Perceptions and factors associated with the uptake of the community client-led antiretroviral therapy delivery model (CCLAD) at a large urban clinic in Uganda: a mixed methods study

INTRODUCTION

Community Client-Led ART Delivery (CCLAD) is a community HIV care model. In this model, a group of persons living with HIV (PLHIV) in a specific location, take turns going to the HIV clinic to pick up Antiretroviral Treatment refills for members. The uptake of this model, however, remains low despite its improvements in patient retention. In this study, we explored PLHIV's perceptions of this model and identified the factors associated with its low uptake.

METHODS

This was a mixed methods study based on a retrospective review of records of PLHIV and in-depth interviews. We reviewed the medical records of people receiving ART to determine their current model of ART delivery and conducted in-depth interviews with 30 participants who were eligible to be enrolled in the CCLAD model at the Mulago ISS clinic. We performed logistic regression to identify factors associated with the uptake of the CCLAD model and inductive thematic analysis to explore PLHIV's perceptions of the CCLAD model.

RESULTS

A total of 776 PLHIV were sampled for the study, 545 (70.2%) of whom were female. The mean age (standard deviation) was 42 (± 9.3) years. Overall, 55 (7.1%) received ART using the CCLAD model. Compared to other ART-delivery models, CCLAD was associated with being on ART for at least eight years (AOR 3.72; 95% CI: 1.35-10.25) and having no prior missed clinic appointments (AOR 10.68; 95% CI: 3.31-34.55). Mixed perceptions were expressed about the CCLAD model. Participants interviewed appreciated CCLAD for its convenience and the opportunities it offered members to talk and support each other. Others however, expressed concerns about the process of group formation, and feeling detached from the health facility with consequences of lack of confidentiality.

CONCLUSION

The current uptake of the CCLAD model is lower than the national recommended percentage of 15%. Its uptake was associated with those who had been in care for a longer period and who did not miss appointments. Despite CCLAD being perceived as convenient and as promoting support among members, several challenges were expressed. These included complexities of group formation, fear of stigma and feelings of detachment from health facilities among others. So, while CCLAD presents a promising alternative ART delivery model, more attention needs to be paid to the processes of group formation and improved patient monitoring to address the feelings of detachment from the facility and facility staff.

Sustainability of health services in refugee hosting districts: a qualitative study of health services in three west Nile refugee hosting districts, Uganda

BACKGROUND

Humanitarian health assistance programmes have expanded from temporary approaches addressing short-term needs to providing long-term interventions in emergency settings. Measuring sustainability of humanitarian health services is important towards improving the quality of health services in refugee settings.

OBJECTIVE

To explore the sustainability of health services following the repatriation of refugees from the west Nile districts of Arua, Adjumani and Moyo.

METHODS

This was a qualitative comparative case study conducted in three west Nile refugee-hosting districts of Arua, Adjumani, and Moyo. In-depth interviews were conducted with 28 purposefully selected respondents in each of the three districts. Respondents included health workers and managers, district civic leaders, planners, chief administrative officers, district health officers, project staff of aid agencies, refugee health focal persons and community development officers.

RESULTS

The study shows that in terms of organization capacity, the District Health Teams provided health services to both refugee and host communities with minimal support from aid agencies. Health services were available in most former refugee hosting areas in Adjumani, Arua and Moyo districts. However, there were several disruptions notably reduction and inadequate services due to shortage of drugs and essential supplies, lack of health workers, and closure or relocation of health facilities in around former settlements. To minimize disruptions the district health office reorganized health services. In restructuring health services, the district local governments closed or upgraded health facilities to address reduced capacity and catchment population. Health workers employed by aid agencies were recruited into government services while others who were deemed excess or unqualified were laid off. Equipment and machinery including machines and vehicles were transferred to the district health office in specific health facilities. Funding for health services was mainly provided by the Government of Uganda through the Primary Health Care Grant. Aid agencies, however, continued to provide minimal support health services for refugees who remained in Adjumani district.

CONCLUSION

Our study showed that while humanitarian health services are not designed for sustainability, several interventions continued at the end of the refugee emergency in the three districts. The embeddedness of the refugee health services in the district health systems ensured health services continued through public service delivery structures. It is important to strengthen the capacity of the local service delivery structures and ensure health assistance programmes are integrated into local health systems to promote sustainability.

Drivers of Solid Waste Segregation and Recycling in Kampala Slums, Uganda: A Qualitative Exploration Using the Behavior Centered Design Model

Solid-waste management is a challenge in many cities, especially in low-income countries, including Uganda. Simple and inexpensive strategies such as solid-waste segregation and recycling have the potential to reduce risks associated with indiscriminate waste management. Unfortunately, these strategies have not been studied and adopted in slums in low-income countries. This cross-sectional qualitative study, therefore, used the behavioral-centered design model to understand the drivers of recycling in Kampala slums. Data were coded using ATLAS ti version 7.0, and content analysis was used for interpreting the findings. Our findings revealed that the study practices were not yet habitual and were driven by the presence of physical space for segregation containers, and functional social networks in the communities. Additionally, financial rewards and awareness related to the recycling benefits, and available community support were found to be critical drivers. The availability of infrastructure and objects for segregation and recycling and the influence of politics and policies were identified. There is, therefore, need for both the public and private sector to engage in developing and implementing the relevant laws and policies on solid waste recycling, increase community awareness of the critical behavior, and create sustainable markets for waste segregated and recycled products.

Ambient air pollution is associated with vascular disease in Ugandan HIV-positive adolescents

OBJECTIVE

In this study, we aim to investigate the relationship between particulate matter, a common proxy indicator for air pollution, and markers of inflammation, monocyte activation, and subclinical vascular disease.

DESIGN

A cross-sectional study.

METHODS

Adolescents with perinatally acquired HIV (PHIV) and HIV-uninfected adolescents between 10 and 18years living near Kampala, Uganda were included. Daily ambient concentrations of particulate matter (PM2.5) were measured from the Eastern Arica GEOHealth Hub. Outcome variables measured were carotid intima-media thickness (IMT), as well as plasma markers of systemic inflammation, oxidized lipids, and gut integrity. Multivariable quantile regression models were used to explore the relationship between PM2.5 and IMT.

RESULTS

One hundred and nineteen participants (69 PHIV, 50 HIV-uninfected) were included. The median (Q1, Q3) age was 12.7 (11.4,14.2) years, 55% were girls. Median daily PM2.5 exposure was 29.08 μg/m3 (23.40, 41.70). There was no significant difference in exposure of PM2.5 between groups (P  = 0.073). PM2.5 significantly correlated with intestinal permeability (zonulin; r = 0.43, P < 0.001), monocyte activation (soluble CD163: r  = 0.25, P = 0.053), and IMT (r  = 0.35, P = 0.004) in PHIV but not in HIV-uninfected (P ≥ 0.05). In multivariable quantile regression, after adjusting for age, sex, poverty level, soluble CD163, and zonulin, daily PM2.5 concentrations remained associated with IMT [β  = 0.005, 95% CI (0.0003-0.010), P = 0.037] in adolescents with PHIV.

CONCLUSION

Adolescents in urban Uganda are exposed to high levels of air pollution. Both PM2.5 and HIV have independently been observed to contribute to atherosclerotic disease, and our findings suggest the combined effects of HIV and air pollution may amplify the development of cardiovascular disease.

'Endure and excuse': a mixed-methods study to understand disclosure of intimate partner violence among women living with HIV in Uganda

Intimate partner violence and HIV remain significant health challenges among women living with HIV. Intimate partner violence has been linked to negative health outcomes and poorer HIV care engagement. This study examined intimate partner violence among Ugandan women living with HIV, their experiences disclosing such violence and how culturally normative factors affected disclosure-related outcomes. In a mixed-methods study conducted in Uganda in 2018, 168 women participated in interviewer-administered surveys; a sub-set who reported experiencing intimate partner violence participated in in-depth interviews (IDIs). Intimate partner violence was prevalent among women in the sample (68.0%); almost half experienced emotional violence (45.2%), while a smaller proportion had experienced physical (32.1%) and/or sexual violence (19.6%). Most women living with HIV (61.8%) had disclosed their experience of intimate partner violence to someone. Women who experienced intimate partner violence had higher odds of disclosure if they feared their partner and perpetrated violence against their partner. Thematic analysis of IDIs revealed enduring violence and blaming alcohol for men's perpetration of violence. Traditional cultural and gender norms, especially concerning motherhood and partnership, influenced women's experiences of intimate partner violence and disclosure. Multi-sectoral responses to challenge and reform cultural norms that perpetuate violence are needed, including mobilising key stakeholders (e.g. family, community, policy-makers) to serve as catalysts for change and encourage resource- and safety-seeking for women living with HIV to escape violence.

Corrigendum to "Hepatitis B birth dose vaccination for newborns in Uganda: A qualitative inquiry on pregnant women's perceptions, barriers and preferences" [J Virus Eradic 7(2) (2021) 100039]

[This corrects the article DOI: 10.1016/j.jve.2021.100039.].

Predictors of job satisfaction and intention to stay in the job among health-care providers in Uganda and Zambia

BACKGROUND

A shortage of competent health-care providers is a major contributor to poor quality health care in sub-Saharan Africa. To increase the retention of skilled health-care providers, we need to understand which factors make them feel satisfied with their work and want to stay in their job. This study investigates the relative contribution of provider, facility and contextual factors to job satisfaction and intention to stay on the job among health-care providers who performed obstetric care in Uganda and Zambia.

METHODS

This study was a secondary analysis of data from a maternal and newborn health program implementation evaluation in Uganda and Zambia. Using a Likert scale, providers rated their job satisfaction and intention to stay in their job. Predictors included gender, cadre, satisfaction with various facility resources and country. We used the Shapley and Owen decomposition of R2 method to estimate the variance explained by individual factors and groups of factors, adjusting for covariates at the facility and provider levels.

RESULTS

Of the 1134 providers included in the study, 68.3% were female, 32.4% were nurses and 77.1% worked in the public sector. Slightly more than half (52.3%) of providers were strongly satisfied with their job and 42.8% strongly agreed that they would continue to work at their facility for some time. A group of variables related to facility management explained most of the variance in both job satisfaction (37.6%) and intention to stay (43.1%). Among these, the most important individual variables were satisfaction with pay (20.57%) for job satisfaction and opinions being respected in the workplace (17.52%) for intention to stay. Doctors reported lower intention to stay than nurses. Provider demographics and facility level and ownership (public/private) were not associated with either outcome. There were also differences in job satisfaction and intention to stay between Ugandan and Zambian health-care providers.

CONCLUSION

Our study suggests that managers play a crucial role in retaining a sufficient number of satisfied health-care providers providing obstetric care in two sub-Saharan African countries, Uganda and Zambia. Prioritizing and investing in health management systems and health managers are essential foundations for high-quality health systems.

Framing Contraceptive Use Motivations Among Adolescents and Young Adults Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda

Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not). Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda. Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives. Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

Hepatitis B birth dose vaccination for newborns in Uganda: A qualitative inquiry on pregnant women's perceptions, barriers and preferences

BACKGROUND

Sub-Saharan Africa continues with very low hepatitis B (HBV) birth dose vaccination coverage. To guide policy on HBV vaccine for newborns, we explored perceptions, barriers and preferences of pregnant women regarding HBV and the HBV birth dose vaccination.

METHODS

We conducted eight focus groups discussions (FGDs) among 70 pregnant women, stratified by rural-urban residence, age and education level, using a structured focus group discussion guide to explore birth dose awareness, perceptions, barriers and preferences. Data were transcribed, coded and analysed using framework analysis.

RESULTS

Perceptions related to HBV and liver cancer causes and prevention were diverse; most FGD participants did not perceive illnesses as distinctly different. Older women-groups, both urban and rural, had never heard about HBV, but were aware of liver cancer, viewing the disease as fatal. No FGD participants were aware of HBV birth dose. Concerns included vaccine safety, its availability to women who deliver outside the health system and mistrust in health-care worker (HCWs) when handling newborns. Rural-dwelling groups perceived absence of HBV services, while FGDs with young participants believed vaccine side-effects hampered birth dose planning. Most women-groups preferred (i) oral to injectable vaccines; (ii) receiving birth dose education during antenatal, to media-based education; (iii) that newborns receive the birth dose immediately after delivery in the mother's presence.

CONCLUSION

Although the birth dose is acceptable among pregnant women, planners need to continuously engage them as key stakeholders during planning to address concerns, in order to raise confidence, maximize uptake and strengthen HBV eradication efforts.

Measuring Service Quality and Assessing Its Relationship to Contraceptive Discontinuation: A Prospective Cohort Study in Pakistan and Uganda

BACKGROUND

The quality of contraceptive counseling that women receive from their provider can influence their future contraceptive continuation. We examined (1) whether the quality of contraceptive service provision could be measured in a consistent way by using existing tools from 2 large-scale social franchises, and (2) whether facility quality measures based on these tools were consistently associated with contraceptive discontinuation.

METHODS

We linked existing, routinely collected facility audit data from social franchise clinics in Pakistan and Uganda with client data. Clients were women aged 15-49 who initiated a modern, reversible contraceptive method from a sampled clinic. Consented participants completed an exit interview and were contacted 3, 6, and 12 months later. We collapsed indicators into quality domains using theory-based categorization, created summative quality domain scores, and used Cox proportional hazards models to estimate the relationship between these quality domains and discontinuation while in need of contraception.

RESULTS

The 12-month all-modern method discontinuation rate was 12.5% among the 813 enrolled women in Pakistan and 5.1% among the 1,185 women in Uganda. We did not observe similar associations between facility-level quality measures and discontinuation across these 2 settings. In Pakistan, an increase in the structural privacy domain was associated with a 60% lower risk of discontinuation, adjusting for age and baseline method (P<.001). In Uganda, an increase in the management support domain was associated with a 33% reduction in discontinuation risk, controlling for age and baseline method (P=.005).

CONCLUSIONS

We were not able to leverage existing, widely used quality measurement tools to create quality domains that were consistently associated with discontinuation in 2 study settings. Given the importance of contraceptive service quality and recent advances in indicator standardization in other areas, we recommend further effort to harmonize and simplify measurement tools to measure and improve contraceptive quality of care for all.

Determinants of healthcare providers' confidence in their clinical skills to deliver quality obstetric and newborn care in Uganda and Zambia

Background

Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals’ knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia.

Methods

This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics.

Results

Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers’ mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence.

Conclusions

Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.

Prevalence and factors associated with utilization of rehabilitation services among people with physical disabilities in Kampala, Uganda. A descriptive cross sectional study

BACKGROUND

Worldwide, fifteen percent (15%) of the world's population or one (1) billion people live with some form of disability. In Uganda, 12.4% of the Uganda's population lives with some form of disability and Kawempe division accounts for (22.6%) of all persons with disabilities living in Kampala district. Rehabilitation services are provided within Kawempe division at Mulago hospital physiotherapy department and Katalemwa rehabilitation center in Kampala district, Uganda at a free and a subsidized cost to help to improve the function, independence, and quality of life of persons with physical disabilities. However, many people with physical disabilities do not utilize the services and the reasons are not clear.

METHODS

The study design was a descriptive cross-sectional study employing quantitative methods of data collection. A total of 318 participants were included in the study. Simple random sampling was used to select the study participants. Ethical issues were maintained at all levels during data collection and dissemination of results.

RESULTS

The study revealed a prevalence of 26.4% of the utilization rehabilitation services among people with physical disabilities in Kawempe division, Kampala, Uganda. Factors that were significantly associated with utilization of rehabilitation services among people with physical disabilities at multivariable logistic regression analysis included; age (AOR: 0.30; 95% CI: 0.12-0.74), socioeconomic status (AOR: 2.13; 95% CI: 1.03-4.41), education level (AOR: 4.3; 95% CI: 1.34-13.91) and awareness of the participants about the rehabilitation services (AOR: 5.1; 95% CI: 2.74-9.54) at p value ≤0.05.

CONCLUSION

The study revealed a prevalence of 26.4% of the utilization rehabilitation services among people with physical disabilities in Kawempe division, Uganda. Factors that were significantly associated with utilization of rehabilitation services included; age, socioeconomic status, education level and awareness of the participants about the services. Therefore, the government and other relevant stake holders should increase sensitization and awareness of rehabilitation services, their benefits and facilities providing such services to people with physical disabilities, healthcare professionals and the general public.

Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda

Objective

The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso and Village Health Teams (VHTs) in Uganda.

Study design

Participants were family planning clients of health centers (Burkina Faso) or VHTs (Uganda) who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12 months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection and if they discontinued either product.

Results

Twelve-month continuation in Burkina Faso was 50% for DMPA-SC and 47.4% for DMPA-IM (p=.41, N=990, 492 DMPA-SC and 498 DMPA-IM). Twelve-month continuation in Uganda was 77.8% for DMPA-SC and 77.4% for DMPA-IM (p=.85, N=1224, 609 DMPA-SC and 615 DMPA-IM). Reasons for discontinuation of DMPA across groups in Burkina Faso included side effects (90/492, 18.3%), being late for injection (68/492, 13.8%) and refusal of spouse (51/492, 10.4%). Reasons for discontinuation in Uganda included being late for injection (65/229, 28.4%), received from non-VHT (50/229, 21.8%) and side effects (34/229, 14.8%). Increased age (adjusted hazard ratio=0.98, p=.01) and partner acceptance of family planning (adjusted hazard ratio=0.48, p<.001) had protective effects against discontinuation in Burkina Faso; we did not find statistically significant variables in Uganda.

Conclusions

There is no difference in 12-month continuation (through four injections) between DMPA-SC and DMPA-IM whether from facility-based health workers in Burkina Faso or VHTs in Uganda. Continuation was higher through community-based distribution in Uganda than health facilities in Burkina Faso.

Implications

The subcutaneous formulation of depot medroxyprogesterone acetate (DMPA-SC) is increasingly available in Family Planning 2020 countries. Use of DMPA-SC does not appear to change continuation relative to traditional intramuscular DMPA. Growing evidence of DMPA-SC's suitability for community-based distribution and self-injection may yield indirect benefits for contraceptive continuation and help reach new users.

Community Perspective on Policy Options for Resettlement Management: A Case Study of Risk Reduction in Bududa, Eastern Uganda

Introduction: Despite existing policy actions on Disaster Risk Reduction (DRR), many community members in Bududa still continue to settle in high-risk areas re-zoned for nonsettlement. There seems to be an apparent information asymmetry on expectations between the community and Government. The challenge then is ‘how to consult communities and seek their opinion in an adequately representative unbiased way’. This paper sets out to explore policy options on resettlement management as a DRR approach and how engaging with communities in a public discourse using the Deliberative Polling (DP) approach; to obtain their opinions and insights on these policy issues, revealed underlying challenges to policy implementation.

Methods: A qualitative study was conducted in Bududa in eastern Uganda with fourteen group discussions; comprising 12-15 randomly assigned participants of mixed socio-economic variables. Trained research assistants and moderators collected data. All discussions were audio taped, transcribed verbatim before analysis. Data were analyzed using latent content analysis by identifying codes from which sub-themes were generated and grouped into main themes on policy options for resettlement management.

Results and Discussion: We used Deliberative Polling, an innovative approach to public policy consultation and found that although the community is in agreement with most government policy options under resettlement management, they lacked an understanding of the rationale underlying these policy options leading to challenges in implementation. The community members seemed uncertain and had mistrust in government’s ability to implement the policies especially on issues of compensation for land lost.

Key Words: Policy, Deliberative Polling, Climate change, risk-reduction, landslides, Uganda

Incidence of Induced Abortion in Uganda, 2013: New Estimates Since 2003

BACKGROUND

In Uganda, abortion is permitted only when the life of a woman is in danger. This restriction compels the perpetuation of the practice in secrecy and often under unsafe conditions. In 2003, 294,000 induced abortions were estimated to occur each year in Uganda. Since then, no other research on abortion incidence has been conducted in the country.

METHODS

Data from 418 health facilities were used to estimate the number and rate of induced abortion in 2013. An indirect estimation methodology was used to calculate the annual incidence of induced abortions ─ nationally and by major regions. The use of a comparable methodology in an earlier study permits assessment of trends between 2003 and 2013.

RESULTS

In 2013, an estimated 128,682 women were treated for abortion complications and an estimated 314,304 induced abortions occurred, both slightly up from 110,000 and 294,000 in 2003, respectively. The national abortion rate was 39 abortions per 1,000 women aged 15-49, down from 51 in 2003. Regional variation in abortion rates is very large, from as high as an estimated 77 per 1,000 women 15-49 in Kampala region, to as low as 18 per 1,000 women in Western region. The overall pregnancy rate also declined from 326 to 288; however the proportion of pregnancies that were unintended increased slightly, from 49% to 52%.

CONCLUSION

Unsafe abortion remains a major problem confronting Ugandan women. Although the overall pregnancy rate and the abortion rate declined in the past decade, the majority of pregnancies to Ugandan women are still unintended. These findings reflect the increase in the use of modern contraception but also suggest that a large proportion of women are still having difficulty practicing contraception effectively. Improved access to contraceptive services and abortion-related care are still needed.

Undergraduate students' contributions to health service delivery through community-based education: A qualitative study by the MESAU Consortium in Uganda

BACKGROUND

It has been realised that there is need to have medical training closer to communities where the majority of the population lives in order to orient the trainees' attitudes towards future practice in such communities. Although community based education (CBE) has increasingly been integrated into health professions curricula since the 1990s, the contribution students make to service delivery during CBE remains largely undocumented. In this study, we examined undergraduate health professions students' contribution to primary health care during their CBE placements.

METHODS

This was a qualitative study involving the Medical Education for Equitable Services to All Ugandans consortium (MESAU). Overall, we conducted 36 Focus Group Discussions (FGDs): one each with youth, men and women at each of 12 CBE sites. Additionally, we interviewed 64 community key-informants. All data were audio-recorded, transcribed and analysed using qualitative data analysis software Atlas.ti Ver7.

RESULTS

Two themes emerged: students' contribution at health facility level and students' contribution at community level. Under theme one, we established that students were not only learning; they also contributed to delivery of health services at the facilities. Their contribution was highly appreciated especially by community members. Students were described as caring and compassionate, available on time and anytime, and as participating in patient care. They were willing to share their knowledge and skills, and stimulated discussion on work ethics. Under the second theme, students were reported to have participated in water, sanitation, and hygiene education in the community. Students contributed to maintenance of safe water sources, educated communities on drinking safe water and on good sanitation practices (hand washing and proper waste disposal). Hygiene promotion was done at household level (food hygiene, hand washing, cleanliness) and to the public. Public health education was extended to institutions. School pupils were sensitised on various health-related issues including sexuality and sexual health.

CONCLUSION

Health professions students at the MESAU institutions contribute meaningfully to primary health care delivery. We recommend CBE to all health training programs in sub-Saharan Africa.

Factors Associated with Injuries among Commercial Motorcyclists: Evidence from a Matched Case Control Study in Kampala City, Uganda

INTRODUCTION

Road traffic injuries are the eighth leading cause of death globally and the most affected are young people aged 15-29. By 2030 road traffic deaths will become the fifth leading cause of death unless urgent action is taken. Motorcyclists are among the most vulnerable road users and in Uganda they contribute 41% of all road traffic injuries. This paper establishes factors associated with the injuries of commercial motorcycle riders also known as boda-boda riders in Kampala, Uganda's capital city.

METHODS

The study was matched case-control with a case being a boda-boda rider that was seen at one of the 5 major city hospitals with a road traffic injury while a control was a boda-boda rider that was at the parking stage where the case operated from before the injury. The sample size was 289 riders per arm and data collection took 7 months. A structured questionnaire was used to collect data on background and exposing factors. Being matched case-control data conditional logistic regression was used in the analysis.

RESULTS

Factors independently associated with injury among motorcyclists were younger age group, being a current alcohol drinker (OR = 2.30, 95%CI: 1.19-4.45), lower engine capacity (<100 cc) (OR = 5.03, 95%CI: 2.91-8.70), riding experience of less than 3 years, not changing a motorcycle in past 1 year (OR = 2.04, 95%CI: 1.19-3.52), riding for a longer time in a day (OR = 6.05, 95%CI: 2.58-14.18) and sharing a motorcycle (OR = 8.25, 95%CI:2.62-25.9). Other factors associated with injury were low level of knowledge of traffic rules, being stopped by police for checks on condition of motorcycle/license/insurance, working till late.

RECOMMENDATIONS

More road safety sensitization is required among riders to raise awareness against sharing motorcycles, working for a longer time and alcohol consumption. Police enforcement of drink-driving laws should include riders of commercial motorcycles. Investigate the validity of motorcycle riding licenses and test the riding competency of all who got licenses in last 3 years.

"I Spent a Full Month Bleeding, I Thought I Was Going to Die…" A Qualitative Study of Experiences of Women Using Modern Contraception in Wakiso District, Uganda

Introduction

There is high unmet need for family planning (FP) in Uganda as well as high contraceptive discontinuation rates. These contribute to the high fertility rates that in part are due to unplanned pregnancies. There are gaps in knowledge about experiences that couples go through while using contraceptives in their lives. This study explored women’s experiences during the course of their contraceptive use.

Methods

We conducted a qualitative study involving 30 women who had used modern contraception for at least one year in Wakiso district, central Uganda. We used in-depth interviews to obtain their personal accounts. Index women were approached through health officers at four health centres in the district. All ethical approvals and informed consent were obtained. We used conventional content analysis; identifying codes through open coding, on which basis categories were developed and grouped into overarching themes.

Results

Women’s accounts were summarised in the following themes: negative experiences with modern contraceptive use, motivation to continue using FP in spite of these negative experiences, the role of influential people, and discontinuation of use. Negative accounts dominated the experiences of most women but they expressed strong desire to continue using modern contraception even amidst all challenges. Health workers emerged as the most influential people that played a vital role in women’s decisions.

Conclusion

Varied negative experiences with modern contraception and misperceptions exist amidst a determination to continue use. Partner engagement, health service strengthening to improve side effects management and health worker skills, and engaging older women that have successfully used contraception as community champions, are potential strategies to support women’s contraceptive decisions.

Has Uganda experienced any stalled fertility transitions? Reflecting on the last four decades (1973-2011)

Background

Persistent high fertility is associated with mother and child mortality. While most regions in the world have experienced declines in fertility rates, there are conflicting views as to whether Uganda has entered a period of fertility transition. There are limited data available that explicitly detail the fertility trends and patterns in Uganda over the last four decades, from 1973 to 2011. Total fertility rate (TFR) is number of live births that a woman would have throughout her reproductive years if she were subject to the prevailing age specific fertility patterns. The current TFR for Uganda stands at 6.2 children born per woman, which is one of the highest in the region. This study therefore sought to examine whether there has been a fertility stall in Uganda using all existing Demographic Health Survey data, to provide estimates for the current fertility levels and trends in Uganda, and finally to examine the demographic and socioeconomic factors responsible for fertility levels in Uganda.

This is a secondary analysis of data from five consecutive Ugandan Demographic Health Surveys (UDHS); 1988/1989, 1995, 2000/2001, 2006 and 2011. Using pooled data to estimate for fertility levels, patterns and trends, we applied a recently developed fertility estimation approach. A Poisson regression model was also used to analyze fertility differentials over the study period.

Results

Over the studied period, fertility trends and levels fluctuated from highs of 8.8 to lows of 5.7, with no specific lag over the study period. These findings suggest Uganda is at the pre-transitional stage, with indications of imminent fertility rate reductions in forthcoming years. Marital status remained a strong predictor for number of children born, even after controlling for other variables.

Conclusions

This study suggests there is no evidence of a fertility stall in Uganda, but demonstrates an onset of fertility transition in the country. If this trend continues, Uganda will experience a low fertility rate in the future—a finding pertinent for policy makers, especially as the continent and the country focus on harnessing the demographic dividend.

Community Perceptions on Integrating Animal Vaccination and Health Education by Veterinary and Public Health Workers in the Prevention of Brucellosis among Pastoral Communities of South Western Uganda

BACKGROUND

Brucellosis is a zoonotic disease of veterinary, public health, and economic significance in most developing countries, yet there are few studies that show integrated human and veterinary health care intervention focusing on integration at both activity and actors levels. The aim of our study, therefore, was to explore community perceptions on integration of animal vaccination and health education by veterinary and public health workers in the management of brucellosis in Uganda.

METHODS

This study used a qualitative design where six Focus Group Discussions (FGDs) that were homogenous in nature were conducted, two from each sub-county, one with the local leaders, and another with pastoralists and farmers. Five Key Informant Interviews (KIIs) with two public health workers and three veterinary extension workers from three sub-counties in Kiruhura district, Uganda were conducted. All FGDs were conducted in the local language and tape recorded with consent from the participants. KIIs were in English and later transcribed and analyzed using latent content data analysis method.

RESULTS

All the groups mentioned that they lacked awareness on brucellosis commonly known as Brucella and its vaccination in animals. Respondents perceived improvement in human resources in terms of training and recruiting more health personnel, facilitation of the necessary activities such as sensitization of the communities about brucellosis, and provision of vaccines and diagnostic tests as very important in the integration process in the communities. The FGD participants also believed that community participation was crucial for sustainability and ownership of the integration process.

CONCLUSIONS

The respondents reported limited knowledge of brucellosis and its vaccination in animals. The community members believed that mass animal vaccination in combination with health education about the disease is important and possible if it involves government and all other stakeholders such as wildlife authorities, community members, local to national political leaders, as well as the technical personnel from veterinary, medical and public health sectors since it affects both humans and animals.

Factors influencing modes of transport and travel time for obstetric care: a mixed methods study in Zambia and Uganda

Transportation is an important barrier to accessing obstetric care for many pregnant and postpartum women in low-resource settings, particularly in rural areas. However, little is known about how pregnant women travel to health facilities in these settings. We conducted 1633 exit surveys with women who had a recent facility delivery and 48 focus group discussions with women who had either a home or a facility birth in the past year in eight districts in Uganda and Zambia. Quantitative data were analysed using univariate statistics, and qualitative data were analysed using thematic content analysis techniques. On average, women spent 62-68 min travelling to a clinic for delivery. Very different patterns in modes of transport were observed in the two countries: 91% of Ugandan women employed motorized forms of transportation, while only 57% of women in Zambia did. Motorcycle taxis were the most commonly used in Uganda, while cars, trucks and taxis were the most commonly used mode of transportation in Zambia. Lower-income women were less likely to use motorized modes of transportation: in Zambia, women in the poorest quintile took 94 min to travel to a health facility, compared with 34 for the wealthiest quintile; this difference between quintiles was ∼50 min in Uganda. Focus group discussions confirmed that transport is a major challenge due to a number of factors we categorized as the 'three A's:' affordability, accessibility and adequacy of transport options. Women reported that all of these factors had influenced their decision not to deliver in a health facility. The two countries had markedly different patterns of transportation for obstetric care, and modes of transport and travel times varied dramatically by wealth quintile, which policymakers need to take into account when designing obstetric transport interventions.

Understanding sexual and reproductive health needs of adolescents: evidence from a formative evaluation in Wakiso district, Uganda

Introduction

Adolescents are frequently reluctant to seek sexual and reproductive health services (SRH). In Uganda, adolescent health and development is constrained by translation of the relevant policies to practice. Recent studies done in central Uganda have shown that there is need for a critical assessment of adolescent friendly services (AFS) to gain insights on current practice and inform future interventions. This study aimed to assess the sexual reproductive health needs of the adolescents and explored their attitudes towards current services available.

Methods

A qualitative study was conducted in Wakiso district, central Uganda in September 2013.Twenty focus group discussions (FGDs) stratified by gender (10 out-of-school, and 10 in-school), were purposefully sampled. We used trained research assistants (moderator and note taker) who used a pretested FGD guide translated into the local language to collect data. All discussions were audio taped, and were transcribed verbatim before analysis. Thematic areas on; adolescent health problems, adolescent SRH needs, health seeking behaviour and attitudes towards services, and preferred services were explored. Data was analysed using atlas ti version 7 software.

Results

Our results clearly show that adolescents have real SRH issues that need to be addressed. In and out-of-school adolescents had sexuality problems such as unwanted pregnancies, sexually transmitted infections (STIs), defilement, rape, substance abuse. Unique to the females was the issue of sexual advances by older men and adolescents. We further highlight RH needs which would be solved by establishing adolescent friendly clinics with standard recommended characteristics (sexuality information, friendly health providers, a range of good clinical services such as post abortion care etc.). With regard to health seeking behaviour, most adolescents do not take any action at first until disease severity increase.

Conclusions

Adolescents in Uganda have multiple sexual and reproductive health needs that require special focus through adolescent friendly services. This calls for resource support in terms of health provider training, information education and communication materials as well as involvement of key stakeholders that include parents, teachers and legislators.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0026-7) contains supplementary material, which is available to authorized users.

Influences on participant reporting in the World Health Organisation drugs exposure pregnancy registry; a qualitative study

Background

The World Health Organisation has designed a pregnancy registry to investigate the effect of maternal drug use on pregnancy outcomes in resource-limited settings. In this sentinel surveillance system, detailed health and drug use data are prospectively collected from the first antenatal clinic visit until delivery. Over and above other clinical records, the registry relies on accurate participant reports about the drugs they use. Qualitative methods were incorporated into a pilot registry study during 2010 and 2011 to examine barriers to women reporting these drugs and other exposures at antenatal clinics, and how they might be overcome.

Methods

Twenty-seven focus group discussions were conducted in Ghana, Kenya and Uganda with a total of 208 women either enrolled in the registry or from its source communities. A question guide was designed to uncover the types of exposure data under- or inaccurately reported at antenatal clinics, the underlying reasons, and how women prefer to be asked questions. Transcripts were analysed thematically.

Results

Women said it was important for them to report everything they had used during pregnancy. However, they expressed reservations about revealing their consumption of traditional, over-the-counter medicines and alcohol to antenatal staff because of anticipated negative reactions. Some enrolled participants' improved relationship with registry staff facilitated information sharing and the registry tools helped overcome problems with recall and naming of medicines. Decisions about where women sought care, which influenced medicines used and antenatal clinic attendance, were influenced by pressure within and outside of the formal healthcare system to conform to conflicting behaviours. Conversations also reflected women's responsibilities for producing a healthy baby.

Conclusions

Women in this study commonly take traditional medicines in pregnancy, and to a lesser extent over-the-counter medicines and alcohol. The World Health Organisation pregnancy registry shows potential to enhance their reporting of these substances at the antenatal clinic. However, more work is needed to find optimal techniques for eliciting accurate reports, especially where the detail of constituents may never be known. It will also be important to find ways of sustaining such drug exposure surveillance systems in busy antenatal clinics.

Differences in risky sexual behaviors and HIV prevalence of circumcised and uncircumcised men in Uganda: evidence from a 2011 cross-sectional national survey

Background

Safe male circumcision (SMC) is a known efficacious intervention in the prevention of heterosexual HIV acquisition. However, there are perceptions that SMC may lead to behavior disinhibition towards risky sexual behaviors. We assessed the association between male circumcision, risky sexual behaviors and HIV prevalence among men in a nationally representative sample.

Methods

Data was extracted from the Uganda AIDS Indicator Survey (2011), a stratified two-stage cluster sample, with a total of 7,969 ever sexually active men aged 15–59 years. The association between risky sexual behaviors (non- marital/non-cohabiting sexual relations, non-use of condoms, transactional sex, multiple (4+) lifetime partners) and male circumcision status were determined using odds ratios (OR) and their 95% confidence intervals, through logistic regression models. All analyses were conducted in Stata version 12.

Results

Overall, the prevalence of male circumcision was 28%; higher among men aged 25–34 years, 32%, and lowest among those aged 45–59 years, 18%. HIV prevalence was significantly lower among the circumcised, 4.8% compared to the uncircumcised men, 7.8% (p < 0.001). The commonest risky sexual behaviors were multiple life-time sexual partners (4+), 59%; non-use of condoms with non-marital sexual partners, 55%; and having non-marital sex, 33%. In comparison with the uncircumcised, circumcised men had higher odds of engaging in non-marital sex AOR = 1.26 (95% CI: 1.05-1.52), reporting multiple (4+) life-time partners, AOR = 1.46 (95% CI: 1.27-1.67). The odds of non-use of condoms with a non-marital partner were also significantly lower among the circumcised compared to the uncircumcised men, AOR = 0.79 (95% CI: 0.63-0.98).

Conclusions

Although risky sexual behaviors were more common among circumcised men, HIV prevalence was lower among the circumcised men relative to the uncircumcised. These observations suggest a need to promote the already known HIV intervention strategies especially among the circumcised men.

Using a clinic based creativity initiative to reduce HIV related stigma at the Infectious Diseases Institute, Mulago National Referral Hospital, Uganda

BACKGROUND

Stigma has been associated with chronic health conditions such as HIV/AIDS, leprosy, tuberculosis, Mental illness and Epilepsy. Different forms of stigma have been identified: enacted stigma, perceived stigma, and self stigma. Stigma is increasingly regarded as a key driver of the HIV/AIDS epidemic and has a major impact on public health interventions.

OBJECTIVES

The initiative was to provide activities in the clinic while patients waited to be seen by healthcare professionals. It was envisaged this would contribute to reduction of clinic based stigma felt by clients.

METHODS

This was a repeated cross-sectional survey (October-November 2005 and March-April 2007) that was conducted at the Infectious Diseases Institute clinic (IDC) at Mulago, the national referral hospital in Uganda. We utilized quantitative (survey) and qualitative (key informants, focus group discussions) methods to collect the data. Data were collected on stigma before the creativity initiative intervention was implemented, and a second phase survey was conducted to assess effectiveness of the interventions.

RESULTS

Clients who attended the IDC before the creativity intervention were about twice as likely to fear catching an infection as those who came after the intervention. The proportion that had fears to be seen by a friend or relative at the clinic decreased. Thus during the implementation of the Creativity intervention, HIV related stigma was reduced in this clinic setting.

CONCLUSIONS

The creativity intervention helped to build self esteem and improved communication among those attending the clinic; there was observed ambiance at the clinic and clients became empowered, with creative, communication and networking skills. Improved knowledge and communication are key in addressing self stigma among HIV positive individuals.

Land slide disaster in eastern Uganda: rapid assessment of water, sanitation and hygiene situation in Bulucheke camp, Bududa district

BACKGROUND

On 1st March 2010, a major landslide occurred on Mt. Elgon in Eastern Uganda. This was triggered by heavy rains that lasted over three months. The landslide buried three villages in Bududa district, killing over 400 and displacing an estimate of 5,000 people. A comprehensive assessment of water, sanitation and hygiene was urgently needed to inform interventions by the Ministries of Health, and Relief, Disaster Preparedness and Refugees, Uganda.

METHODS

This was a cross-sectional study where both qualitative and quantitative data were collected two weeks after the disaster. Quantitative interviews involved 397 heads of households and qualitative methods comprised of 27 Key Informant interviews, four focus group discussions and observations. The survey quantified water safety (collection, treatment, storage) and hygiene practices. This was supplemented and triangulated with qualitative data that focused on community perceptions and beliefs regarding water and sanitation needs and practices. Quantitative data was entered in Epi-Info Version 3.2.2 software and then exported to SPSS Version 12 for analysis. Summary statistics and proportions were generated and bi-variable analysis performed for selected variables. Associations were assessed using odds ratios at 95% confidence intervals. Qualitative data was analyzed using content analysis.

RESULTS

Qualitative results showed that there were strong traditional beliefs governing water use and human excreta disposal. The use of river Manafwa water for household consumption was observed to potentially lead to disease outbreaks. Water from this river was reported tastier and the community culturally saw no need to boil drinking water. Latrines were few (23 for 5000 people), shallow, dirty (70% reported flies, 60% fecal littering), not separated by sex and had limited privacy and no light at night. This affected their use. Males were 3 times more likely to wash hands with soap after latrine use than females (OR = 3.584, 95%CI: 1.658-7.748). Of the 90% respondents who indicated that they always washed hands after latrine use, 76% said they used water and soap. Observations showed that water and soap were inconsistently available at the hand washing facilities. This situation influenced people's sanitation and hygiene behaviours. Nearly half (48%) indicated that at least a member of their household had fallen sick at least once since arrival at the camp.

CONCLUSION

There was inadequate access to safe water in the camp. Pit-latrines were inadequate, poorly maintained and not user-friendly for most people. Responsible authorities should design means of increasing and sustaining access to safe water, increase sanitation facilities and continuously educate the public on the need to observe good hygiene practices.