. All pregnant women recruited had already given birth to at least one child. Data were collected using a semi-structured questionnaire, and we recruited participants through systematic sampling. Used frequencies, percentages and means with standard deviations to summarize variables. Assessed the association between the acceptability of donated milk and selected factors by comparing their arithmetic means using a generalized linear model to allow for clustering at the health facility level. Used a normal distribution and an identity link and calculated the adjusted mean differences together with 95% CIs [generated using robust variance estimators to correct for model misspecification].

RESULTS

A total of 244 pregnant women with a mean age of 30 (± 5.25) years were enrolled. Sixty-one-point 5% (150/244) of the women reported that they would accept donated breast milk. Higher education (adjusted mean difference, technical versus primary level: 1.33; 95% CI 0.64, 2.02), being Muslim (adjusted mean difference, Muslim versus Christian: 1.24; 95% CI 0.77, 1.70), having heard of donated breast milk banking (adjusted mean difference, ever versus never: 0.62; 95% CI 0.18, 1.06) and presence of a serious medical condition (adjusted mean difference, preference of donated milk versus other feeds in a serious medical condition: 3.96; 95% CI, 3.28, 4.64) were associated with acceptability of donated breast milk.

CONCLUSIONS

The acceptability of using donated breast milk for infant feeding was high among pregnant women. Public sensitization and education campaigns are indispensable for the acceptability of donated milk. These programs should be designed to include women with lower education levels.

Limitations and opportunities of smallholders' practical knowledge when dealing with pig health issues in northern Uganda

Pig production has a short history in Uganda. The majority of pigs are kept by smallholder farmers in rural areas where access to veterinary services is limited, and pig keeping has been suggested as a potential pathway out of poverty for smallholders. Previous research has identified the disease of African swine fever (ASF) as a major threat, causing high mortalities in pigs. With no available cure or vaccine, the only option is to implement biosecurity measures, i.e. strategies that prevent the spread of ASF. This paper draws on data from four months of ethnographic fieldwork in rural northern Uganda. Combining methods of participant observation, semi-structured interviews, focus group discussions and a survey, the aim was to improve understanding of smallholders' perceptions and responses to pig health issues such as ASF. Applying the concept of practical knowledge, this paper analyses the potential and limitations of smallholders' practice-based knowledge as a means of dealing with pig health issues. The results show that while pigs were appreciated locally for providing an income, many informants found it difficult to deal with pig diseases effectively. Consequently, informants commonly expressed a need for other kinds of knowledge in their pig production, indicating that veterinary advice can play an important role in reducing the negative impact of pig health issues. For animal health provision to have relevance in this context, however, veterinary practitioners must pay close attention to smallholders' priorities and ways of knowing in their livestock keeping. Results further show that pig health issues made some informants abandon pig production altogether. To enhance the potential of pig production as a poverty mitigation strategy in Uganda, research and policy need to focus on ways of bettering general conditions for smallholder pig keeping, including improving the quality of and access to veterinary services in rural areas.

"It's just like a blood transfusion": perceptions on the use of donated breast milk in selected hospitals in central Uganda: a qualitative study

BACKGROUND

Breast milk is crucial for the nutritional and developmental milestones in the first two years of life. Uganda has recognized the need for a human milk bank as an opportunity that offers reliable and healthy milk to babies who lack access to their mothers. However, there is little information on the perceptions towards donated breast milk in Uganda. This study aimed to explore the perceptions of mothers, fathers, and health workers on the use of donated breast milk at Nsambya and Naguru hospitals in Kampala district, central Uganda.

METHODS

A qualitative descriptive study was conducted at Nsambya and Naguru hospitals in central Uganda. The study consisted of 8 focus group discussions (FGDs) of 6 participants each and 19 key informant interviews (KIIs) among mothers, fathers, and health workers. Participants were purposively selected. Data collected were transcribed, translated from Luganda to English, and analyzed using thematic analysis. All data were organized and managed in Nvivo version 12.0.

RESULTS

A total of 67 participants were involved in the study. Two main themes were identified: positive perceptions and negative perceptions. Participants linked donated breast milk to blood transfusion, believed it had nutrients comparable to the biological mother's milk, and thought it was an opportunity to avoid formula or cow milk and help babies that cannot access breast milk. However, the notable negative perceptions were; the feeling that donated breast milk is disgusting, could result in acquiring non-parental genes and traits, and that it was unsafe. Participants also feared that donated breast milk could be expensive and affect the bond between mother and child.

CONCLUSION

In summary, participants had positive perceptions about donated breast milk but were concerned about the potential side effects. Health workers should take extra precautions to ensure that donated breast milk is safe. The development of appropriate information and communication programs to sensitize the public about the benefits of donated breast milk will improve the uptake. Further research should focus on understanding the social-cultural beliefs regarding donated breast milk.

Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda

BACKGROUND

Transwomen (also known as transgender women) are disproportionately affected by all forms of gender-based violence (GBV). The high prevalence of physical, sexual and emotional violence not only predisposes transwomen to HIV infection but also limits the uptake/access to HIV prevention, care, and treatment services. Despite the high prevalence of HIV infection and GBV among transwomen, there is limited evidence on how GBV affects the uptake and utilisation of HIV prevention, care, and treatment services. Therefore, this qualitative study explored how GBV affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area (GKMA), Uganda.

METHODS

This participatory qualitative study was conducted among transwomen in the GKMA. A total of 20 in-depth interviews, 6 focus group discussions, and 10 key informant interviews were conducted to explore how GBV affects the uptake and utilisation of HIV prevention, treatment, and care services among transwomen. Data were analysed using a thematic content analysis framework. Data were transcribed verbatim, and NVivo version 12 was used for coding.

RESULTS

At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy (ART). Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level led to fear among transwomen traveling to healthcare facilities. Emotional violence suffered by transwomen in healthcare settings led to the limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. The fear of emotional violence also made it difficult for transwomen to approach healthcare providers. Fear of physical violence such as being beaten while in healthcare settings made transwomen shun healthcare facilities.

CONCLUSION

The effects of GBV on the uptake and utilisation of HIV prevention, care, and treatment services were observed in individual, community, and healthcare settings. Across all levels, physical, emotional, and sexual violence suffered by transwomen led to the shunning of healthcare facilities, denial of healthcare services, delays in receiving appropriate care, and the low utilisation of post-exposure prophylaxis, and HIV testing services. Given its effects on HIV transmission, there is a need to develop and implement strategies/ interventions targeting a reduction in GBV. Interventions should include strategies to sensitize communities to accept transwomen. Healthcare settings should provide an enabling environment for transwomen to approach any healthcare provider of their choice without fear of experiencing GBV.

Cultural beliefs and practices on perinatal death: a qualitative study among the Lango community in Northern Uganda

BACKGROUND

Perinatal death has profound psychosocial effects on women and their families. Sociocultural contexts influence the burden, rituals and bereaved's support. Little is known about cultural beliefs and practices related to perinatal death. This study explored the cultural perspectives of the Lango community on perinatal death.

METHODS

This study utilised a focused ethnographic design anchored on a symbolic interactionist framework to understand the meanings attached to beliefs and practices on stillbirth or neonatal death among the Lango community in Lira District, Northern Uganda. Participants were sampled purposively for FGD while key informants were identified through snowballing technique. Data were audio recorded in Lango, transcribed, and later translated, a codebook was developed and data entered into Atlas. ti version 8.4.26 and then coded. It was analysed both deductively and inductively into themes.

RESULTS

Stillbirth and early neonatal death both attract similar rituals as would an older child. Burial is not rushed and is attended by family members and close friends. Stillbirths and children that die before naming are buried without names. Bereaved families are comforted and encouraged about future pregnancies. Currently, Lango associates the deaths to biomedical explanations such as teenage pregnancies, inadequate pregnancy care, health system challenges and poor health-seeking behaviour, unlike previously when they were attributed to consequences of unacceptable social behaviours, superstitious beliefs and witchcraft. Antenatal care and health facility childbirths are currently preferred over traditional practices for good pregnancy outcomes.

CONCLUSION

Stillbirth or early neonatal death is viewed as the death of a child, different from other settings. Thus, rituals are performed to honour, create memory, and maintain the connection with deceased babies. Bereaved parents are supported. Health care workers need to provide culturally sensitive support to parents after perinatal loss. The prevailing beliefs of perinatal death cause in terms of biomedical explanations consistent with known determinants and preference for health facility care for prevention creates an opportunity for improving perinatal health.

Knowledge, attitude and practices related to the use of personal protective equipment among welders in small-scale metal workshops in Nansana Municipality, Wakiso District, Uganda

Background

Despite the risks involved in welding, there is limited evidence of the knowledge, attitude and practices related to the use of personal protective equipment (PPE) among welders in small-scale metal workshops. We assessed the level of knowledge, attitude and practices (KAP) related to PPE use among welders in small-scale workshops in Nansana Municipality, Wakiso district, Uganda.

Methods

A cross-sectional study was conducted among 329 welders. A structured questionnaire was used to collect data on welder knowledge and attitude while an observation checklist was used to establish utilization of PPE. Ten key informant interviews were conducted to further understand welders’ knowledge, attitude and PPE-related practices. A ‘modified Poisson’ regression analysis was done to establish the independent factors associated with PPE KAP. NVivo 12 was used for the management of qualitative data. A thematic content approach guided qualitative data analysis.

Results

About 61.4% (202/329) of the respondents had a high level of knowledge, 68.7% (226/329) had a negative attitude, and only 37.1% (122/329) exhibited good PPE-related practices. Knowledge of PPE use was associated with the type of training (aPR = 1.52, CI = 1.29–1.80). Attitude toward PPE use was associated with the level of education (aPR = 2.31, CI = 1.28–4.14), duration of work experience (aPR = 2.37, CI = 1.01–5.55), (aPR = 2.79, CI = 1.13–6.89), and level of knowledge (aPR = 1.73, CI = 1.13–2.65). PPE-related practices were associated with the type of training (aPR = 2.91, CI = 2.14–3.96) and attitude (aPR = 1.45, CI = 1.08–1.93).

Conclusion

While the welders’ level of knowledge of PPE was found to be high, the majority exhibited a negative attitude and poor PPE-related practices. A high level of knowledge was associated with a positive attitude. In turn, a positive attitude was associated with good PPE practices. Welders need to be sensitized on the health risks that may arise from the non-use of PPE.

Effect of a communication intervention on alcohol use during pregnancy in post conflict Northern Uganda: a quasi experimental study

BACKGROUND

Alcohol use during pregnancy is a preventable risk factor for Fetal Alcohol Spectrum disorders. Psycho-social and educational interventions have been reported to enable women reduce alcohol intake levels during pregnancy and help improve some health outcomes of unhealthy alcohol use. We set out to assess the effect of a communication intervention on alcohol use during pregnancy in post conflict northern Uganda.

METHODS

The study employed a quasi - experimental design to assess the effect of a community health worker led communication strategy on pregnant women's knowledge, attitudes and various patterns of alcohol use using Difference in Difference(DiD). 420 respondents were recruited at baseline as at endline.

RESULTS

The communication messages were significantly associated with reduced odds of binge drinking (P = 0.018; OR = 0.09; CI = 0.012-0.66). Also those who received the intervention were less likely to drink frequently (P = 0.80; OR = 0.75; 95%CI = 0.074-7.5) or be harmful alcohol users(P = 0.948). The intervention also positively influenced having fair (β =0.49;P = 0.217;RRR =1.63)or adequate knowledge(β = 0.89;P = 0.25;RRR = 2.44) and having positive(β = 0.37;RRR =1.44;P = 0.46) or fair attitude(β = 0.19;RRR = 1.21; P = 0.693) although not to a significant level.

CONCLUSIONS

The communication intervention affected some patterns of alcohol use among pregnant women and not others. Our results contribute to existing evidence that communication interventions are a promising approach in reduction of alcohol exposed pregnancies. Interventions aimed at promoting alcohol abstinence during pregnancy should be implemented alongside other strategies that address factors that influence pregnant women to drink to achieve maximum results.

Help-seeking and challenges faced by transwomen following exposure to gender-based violence; a qualitative study in the Greater Kampala Metropolitan Area, Uganda

BACKGROUND

The high prevalence of gender-based violence (GBV) among transwomen is a human rights and public health challenge. Nonetheless, there is limited evidence of sources of GBV support services and the challenges faced by transwomen while help-seeking, especially in transphobic settings like Uganda. This study explored the sources of GBV support services and the challenges faced by transwomen in the Greater Kampala Metropolitan Area during help-seeking.

METHODS

A qualitative study design involving 60 transwomen and 10 key informants was conducted. Respondents were recruited using snowball sampling. An in-depth interview (IDI), and a focus group discussion guide were used to collect data from 20 IDI respondents and six focus group discussants. Each focus group discussion averaged six participants. A key informant interview guide was used for key informant interviews. Data were transcribed verbatim and analysed following a thematic framework, informed by the socio-ecological model. Data were organised into themes and subthemes using NVivo 12.0.

RESULTS

The sources of support following exposure to GBV included key population-friendly healthcare facilities and civil society organisations (CSOs), and friends and family. Friends and family provided emotional support while key population-friendly healthcare facilities offered medical services including HIV post-exposure prophylaxis. Key population CSOs provided shelter, nutritional support, and legal advice to GBV victims. Lack of recognition of transgender identity; long distances to healthcare facilities; discrimination by healthcare providers and CSO staff, inappropriate questioning of the trans-gender identity by police officers and healthcare providers, and the lack of trans-competent healthcare providers and legal personnel hindered help-seeking following exposure to GBV.

CONCLUSION

The immediate sources of GBV support services included key population-friendly healthcare facilities and CSOs, police, and friends and family. However, a significant number of transwomen did not report incidences of GBV. Transwomen were discriminated against at some key population healthcare facilities and CSOs, and police, which hindered help-seeking following exposure to GBV. This study highlights the need to tackle internalized stigma and discrimination against transwomen at the existing sources of GBV support. There is also a need to train law enforcers and legal personnel on the right to access healthcare among transwomen in Uganda.

Factors associated with uptake of contraceptives among HIV positive women on dolutegravir based anti-retroviral treatment-a cross sectional survey in urban Uganda

Background

In May 2018, following the preliminary results of a study in Botswana that reported congenital anomalies in babies born to HIV-positive women taking dolutegravir drug, the WHO issued a teratogenicity alert. However, there are scarce data on the impact of this guidance on contraceptive uptake among women taking dolutegravir. We assessed the uptake of contraceptives in HIV-positive women of reproductive age on dolutegravir regimens.

Methods

We conducted a cross-sectional survey from April 2019 to July 2019 in five government health facilities in central Uganda, where dolutegravir-based regimens were offered as the preferred first-line antiretroviral treatment. We randomly selected 359 non-pregnant women aged 15–49 years taking dolutegravir-based regimens and interviewed them using semi-structured interviewer-administered questionnaires. We collected data on demographics, contraceptive use, individual, social, and health system factors. We described patients’ characteristics using descriptive statistics and assessed factors associated with contraceptive uptake using a modified Poisson regression model.

Results

A total of 359 women were included in the study. The mean age was 37 years (standard deviation = 6.8) and overall contraceptive uptake was 38.4%. The most utilized method was injectable method at 58.4% followed by condoms (15%), intrauterine device (10.7%), pills (6.4%), implants (5.4%), and sterilization (0.7%). Predictors for contraceptive uptake were parity of 3–4 children (Adjusted Prevalence Ratio (APR) = 1.48, 95% confidence interval (CI): 1.14, 1.92) in reference to those with 1–2 children. There was reduced contraceptive uptake in women of the age range 40–49 years (APR = 0.45, CI: 0.21–0.94) compared to those aged 15–24 years. Unemployed women were less likely to use contraceptives (APR: 0.6, CI: 0.42- 0.94) than the formally employed. Contraceptive uptake was lower among women who did not discuss family planning with their partners (APR = 0.39, CI: 0.29–0.52) than those who discussed family planning with their partners and women who did not receive family planning counseling (APR = 0.56, CI: 0.34–0.92) than those who received family planning counselling.

Conclusion

We observed a low-level uptake of contraceptives, with injectables as the most used method. Family planning counseling and partner discussion on family planning were associated with contraceptive uptake among the women who used dolutegravir-based regimens. There is a need for more strategies to integrate FP services and increase male involvement in HIV care programs.

Using community influencer groups to address COVID-19 misinformation and vaccine hesitancy in Uganda: a protocol for a prospective quasi-experimental study

INTRODUCTION

Coronovirus disease 2019 (COVID-19) misinformation has been reported globally and locally. This has the potential to influence public risk perception and reduce the acceptance of the COVID-19 vaccine. This study aims to determine the prevalence of COVID-19 misinformation and vaccine hesitancy in Buikwe district. The study will also pilot a social mobilisation intervention using community influencers and determine its effect on COVID-19 misinformation and vaccine hesitancy.

METHODS AND ANALYSIS

The study will be conducted using a quasi-experimental study design, in which two villages will be assigned to the intervention arm and two villages assigned controls. A mixed-methods technique employing both quantitative and qualitative methods will be employed. Data will be collected from healthy men and women aged 18 years and older who reside in the selected villages. The study will be implemented in three phases. First, a baseline study of 12 in-depth interviews with key informants and 6 focus group discussions and a household survey among 632 participants will be done. Second, an intervention employing dialogue-based social mobilisation approach using 10-man community groups per village will be developed and implemented. These will be trained and facilitated to educate and sensitise their communities about COVID-19. Third, an end-line household survey done after 6-months of intervention implementation in the four villages to assess the effect of the intervention on COVID-19 misinformation and vaccine hesitancy. Post-intervention qualitative evaluation will be done after the endline quantitative assessment. Preliminary analysis of the endline quantitative analysis will inform any revisions of the discussion guides. Qualitative data collected will be analysed using thematic content analysis while quantitative data will be analysed using χ² tests or logistic regression, by intention-to-treat analysis.

ETHICS AND DISSEMINATION

The study was reviewed for ethics and approved by the Makerere University School of Health Sciences Research Ethics Committee, reference number MakSHSREC-2020-45 and the Uganda National Council of Science and Technology, reference number HS1140ES. Study finding shall be presented to the district and national COVID-19 task force and at scientific gatherings and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PACTR202102846261362.

"Your heart keeps bleeding": lived experiences of parents with a perinatal death in Northern Uganda

Background

Worldwide, two million babies are stillborn and 1.8 million babies die before completing seven days of life. Approximately 4% of pregnant women in Uganda experience perinatal death. The response following a perinatal death tends to be socio-culturally constructed. Investigating the unique personal experiences of parents from a low-income setting with unique cultural beliefs and practices is crucial for the design and implementation of appropriate interventions.

Objective

To describe the lived experiences of parents following perinatal death in Lira district, Northern Uganda.

Methods

A qualitative study was carried out drawing on the tenets of descriptive phenomenology. We conducted 32 in-depth interviews in Lira district, Northern Uganda between August 2019 and September 2020 with 18 women and 14 men who had experienced a stillbirth or an early neonatal death within the preceding 2 years. Participants were selected from different families and interviewed. A local IRB approved the study. All in-depth interviews were audio-recorded, transcribed, translated, and data were analysed using a content thematic approach. Key findings were discussed based on Worden’s Four Tasks of Mourning theory.

Results

The themes that emerged from the analyses included reaction to the perinatal loss and suggestions for support. The participants’ immediate reactions were pain, confusion, and feelings of guilt which were aggravated by the unsupportive behaviour of health care providers. Men cumulatively lost financial resources in addition to facing multiple stressful roles. Delayed reactions such as pain and worries were triggered by the sight of similar-age-babies, subsequent pregnancy losses, and marital challenges. Participants recommended emotional support and management of postnatal complications for parents faced with perinatal loss.

Conclusion

Losing a baby during the perinatal period in a resource-constrained setting negatively affected both gender. In addition, men suffered the loss of financial resources and the burden of multiple stressful roles. Acknowledging the pain and offering support to the grieving parents reinforce their coping with a perinatal loss. In addition to family and community members, health care providers need to provide emotional support and postnatal care to parents who experience perinatal death.

Are we overlooking alcohol use by younger children?

Alcohol use is a leading contributor to the burden of disease among youth. Early-onset use is associated with later life dependency, ill health and poor social functioning. Yet, research on and treatment opportunities for alcohol use among younger children are scarce. Despite knowledge that alcohol intake occurs in childhood, and the fact that children understand alcohol related norms and develop alcohol expectancies from age 4, younger children are rarely included in studies on alcohol use.Patterns of early alcohol use vary greatly across the globe and are part of complex interplays between sociocultural, economic and health-related factors. Family influence has proven important, but genetic factors do not seem to play a crucial role at this age. Stressful circumstances, including mental health problems and sociocultural factors can entice alcohol use to cope with difficult situations. The World Health Organization has developed guidelines for effective strategies to reduce the harmful use of alcohol, including preventative and treatment interventions, but important gaps in implementation remain. An increased focus on research, policy and implementation strategies related to early alcohol use is warranted, granted its wide-ranging implications for public health and social functioning. In this summary of literature on alcohol use among younger children and adolescents, we show that younger children (aged 10 and younger) tend to be systematically overlooked. However, research, interventions and policy implementation strategies need to include younger children to mitigate the global burden of harmful alcohol use more effectively.

Patient Representatives' Perspectives on Healthcare at the Time of COVID-19 and Suggestions for Care Redesign After the Pandemic: A Qualitative Study in Twenty-Four Countries

Objective

Several comments and recommendations called to embed better the patients' and public voice in healthcare policymaking. Still, no studies captured patients' bottom-up perspectives regarding healthcare at the time of COVID-19 at a micro-level in a range of different countries. We, therefore, explored the perspectives of patient representatives in all six World Health Organisation (WHO) regions and extracted suggestions for care redesign after the pandemic.

Methods

We conducted semi-structured interviews with patient representatives until saturation. Thematic analysis followed a modified form of meaning condensation. We established rigour by transcript checking, inter-coder agreement, quote variation and standardised reporting.

Results

Disadvantaged people experienced an unprecedented inequity in healthcare from limited access to physical violence. The narratives revealed the extent of this inequity, but also opportunities for health workers to act and improve. Stigmatisation from COVID-19 differed between cultures and countries and ranged from none to feeling "ashamed" and "totally bashed". While experienced as indispensable in the future, patients refused telehealth when they were given "bad news", such as having an eye removed because of melanoma, and in end-of-life care. Patient representatives redefined their role and became indispensable influencers throughout the pandemic and beyond.

Conclusion

We reached out to patient representatives with diverse perspectives, including those who represent minorities and marginalised patient populations. Since preferences and personal meanings drive behaviour and could be foundations for targeted interventions, they must be considered in all groups of people to increase society's resilience as a whole. Future healthcare should tackle inequity, address stigmatisation and consider patients' narratives to optimize telemedicine.

Prevention and management of type 2 diabetes mellitus in Uganda and South Africa: Findings from the SMART2D pragmatic implementation trial

Health systems in many low- and middle-income countries are struggling to manage type 2 diabetes (T2D). Management of glycaemia via well-organized care can reduce T2D incidence, and associated morbidity and mortality. The primary aim of this study was to evaluate the effectiveness of facility plus community care interventions (integrated care), compared to facility only care interventions (facility care) towards improvement of T2D outcomes in Uganda and South Africa. A pragmatic cluster randomized trial design was used to compare outcomes among participants with T2D and those at high risk. The trial had two study arms; the integrated care arm, and the facility care arm; and in Uganda only, an additional usual care arm. Participants were enrolled at nine primary health facilities in Uganda, and two in South Africa. Participants were adults aged 30 to 75 years, and followed for up to 12 months. Primary outcomes were glycaemic control among participants with T2D, and reduction in HbA1c > = 3 mmol/mol among participants at high risk. Secondary outcomes were retention into care and incident T2D. Adjusted analysis revealed significantly higher retention into care comparing integrated care and facility care versus usual care in Uganda and integrated care versus facility care in South Africa. The effect was particularly high among participants at high risk in Uganda with an incident rate ratio of 2.46 [1.33-4.53] for the facility care arm and 3.52 [2.13-5.80] for the integrated care arm. No improvement in glycaemic control or reduction in HbA1c was found in either country. However, considerable and unbalanced loss to follow-up compromised assessment of the intervention effect on HbA1c. Study interventions significantly improved retention into care, especially compared to usual care in Uganda. This highlights the need for adequate primary care for T2D and suggest a role for the community in T2D prevention. Trial registration number: ISRCTN11913581.

Alcohol use during pregnancy in post-conflict northern Uganda: pregnant women's experiences and provider perceptions

BACKGROUND

Alcohol use during pregnancy has been associated with several birth defects and developmental disabilities generally known as Fetal Alcohol Spectrum Disorders (FASD). Contextual in-depth understanding on why women drink while pregnant is scarce. For this reason, we explored pregnant women's experiences, knowledge, attitudes as well as provider perceptions regarding prenatal alcohol consumption to inform interventions meant to address alcohol-exposed pregnancies in post-conflict settings.

METHODS

In the months of May and June 2019, 30 in-depth interviews were conducted with pregnant mothers who reported maternal alcohol use during pregnancy. In addition 30 Key informant interviews were carried out with health workers providing Antenatal Care services (ANC) in health facilities in Gulu, Kitgum and Pader districts in Northern Uganda. Data was recorded, transcribed and subjected to thematic content analysis.

RESULTS

Women reported diverse views regarding maternal alcohol use during pregnancy. Whereas some felt it was favourable, others had misgivings about it. There was marked variability in knowledge on dangers of drinking during pregnancy. In this study, women reported that they found themselves in alluring situations that predisposed them to drinking alcohol. These included brewing alcohol as a source of livelihood, pregnancy-induced craving for alcohol, and participation in cultural festivities that are characterised by eating and drinking alcohol. Nonetheless, women who consume alcohol during pregnancy were not held in high esteem in the Acholi communities. Various prevention interventions reportedly existed in communities to address alcohol use during pregnancy including ANC health education, public debates, radio talk shows, community health worker group and individual counselling, and local council by laws.

CONCLUSIONS AND RECOMMENDATIONS

Pregnant mothers in post-conflict northern Uganda regard alcohol as a remedy to some of the social, economic and health challenges they face. Hence they continue drinking even during pregnancy because of the existing socio-cultural norms that promote it. The findings of this study demonstrate a need for sensitising communities in which pregnant women live so they can provide a supportive environment for mothers to abstain from alcohol consumption during pregnancy. Health care providers should ensure pregnant women consistently receive accurate and honest messages on the dangers of drinking during pregnancy so they can make informed decisions.

"I felt very small and embarrassed by the health care provider when I requested to be tested for syphilis": barriers and facilitators of regular syphilis and HIV testing among female sex workers in Uganda

Background

Periodic testing of female sex workers (FSW) for sexually transmitted infections (STIs) is a core component of global and national responses to achieve population-level STI elimination. We conducted a qualitative study to explore barriers and facilitators of regular syphilis and HIV testing among FSW in Uganda.

Methods

Within a quasi-experimental study among 436 FSW to assess the effect of peer education and text message reminders on uptake of regular STI and HIV testing among FSW, we conducted 48 qualitative interviews in four cities in Uganda from August–December 2018. We purposively selected FSW who tested for syphilis and HIV every 3–6 months; 12 FSW were interviewed in each city. Sex worker interviews explored: 1) reasons for periodic syphilis and HIV testing; 2) barriers and facilitators of testing; 3) experiences of testing; and 4) challenges faced while seeking testing services. Data were analyzed using thematic content analysis.

Results

Thematic analysis revealed individual- and health system-level barriers and facilitators of testing. For syphilis, barriers were a) interpersonal stigma, low perceived severity of syphilis and testing misconceptions (individual); and b) judgmental provider attitudes, paucity of facilities offering syphilis testing, stockouts of test kits and high cost (health system). Facilitators were c) desire to remain healthy, get married and have children, knowing the benefits of early treatment, influence of male partners/clients and normative testing behaviors (individual); and d) sex worker clinics offering dual syphilis/HIV testing (health system). For HIV, barriers included: a) internalized stigma (individual); and b) unfavorable clinic hours, stigma, discrimination, and unfriendly provider (health system). Facilitators were a) motivations to stay healthy and attract clients, habitual testing, self-efficacy, doubts about accuracy of negative test results, and use of post-exposure prophylaxis (individual); and d) availability of testing facilities (health system). Syphilis and HIV had similar testing barriers and facilitators.

Conclusions

HIV programs are likely to be important entry points for syphilis testing among FSW. Multi-level interventions to address testing barriers should consider focusing on these service delivery points. Extending the dual syphilis and HIV testing approach to FSW may improve testing uptake for both infections at public health facilities and decrease population-level incidence.

The Ambiguity Imperative: "Success" in a Maternal Health Program in Uganda

Global health programs are compelled to demonstrate impact on their target populations. We study an example of social franchising - a popular healthcare delivery model in low/middle-income countries - in the Ugandan private maternal health sector. The discrepancies between the program's official profile and its actual operation reveal the franchise responded to its beneficiaries, but in a way incoherent with typical evidence production on social franchises, which privileges simple narratives blurring the details of program enactment. Building on concepts of not-knowing and the production of success, we consider the implications of an imperative to maintain ambiguity in global health programming and academia.

Text message reminders and peer education increase HIV and Syphilis testing among female sex workers: a pilot quasi-experimental study in Uganda

BACKGROUND

Globally, female sex workers (FSW) are disproportionately affected by HIV and other sexually transmitted infections (STIs). However, uptake of STI and HIV testing services among FSW in sub-Saharan Africa remains low. We aimed to assess the effect of FSW-led peer education and text message reminders on 3-monthly syphilis and HIV testing among FSW in Uganda.

METHODS

Between September 2019 and February 2020, we implemented weekly peer education sessions and bi-monthly SMS reminders for FSW in Mbarara (intervention city). Peer education sessions were implemented by 20 FSW, who received five days of basic training as peer educators. We held monthly meetings with peer educators throughout the six-month implementation period. FSW in Mbale (control city) continued to receive standard of care consisting of HIV testing outreach campaigns, and facility-based testing. Using a quasi-experimental design in one intervention city, and one control city, we conducted pre- and post- questionnaire-based surveys on recent syphilis and HIV testing behavior among FSW in July-October 2018, and March 2020. We compared proportions and prevalence ratios at baseline and follow-up using chi-square tests and negative binomial regression.

RESULTS

We conducted 436 interviews (200 before/236 after) with FSW. At baseline similar proportions reported taking an HIV test (57 % vs. 54 %; p = 0.72), and a syphilis serology test (35 % vs. 39 %; p = 0.67) in the intervention and control cities, respectively, in the prior three months. After the intervention, this proportion increased to 82 % (95 % confidence interval [CI] 74.0-88.2) for HIV, and 81 % (95 % CI: 73.0-87.0) for syphilis in the intervention city. Relative to baseline in the control city, the proportion testing for HIV was unchanged (52 %) but decreased for syphilis (26 %).

CONCLUSIONS

Bi-monthly text message reminders with weekly peer education sessions increased uptake of 3-monthly syphilis and HIV testing in a Ugandan female sex work population and could help increase sex worker engagement in HIV/STI services in line with World Health Organization recommendations.

Various forms of alcohol use and their predictors among pregnant women in post conflict northern Uganda: a cross sectional study

Background

Alcohol use during pregnancy has been associated with several births and developmental disorders. This study set out to determine the various forms of alcohol consumption among pregnant women and their predictors in post conflict Northern Uganda.

Methods

In the months of May to June 2019, we conducted a cross sectional study among 420 pregnant women seeking antenatal care services at both Government and private health facilities in Gulu, Kitgum and Pader districts in Northern Uganda. We asked them about consumption of various alcoholic beverages. A three stage stratified cluster sampling approach was used and study participants randomly selected from health facilities of interest. We used descriptive statistics to estimate the prevalence of various forms of alcohol use. The chi- square test and logistic regression were used to assess associations of alcohol use among respondents and their socio - demographic and other characteristics.

Results

Overall 99 women (23.6%) reported current alcohol use (any amount). Up to 11% (N = 11) of all drinkers were identified by the AUDIT to be women with problem drinking behavior, 8% (N = 8) of women reported hazardous drinking and only four (4%) were women with active alcohol dependent behavior. Predictors of maternal alcohol use included pre-pregnancy alcohol consumption, knowledge, attitude, education level, parity and residence.

Conclusions

This study indicates that alcohol use (any mount) during pregnancy is high while alcohol dependence, problematic and hazardous drinking is low. Knowledge and attitude were important predictors of alcohol use. While alleviating alcohol use, development partners and relevant government departments should consider communication and other interventions that increase knowledge and risk perception on maternal drinking. Other risk factors that predict maternal drinking such as prior alcohol use, residence and parity should be mitigated or eliminated.

Perinatal death in Northern Uganda: incidence and risk factors in a community-based prospective cohort study

Background: Perinatal mortality in Uganda remains high at 38 deaths/1,000 births, an estimate greater than the every newborn action plan (ENAP) target of ≤24/1,000 births by 2030. To improve perinatal survival, there is a need to understand the persisting risk factors for death. Objective: We determined the incidence, risk factors, and causes of perinatal death in Lira district, Northern Uganda. Methods: This was a community-based prospective cohort study among pregnant women in Lira district, Northern Uganda. Female community volunteers identified pregnant women in each household who were recruited at ≥28 weeks of gestation and followed until 50 days postpartum. Information on perinatal survival was gathered from participants within 24 hours after childbirth and at 7 days postpartum. The cause of death was ascertained using verbal autopsies. We used generalized estimating equations of the Poisson family to determine the risk factors for perinatal death. Results: Of the 1,877 women enrolled, the majority were ≤30 years old (79.8%), married or cohabiting (91.3%), and had attained only a primary education (77.7%). There were 81 perinatal deaths among them, giving a perinatal mortality rate of 43/1,000 births [95% confidence interval (95% CI: 35, 53)], of these 37 were stillbirths (20 deaths/1,000 total births) and 44 were early neonatal deaths (23 deaths/1,000 live births). Birth asphyxia, respiratory failure, infections and intra-partum events were the major probable contributors to perinatal death. The risk factors for perinatal death were nulliparity at enrolment (adjusted IRR 2.7, [95% CI: 1.3, 5.6]) and maternal age >30 years (adjusted IRR 2.5, [95% CI: 1.1, 5.8]). Conclusion: The incidence of perinatal death in this region was higher than had previously been reported in Uganda. Risk factors for perinatal mortality were nulliparity and maternal age >30 years. Pregnant women in this region need improved access to care during pregnancy and childbirth.

Perinatal death triples the prevalence of postpartum depression among women in Northern Uganda: A community-based cross-sectional study

INTRODUCTION

Deaths during the perinatal period remain a big challenge in Africa, with 38 deaths per 1000 pregnancies in Uganda. The consequences of these deaths can be detrimental to the women; some ending up with postpartum depression. We examined the association between perinatal death and postpartum depression among women in Lira district, Northern Uganda.

METHODS

We conducted a community-based cross-sectional study of 1,789 women. Trained research assistants screened women for postpartum depressive symptoms on day 50 postpartum using the Edinburgh postpartum depression scale (EPDS). Socio-demographic, economic, birth and survival status of the neonate were collected during pregnancy and within one week postpartum. We used generalized estimating equation for the Poisson family with a log link using Stata to estimate the prevalence ratio of the association between postpartum depressive symptoms (EPDS scores ≥14) and perinatal death. Mothers who lost their babies between 7-49 days postpartum were excluded.

RESULTS

Of the 1,789 participants symptomatically screened for postpartum depression, 377 (21.1%) [95% confidence interval (95%CI): 17.2%, 23.0%] had probable depressive symptoms. The prevalence of postpartum depressive symptoms among the 77 women who had experienced perinatal death (37 stillbirths and 40 early neonatal deaths (≤7 days of life)) was 62.3% [95% CI: 50.8%, 72.6%] compared to 19.2% [95% CI: 17.4%, 21.2%], among 1,712 with live infants at day 50 postpartum. Women who had experienced a perinatal death were three times as likely to have postpartum depressive symptoms as those who had a live birth [adjusted prevalence ratio 3.45 (95% CI: 2.67, 4.48)].

CONCLUSIONS

The prevalence of postpartum depressive symptoms, assessed by EPDS, was high among women who had had a perinatal death in Northern Uganda. Women experiencing a perinatal death need to be screened for postpartum depressive symptoms in order to intervene and reduce associated morbidity.

HIV and syphilis testing behaviors among heterosexual male and female sex workers in Uganda

Background

In Sub-Saharan Africa where HIV disproportionately affects women, heterosexual male sex workers (HMSW) and their female clients are at risk of acquiring or transmitting HIV and other STIs. However, few studies have described HIV and STI risk among HMSW. We aimed to assess and compare recent HIV and syphilis screening practices among HMSW and female sex workers (FSW) in Uganda.

Methods

Between August and December 2019, we conducted a cross-sectional study among 100 HMSW and 240 female sex workers (FSW). Participants were enrolled through snowball sampling, and an interviewer-administered questionnaire used to collect data on HIV and syphilis testing in the prior 12 and 6 months respectively. Integrated change model constructs were used to assess intentions, attitudes, social influences, norms and self-efficacy of 3-monthly Syphilis and 6-monthly HIV testing. Predictors of HIV and syphilis recent testing behaviors were estimated using negative binomial regression.

Results

We enrolled 340 sex workers of whom 100 (29%) were HMSW. The median age was 27 years [interquartile range (IQR) 25–30] for HMSW and 26 years [IQR], (23–29) for FSW. The median duration of sex work was 36 and 30 months for HMSW and FSW, respectively. HMSW were significantly less likely than FSW to have tested for HIV in the prior 12 months (50% vs. 86%; p = 0.001). For MSW, non-testing for HIV was associated with higher education [adjusted prevalence ratio (aPR) 1.66; 95% confidence interval (CI) 1.09–2.50], poor intention to seek HIV testing (aPR 1.64; 95% CI 1.35–2.04), perception that 6-monthly HIV testing was not normative (aPR 1.33; 95% CI 1.09–1.67) and low self-efficacy (aPR 1.41; 95% CI 1.12–1.79). Not testing for syphilis was associated with low intention to seek testing (aPR 3.13; 95% CI 2.13–4.55), low self-efficacy (aPR 2.56; 95% CI 1.35–4.76), negative testing attitudes (aPR 2.33; 95% CI 1.64–3.33), and perception that regular testing was not normative (aPR 1.59; 95% CI 1.14–2.22).

Conclusions

Non-testing for HIV and syphilis was common among HMSW relative to FSW. Future studies should evaluate strategies to increase testing uptake for this neglected sub-population of sex workers.

Pastoral community practices, microbial quality and associated health risks of raw milk in the milk value chain of Nakasongola District, Uganda

The informal milk value chain in Uganda controls most of the raw marketed milk, albeit of poor quality. A study was conducted to assess the milk handling practices, the bacterial quality and the associated health concerns of raw milk along the informal milk value in Nakasongola District. The cross-sectional study used both qualitative and quantitative methods to obtain information from key players. The qualitative data was categorized and presented into emerging themes. Bacterial contamination of 200 milk samples was determined by morphological and biochemical tests. The antibiotic susceptibility test was done by the disc diffusion method.

Hand milking was carried out mainly by men (92.5%), and most never or rarely practised hand washing (67.5%) during milking. Milk was mainly delivered to mobile milk-collecting centres located under tree shades (50%). The quality of raw milk was affected by poor hygienic, handling and transportation practices. Most participants (75%) were aware of the dangers of drinking raw milk and the requirements to transport milk in metallic cans. Viable bacterial counts above the recommended limit were recorded in 76 samples (38%) that included Staphylococcus aureus (46%), coagulase-negative Staphylococcus (29%), Escherichia coli (12%), Streptococcus agalactiae (8%) and Salmonella spp. (5%). The overall antibiotic resistance was 45% (34/76), which included resistant isolates of S. aureus (17/34), coagulase-negative Staphylococcus (11/22), S. agalactiae (3/6), Salmonella spp. (2/4) and E. coli (2/9).

The raw milk contaminated with antibiotic drug-resistant bacterial pathogens is of public health concern. Thus, measures to improve the quality of milk need to be designed for the pastoral community in Nakasongola district.

Psychosocial correlates of regular syphilis and HIV screening practices among female sex workers in Uganda: a cross-sectional survey

BACKGROUND

Limited data are available regarding correlates of regular sexually transmitted infections (STIs) and HIV screening among female sex workers (FSW) in Sub-Saharan Africa. In this study, we aimed to assess the frequency of regular syphilis and HIV screening and the psychosocial correlates associated with screening among FSW in Uganda.

METHODS

This cross-sectional correlational study was conducted among 441 FSW, aged 17-49 years. We enrolled FSW through peer referrals and ascertained self-reported data on number of serological tests for HIV, syphilis and other STIs in the prior 12 months using an interviewer-administered questionnaire. In addition, we assessed attitudes, norms, social influences and self-efficacy towards 3-monthly Syphilis and 6-monthly HIV testing. We estimated the correlates of regular STI and HIV testing using negative binomial regression.

RESULTS

Of the respondents 420 (95.2%) reported to have ever taken an HIV test with 297 (67.4%) testing two or more times in the prior 12 months. Over half of the respondents (59%) reported ever taking a syphilis test with only 62 (14.1%) reporting testing three or more times in the prior 12 months. After adjusting for socio-demographics, attitude and norms, high perceived self-efficacy was associated with a 33% increase in the likelihood of repeated HIV testing [prevalence ratio (PR), 1.33, 95% confidence interval (CI) 1.15-1.53] while low perceived confidence was associated with a 25% decrease in the likelihood of repeated HIV testing (PR, 0.75, 95% CI 0.63-0.89). Similarly low attitudes and norms were associated with a decrease of 52.6% (PR, 0.47, 95% CI 0.37-0.61) and 47% (PR, 0.53, 95% CI 0.41-0.69) in the likelihood of repeated syphilis testing respectively.

CONCLUSION

Compared to HIV, uptake of repeated syphilis testing was very low. Correlates of HIV testing include; perceived self-efficacy amidst barriers and perceived confidence for HIV and low attitudes and accepting norms for syphilis. Health campaigns should emphasize overcoming barriers to HIV testing while promoting attitudes and norms including integration of serological syphilis testing and other STIs into HIV services.