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Prabhakar P, Singh NS, Sulaiman M, King J, Saddique Z, Mounier-Jack S, Asinde B, Namakula S, Namatovu J, Kapiti R, Kasiri J, Borghi J. Sexual and reproductive healthcare utilisation and affordability for South Sudanese refugees and host populations in Northern Uganda: A mixed methods study. PLOS Glob Public Health 2023; 3:e0002351. [PMID: 37672542 PMCID: PMC10482223 DOI: 10.1371/journal.pgph.0002351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023]
Abstract
Given Uganda's increasing refugee population, the health financing burden on refugee and host populations is likely to increase because Uganda's integrated health system caters to both populations. We used sexual, reproductive, and maternal health (SRMH) as a lens to assess the utilisation and user cost of health services in Northern Uganda to identify potential gaps in SRMH services and their financing. We conducted a cross-sectional survey among 2,533 refugee and host women and girls in Arua and Kiryandongo districts. We conducted 35 focus group discussions and 131 in-depth interviews with host and South Sudanese refugees, community members, health workers, NGO and governmental actors. Qualitative data were analysed thematically using a framework approach. Quantitative data were analysed using t-test, chi-square tests, multivariate logistical regression, and a two-part model. We found high levels of access to maternal care services among refugee and host communities in Northern Uganda, but lower levels of met need for family planning (FP). Refugees had higher uptake of delivery care than host communities due to better-resourced refugee facilities, but incurred higher costs for delivery kits and food and less for transport due to facilities being closer. FP uptake was low for both groups due to perceived risks, cultural and religious beliefs, and lack of agency for most women. Host communities lack access to essential maternal healthcare services relative to refugees, especially for delivery care. Greater investment is needed to increase the number of host facilities, improve the quality of SRMH services provided, and further enhance delivery care access among host communities. Ongoing funding of delivery kits across all communities is needed and new financing mechanisms should be developed to support non-medical costs for deliveries, which our study found to be substantial in our study. All populations must be engaged in co-designing improved strategies to meet their FP needs.
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Affiliation(s)
- Pallavi Prabhakar
- Independent Evaluation and Research Cell, BRAC Uganda, Kampala, Uganda
| | - Neha S. Singh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Munshi Sulaiman
- Independent Evaluation and Research Cell, BRAC Uganda, Kampala, Uganda
| | - Jessica King
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zia Saddique
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sandra Mounier-Jack
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Barbara Asinde
- Independent Evaluation and Research Cell, BRAC Uganda, Kampala, Uganda
| | | | | | | | | | - Josephine Borghi
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Namy S, Namakula S, Nabachwa AG, Ollerhead M, Tsai LC, Kemitare J, Bolton K, Nkwanzi V, Carlson C. "All I was Thinking About was Shattered": Women's Experiences Transitioning Out of Anti-Trafficking Shelters During the COVID-19 Lockdown in Uganda. Affilia 2023; 38:278-293. [PMID: 38603358 PMCID: PMC9726634 DOI: 10.1177/08861099221137058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Human trafficking is an egregious violation of fundamental human rights and a global challenge. The long-term harms to survivors' physical, psychological and social wellbeing are profound and well documented, and yet there are few studies exploring how to best promote resilience and holistic healing. This is especially true within shelter programs (where the majority of anti-trafficking services are provided) and during the transition out of residential shelter care, which is often a sensitive and challenging process. The current study begins to address this gap by centering the lived experiences of six women residing in a trafficking-specific shelter in Uganda as they unexpectedly transitioned back to their home communities due to the COVID-19 lockdown. We explore this pivotal moment in participants' post-trafficking journey, focusing on how these women described and interpreted their rapidly changing life circumstances-including leaving the shelter, adjusting back to the community setting, and simultaneously navigating the uncertainties of a global pandemic. Four core themes emerged from the analysis: economic insecurities as a cross-cutting hardship; intensification of emotional and physical symptoms; social disruptions; and sources of hope and resilience. By centering their personal stories of struggle and strength, we hope to elevate survivors' own accounts and draw on their insights to identify actionable considerations for future programming.
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Affiliation(s)
- Sophie Namy
- Healing and Resilience after Trauma (HaRT),
Asturias, Spain
| | | | | | | | - Laura Cordisco Tsai
- Carr Center for Human Rights Policy, Harvard University John F Kennedy School of
Government, Cambridge, Massachusetts, USA
| | | | - Kelly Bolton
- School of Social Work, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Violet Nkwanzi
- School of Social Work, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Catherine Carlson
- School of Social Work, The University of Alabama, Tuscaloosa, Alabama, USA
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Singh NS, Prabhakar P, Ssali A, Namakula S, Namatovu J, Kapiti R, Kasiri J, Mounier-Jack S. "They will say you want to make their home die": A mixed methods study to assess modern family planning use in partnered South Sudanese refugee and host populations in Northern Uganda. PLOS Glob Public Health 2022; 2:e0000348. [PMID: 36962421 PMCID: PMC10022387 DOI: 10.1371/journal.pgph.0000348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/25/2022] [Indexed: 11/18/2022]
Abstract
The unmet need for family planning among conflict-affected populations is high globally, leaving girls and women vulnerable to unintended pregnancies and poor sexual and reproductive health outcomes. Ours is the first known mixed-methods study to assess the use of modern family planning (FP) methods amongst married or partnered South Sudanese refugee and host populations in Northern Uganda and to explore differences between them. We conducted a cross-sectional survey in July 2019 which included 1,533 partnered women of reproductive age (15-49 years) from host and South Sudanese refugee communities in Kiryandongo and Arua. Qualitative data were collected in October 2019-January 2020 via 34 focus group discussions and 129 key informant interviews with refugee and host populations, health workers, community and religious leaders, health workers, local authorities and humanitarian actors. Our study did not find large differences between South Sudanese refugee and host populations in regard to modern FP use, though refugees reported somewhat poorer FP knowledge, accessibility and utilisation compared to Ugandan women. Reported barriers to FP use relate to access, quality of services, health concerns and family/community opposition, all of which emphasise the importance of men's gendered roles in relationships, cultural and religious beliefs and lack of agency for most women to make their own decisions about reproductive health. Sexual and gender-based violence related to FP use was reported among both refugee and host populations. Additional barriers to FP use include lack of privacy at the public health facilities which reduces confidentiality, mistrust of health workers, and stockouts of FP commodities. Facilitating factors for FP use included: free government health services; the presence of well-trained health workers; and NGOs who give support to populations and conduct community outreaches. The findings of this study underscore the importance of developing and implementing tailored sexual and reproductive health information and services, especially for modern FP methods, in partnership with South Sudanese refugee and host populations in Northern Uganda.
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Affiliation(s)
- Neha S Singh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pallavi Prabhakar
- Independent Evaluation and Research Cell, BRAC Uganda, Kampala, Uganda
| | - Agnes Ssali
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/UVRI & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | | | | | | | - Sandra Mounier-Jack
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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4
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Namy S, Carlson C, O'Hara K, Nakuti J, Bukuluki P, Lwanyaaga J, Namakula S, Nanyunja B, Wainberg ML, Naker D, Michau L. Towards a feminist understanding of intersecting violence against women and children in the family. Soc Sci Med 2017; 184:40-48. [PMID: 28501019 PMCID: PMC5737762 DOI: 10.1016/j.socscimed.2017.04.042] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 12/19/2022]
Abstract
While intimate partner violence (IPV) against women and violence against children (VAC) have emerged as distinct fields of research and programming, a growing number of studies demonstrate the extent to which these forms of violence overlap in the same households. However, existing knowledge of how and why such co-occurrence takes place is limited, particularly in the Global South. The current study aims to advance empirical and conceptual understanding of intersecting IPV and VAC within families in order to inform potential programming. We explore shared perceptions and experiences of IPV and VAC using qualitative data collected in December 2015 from adults and children in Kampala, Uganda (n = 106). We find that the patriarchal family structure creates an environment that normalizes many forms of violence, simultaneously infantilizing women and reinforcing their subordination (alongside children). Based on participant experiences, we identify four potential patterns that suggest how IPV and VAC not only co-occur, but more profoundly intersect within the family, triggering cycles of emotional and physical abuse: bystander trauma, negative role modeling, protection and further victimization, and displaced aggression. The discussion is situated within a feminist analysis, including careful consideration of maternal violence and an emphasis on the ways in which gender and power dynamics can coalesce and contribute to intra-family violence.
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Kyegombe N, Namakula S, Mulindwa J, Lwanyaaga J, Naker D, Namy S, Nakuti J, Parkes J, Knight L, Walakira E, Devries KM. How did the Good School Toolkit reduce the risk of past week physical violence from teachers to students? Qualitative findings on pathways of change in schools in Luwero, Uganda. Soc Sci Med 2017; 180:10-19. [PMID: 28314229 PMCID: PMC5390768 DOI: 10.1016/j.socscimed.2017.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 11/16/2022]
Abstract
Violence against children is a serious violation of children's rights with significant impacts on current and future health and well-being. The Good School Toolkit (GST) is designed to prevent violence against children in primary schools through changing schools' operational cultures. Conducted in the Luwero District in Uganda between 2012 and 2014, findings from previous research indicate that the Toolkit reduced the odds of past week physical violence from school staff (OR = 0.40, 95%CI 0.26-0.64, p < 0.001), corresponding to a 42% reduction in risk of past week physical violence. This nested qualitative study involved 133 interviews with students, teachers, school administration, and parents, and two focus group discussion with teachers. Interviews were conducted using semi-structured tools and analysed using thematic analysis complemented by constant comparison and deviant case analysis techniques. Within a context of normative acceptance of corporal punishment this qualitative paper reports suggestive pathways related to teacher-student relationships through which reductions in violence operated. First, improved student-teacher relationships resulted in improved student voice and less fear of teachers. Second, the intervention helped schools to clarify and encourage desired behaviour amongst students through rewards and praise. Third, many teachers valued positive discipline and alternative discipline methods, including peer-to-peer discipline, as important pathways to reduced use of violence. These shifts were reflected in changes in the views, use, and context of beating. Although the GST is effective for reducing physical violence from teachers to students, violence persisted, though at significantly reduced levels, in all schools with reductions varying across schools and individuals. Much of the success of the Toolkit derives from the support it provides for fostering better student-teacher relationships and alternative discipline options. Such innovation could usefully be incorporated in teacher training syllabi to equip teachers with knowledge and skills to maintain discipline without the use of fear or physical punishment.
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Affiliation(s)
- N Kyegombe
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom.
| | | | | | | | - D Naker
- Raising Voices, 16 Tufnell Drive, Kamwokya, P.O. Box 6770, Kampala, Uganda
| | - S Namy
- Raising Voices, 16 Tufnell Drive, Kamwokya, P.O. Box 6770, Kampala, Uganda
| | - J Nakuti
- Raising Voices, 16 Tufnell Drive, Kamwokya, P.O. Box 6770, Kampala, Uganda
| | - J Parkes
- University College London, Institute of Education, University College London, 20 Bedford Way, London WC1H 0AL, United Kingdom
| | - L Knight
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - E Walakira
- School of Social Sciences, Makerere University, P.O Box 7062, Kampala, Uganda
| | - K M Devries
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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Higgins JA, Mathur S, Eckel E, Kelley L, Kelly L, Nakyanjo N, Sekamwa R, Namatovu J, Ddaaki W, Nakubulwa R, Namakula S, Nalugoda F, Santelli JS. Importance of relationship context in HIV transmission: results from a qualitative case-control study in Rakai, Uganda. Am J Public Health 2014; 104:612-20. [PMID: 24524490 DOI: 10.2105/ajph.2013.301670] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We present results from life history interviews with 60 young adults from southern Uganda. Using a novel qualitative case-control design, we compared newly HIV-positive cases with HIV-negative controls matched on age, gender, marital status, and place of residence. Relationship context was the most salient theme differentiating cases from controls. Compared with HIV-negative respondents, recent seroconverters described relationships marked by poorer communication, greater suspicion and mistrust, and larger and more transitory sexual networks. Results highlight the importance of dyadic approaches to HIV and possibly of couple-based interventions. Using HIV-matched pairs allowed additional understanding of the factors influencing transmission. This hybrid methodological approach holds promise for future studies of sexual health.
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Affiliation(s)
- Jenny A Higgins
- At the time of data collection and analysis, Jenny A. Higgins, Sanyukta Mathur, Elizabeth Eckel, Laura Kelly, and John S. Santelli were with the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY. At the time of article preparation, Jenny A. Higgins was with the Department of Gender and Women's Studies, University of Wisconsin-Madison. Neema Nakyanjo, Richard Sekamwa, Josephine Namatovu, William Ddaaki, Rosette Nakubulwa, and Sylvia Namakula are with the Qualitative Research Section, Rakai Health Sciences Program, Kalisizo, Uganda. Fred Nalugoda is with the Kalisizo Field Station, Rakai Health Sciences Program, Kalisizo, Uganda
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