Equity in family planning policies and programs in Uganda: conceptualization, dimensions and implementation constraints.

BACKGROUND: Equity is at the core and a fundamental principle of achieving the family planning (FP) 2030 Agenda. However, the conceptualization, definition, and measurement of equity remain inconsistent and unclear in many FP programs and policies. This paper aims to document the conceptualization, dimensions and implementation constraints of equity in FP policies and programs in Uganda. METHODS: A review of Ugandan literature and key informant interviews with 25 key stakeholders on equity in FP was undertaken between April and July 2020. We searched Google, Google Scholar and PubMed for published and grey literature from Uganda on equity in FP. A total of 112 documents were identified, 25 met the inclusion criteria and were reviewed. Data from the selected documents were extracted into a Google master matrix in MS Excel. Data analysis was done across the thematic areas by collating similar information. Data were analyzed using thematic content analysis approach. RESULTS: A limited number of documents had an explicit definition of equity, which varied across documents and stakeholders. The definitions revolved around universal access to FP information and services. There was a limited focus on equity in FP programs in Uganda. The dimensions most commonly used to assess equity were either geographical location, or socio-demographics, or wealth quintile. Almost all the key informants noted that equity is a very important element, which needs to be part of FP programming. However, implementation constraints (e.g. lack of quality comprehensive FP services, duplicated FP programs and a generic design of FP programs with limited targeting of the underserved populations) continue to hinder effective implementation of equitable FP programs in Uganda. Clients' constraints (e.g. limited contraceptive information) and policy constraints (inadequate focus on equity in policy documents) also remain key challenges. CONCLUSIONS: There is lack of a common understanding and definition of equity in FP programs in Uganda. There is need to build consensus on the definitions and measurements of equity with a multidimensional lens to inform clear policy and programming focus on equity in FP programs and outcomes. To improve equitable access to and use of FP services, attention must be paid to addressing implementation, client and policy constraints.

Health workforce incentives and dis-incentives during the COVID-19 pandemic: experiences from Democratic Republic of Congo, Nigeria, Senegal, and Uganda.

BACKGROUND: The COVID-19 pandemic presented a myriad of challenges for the health workforce around the world due to its escalating demand on service delivery. A motivated health workforce is critical to effectual emergency response and in some settings, incentivizing health workers motivates them and ensures continuity in the provision of health services. We describe health workforce experiences with incentives and dis-incentives during the COVID-19 response in the Democratic Republic of Congo (DRC), Senegal, Nigeria, and Uganda. METHODS: This is a multi-country qualitative research study involving four African countries namely: DRC, Nigeria, Senegal, and Uganda which assessed the workplace incentives instituted in response to the COVID-19 pandemic. Key informant interviews (n = 60) were conducted with staff at ministries of health, policy makers and health workers. Interviews were virtual using the telephone or Zoom. They were audio recorded, transcribed verbatim, and analyzed thematically. Themes were identified and quotes were used to support findings. RESULTS: Health worker incentives included (i) financial rewards in the form of allowances and salary increments. These motivated health workers, sustaining the health system and the health workers' efforts during the COVID-19 response across the four countries. (ii) Non-financial incentives related to COVID-19 management such as provision of medicines/supplies, on the job trainings, medical care for health workers, social welfare including meals, transportation and housing, recognition, health insurance, psychosocial support, and supervision. Improvised determination and distribution of both financial and non-financial incentives were common across the countries. Dis-incentives included the lack of personal protective equipment, lack of transportation to health facilities during lockdown, long working hours, harassment by security forces and perceived unfairness in access to and inadequacy of financial incentives. CONCLUSION: Although important for worker motivation, financial and non-financial incentives generated some dis-incentives because of the perceived unfairness in their provision. Financial and non-financial incentives deployed during health emergencies should preferably be pre-determined, equitably and transparently provided because when arbitrarily applied, these same financial and non-financial incentives can potentially become dis-incentives. Moreover, financial incentives are useful only as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments. The potential negative impacts of interventions such as service delivery re-organization and lockdown within already weakened systems need to be anticipated and due precautions exercised to reduce dis-incentives during emergencies.

Unintended consequences of implementing non-pharmaceutical interventions for the COVID-19 response in Africa: experiences from DRC, Nigeria, Senegal, and Uganda.

INTRODUCTION: The coronavirus (COVID 19) pandemic is one of the most terrifying disasters of the twenty-first century. The non-pharmaceutical interventions (NPIs) implemented to control the spread of the disease had numerous positive consequences. However, there were also unintended consequences-positively or negatively related to the nature of the interventions, the target, the level and duration of implementation. This article describes the unintended economic, Psychosocial and environmental consequences of NPIs in four African countries. METHODS: We conducted a mixed-methods study in the Democratic Republic of Congo (DRC), Nigeria, Senegal and Uganda. A comprehensive conceptual framework, supported by a clear theory of change was adopted to encompass both systemic and non-systemic interventions. The data collection approaches included: (i) review of literature; (ii) analysis of secondary data for selected indicators; and (ii) key informant interviews with policy makers, civil society, local leaders, and law enforcement staff. The results were synthesized around thematic areas. RESULTS: Over the first six to nine months of the pandemic, NPIs especially lockdowns, travel restrictions, curfews, school closures, and prohibition of mass gathering resulted into both positive and negative unintended consequences cutting across economic, psychological, and environmental platforms. DRC, Nigeria, and Uganda observed reduced crime rates and road traffic accidents, while Uganda also reported reduced air pollution. In addition, hygiene practices have improved through health promotion measures that have been promoted for the response to the pandemic. All countries experienced economic slowdown, job losses heavily impacting women and poor households, increased sexual and gender-based violence, teenage pregnancies, and early marriages, increased poor mental health conditions, increased waste generation with poor disposal, among others. CONCLUSION: Despite achieving pandemic control, the stringent NPIs had several negative and few positive unintended consequences. Governments need to balance the negative and positive consequences of NPIs by anticipating and instituting measures that will support and protect vulnerable groups especially the poor, the elderly, women, and children. Noticeable efforts, including measures to avoid forced into marriage, increasing inequities, economic support to urban poor; those living with disabilities, migrant workers, and refugees, had been conducted to mitigate the negative effects of the NIPs.

Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study.

BACKGROUND: Cervical cancer is a major public health challenge, accounting for substantial morbidity and mortality. Human Papilloma Virus (HPV) vaccination is the recommended primary public health intervention for HPV infection prevention. However, there's limited evidence on the level of knowledge, attitude, and practices of adolescent girls regarding HPV vaccination in Kampala city, Uganda. This study assessed the knowledge, perceptions, and practices of adolescent girls aged 10-14 years towards HPV vaccination program in Kampala, Uganda to generate evidence to guide programs targeted at improving uptake of the vaccine. METHODS: A convergent parallel mixed methods study was conducted in Kampala, Uganda. A structured questionnaire was used to elicit data from 524 adolescent girls. In addition, 6 Focus group discussions, and 24 key informant interviews (teacher and parents) were conducted. Multistage and purposive sampling techniques were used to select quantitative and qualitative participants respectively. Quantitative data were entered using epidata, cleaned and analyzed using Stata v14 while qualitative data were analyzed using thematic content analysis in atlas ti version 8. RESULTS: Overall, only 8.6% (45/524) of the girls had completed the HPV vaccine schedule of two dozes, 49.2% (258/524) of the girls had low knowledge about the HPV vaccine and teachers and parents affirmed this lack of knowledge among adolescent girls especially concerning the target age group, dosage, and vaccine interval. About 51.9% (272/524) of girls had negative perceptions towards HPV vaccination. Parents expressed negative perceptions, beliefs, superstitions, and safety concerns of the vaccine.Girls residing in rural areas (adjusted prevalence ratio, aPR = 0.35, C. I = 0.14-0.85) had lower knowledge levels compared to those in urban areas. Girls whose mothers were healthcare providers (aPR = 1.94, C. I = 1.10-3.41), girls with high knowledge levels (aPR = 1.79, C. I = 1.21-2.63) and positive perceptions (aPR = 2.87, C. I = 1.93-4.27) had a higher prevalence of being fully vaccinated. CONCLUSION: Girls generally had low levels of knowledge, negative perceptions, and poor uptake of HPV vaccination. We recommend sensitization campaigns in schools and communities to improve awareness, perceptions, and practices of stakeholders towards HPV vaccination.

Private sector engagement in the COVID-19 response: experiences and lessons from the Democratic Republic of Congo, Nigeria, Senegal and Uganda.

BACKGROUND: Private entities play a major role in health globally. However, their contribution has not been fully optimized to strengthen delivery of public health services. The COVID-19 pandemic has overwhelmed health systems and precipitated coalitions between public and private sectors to address critical gaps in the response. We conducted a study to document the public and private sector partnerships and engagements to inform current and future responses to public health emergencies. METHODS: This was a multi-country cross-sectional study conducted in the Democratic Republic of Congo, Nigeria, Senegal and Uganda between November 2020 and March 2021 to assess responses to the COVID-19 pandemic. We conducted a scoping literature review and key informant interviews (KIIs) with private and public health sector stakeholders. The literature reviewed included COVID-19 country guidelines and response plans, program reports and peer-reviewed and non-peer-reviewed publications. KIIs elicited information on country approaches and response strategies specifically the engagement of the private sector in any of the strategic response operations. RESULTS: Across the 4 countries, private sector strengthened laboratory systems, COVID-19 case management, risk communication and health service continuity. In the DRC and Nigeria, private entities supported contact tracing and surveillance activities. Across the 4 countries, the private sector supported expansion of access to COVID-19 testing services through establishing partnerships with the public health sector albeit at unregulated fees. In Senegal and Uganda, governments established partnerships with private sector to manufacture COVID-19 rapid diagnostic tests. The private sector also contributed to treatment and management of COVID-19 cases. In addition, private entities provided personal protective equipment, conducted risk communication to promote adherence to safety procedures and health promotion for health service continuity. However, there were concerns related to reporting, quality and cost of services, calling for quality and price regulation in the provision of services. CONCLUSIONS: The private sector contributed to the COVID-19 response through engagement in COVID-19 surveillance and testing, management of COVID-19 cases, and health promotion to maintain health access. There is a need to develop regulatory frameworks for sustainable public-private engagements including regulation of pricing, quality assurance and alignment with national plans and priorities during response to epidemics.

Primary care provider notions on instituting community-based geriatric support in Uganda.

BACKGROUND: Understanding of the most economical and sustainable models of providing geriatric care to Africa's rising ageing population is critical. In Uganda, the number of old adults (60 years and above) continues to rise against absence of policies and guidelines, and models for providing care to this critical population. Our study explored public primary health care provider views on how best community-based geriatric support (CBGS) could be instituted as an adaptable model for delivering geriatric care in Uganda's resource-limited primary public health care settings. METHODS: We interviewed 20 key informants from four districts of Bukomansimbi, Kalungu, Rakai, and Lwengo in Southern Central Uganda. Respondents were leads (in-charges) of public primary health units that had spent at least 6 months at the fore said facilities. All interviews were audio-recorded, transcribed verbatim, and analysed based on Hsieh and Shannon's approach to conventional manifest content analysis. RESULTS: During analysis, four themes emerged: 1) Structures to leverage for CBGS, 2) How to promote CBGS, 3) Who should be involved in CBGS, and 4) What activities need to be leveraged to advance CBGS? The majority of the respondents viewed using the existing village health team and local leadership structures as key to the successful institutionalization of CBGS; leveraging community education and sensitization using radio, television, and engaging health workers, family relatives, and neighbors. Health outreach activities were mentioned as one of the avenues that could be leveraged to provide CBGS. CONCLUSION: Provider notions pointed to CBGS as a viable model for instituting geriatric care in Uganda's public primary healthcare system. However, this requires policymakers to leverage existing village health team and local governance structures, conduct community education and sensitization about CBGS, and bring onboard health workers, family relatives, and neighbors.

Maternal health challenges experienced by adolescents; could community score cards address them? A case study of Kibuku District- Uganda.

INTRODUCTION: Approximately 34.8% of the Ugandan population is adolescents. The national teenage pregnancy rate is 25% and in Kibuku district, 17.6% of adolescents aged 12-19 years have begun child bearing. Adolescents mothers are vulnerable to many maternal health challenges including; stigma, unfriendly services and early marriages. The community score card (CSC) is a social accountability tool that can be used to point out challenges faced by the community in service delivery and utilization and ultimately address them. In this paper we aimed to document the challenges faced by adolescents during pregnancy, delivery and postnatal period and the extent to which the community score card could address these challenges. METHODS: This qualitative study utilized in-depth interviews conducted in August 2018 among 15 purposively selected adolescent women who had given birth 2 years prior to the study and had attended CSC meetings. The study was conducted in six sub counties of Kibuku district where the CSC intervention was implemented. Research assistants transcribed the audio-recorded interviews verbatim, and data was analyzed manually using the framework analysis approach. FINDINGS: This study found five major maternal health challenges faced by adolescents during pregnancy namely; psychosocial challenges, physical abuse, denial of basic human rights, unfriendly adolescent services, lack of legal and cultural protection, and lack of birth preparedness. The CSC addressed general maternal and new born health issues of the community as a whole rather than specific adolescent health related maternal health challenges. CONCLUSION: The maternal health challenges faced by adolescents in Kibuku have a cultural, legal, social and health service dimension. There is therefore need to look at a multi-faceted approach to holistically address them. CSCs that are targeted at the entire community are unlikely to address specific needs of vulnerable groups such as adolescents. To address the maternal health challenges of adolescents, there is need to have separate meetings with adolescents, targeted mobilization for adolescents to attend meetings and deliberate inclusion of their maternal health challenges into the CSC.

Influence of community scorecards on maternal and newborn health service delivery and utilization.

INTRODUCTION: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators. METHODS: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework. RESULTS: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders. CONCLUSIONS AND RECOMMENDATIONS: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.

Uganda's laboratory human resource in the era of global health initiatives: experiences, constraints and opportunities-an assessment of 100 facilities.

INTRODUCTION: Laboratories are vital in disease diagnosis, prevention, treatment and outbreak investigations. Although recent decades have seen rapid advancements in modernised equipment and laboratory processes, minimal investments have been made towards strengthening laboratory professionals in Africa. This workforce is characterised by insufficient numbers, skewed rural-urban distribution, inadequate qualifications, inadequate skill-mix and limited career opportunities. These factors adversely affect the performance of laboratory professionals, who are the backbone of quality services. In the era of Global Health Initiatives, this study describes the status of laboratory human resource and assesses the experiences, constrains and opportunities for strengthening them in Uganda. METHODS: This paper is part of a study, which assessed laboratory capacity in 21 districts during December 2015 to January 2016. We collected data using a laboratory assessment tool adapted from the WHO and USAID assessment tool for laboratory services and supply chain (ATLAS), 2006. Of the 100 laboratories, 16 were referral laboratories (hubs). To assess human resource constraints, we conducted 100 key informant interviews with laboratory managers and in charges. RESULTS: Across the facilities, there was an excess number of laboratory technicians at Health Center (HC) IV level by 30% and laboratory assistants were in excess by 90%. There was a shortage of laboratory technologists with only 50% of the posts filled at general hospitals. About 87.5% of hub laboratories had conducted formal onsite training compared to 51.2% of the non-hub laboratories. Less than half of HC III laboratories had conducted a formal onsite training; hospital laboratories had not conducted training on the use and maintenance of equipment. Almost all HC III laboratories had been supervised though supervision focused on HIV/AIDS. Financial resources, workload and lack of supervision were major constraints to human resource strengthening. CONCLUSION: Although opportunities for continuous education have emerged over the past decade, they are still threatened by inadequate staffing, skill mix and escalating workload. Moreover, excesses in staffing are more in favour of HIV, TB and malaria. The Ministry of Health needs to develop work-based staffing models to ensure adequate staff numbers and skill mix. Staffing norms need to be revised to accommodate laboratory technologists and scientists at high-level laboratories. Training needs to extend beyond HIV, TB and malaria.

Maternal and newborn health needs for women with walking disabilities; "the twists and turns": a case study in Kibuku District Uganda.

BACKGROUND: In Uganda 13% of persons have at least one form of disability. The United Nations' Convention on the Rights of Persons with Disabilities guarantees persons with disabilities the same level of right to access quality and affordable healthcare as persons without disability. Understanding the needs of women with walking disabilities is key in formulating flexible, acceptable and responsive health systems to their needs and hence to improve their access to care. This study therefore explores the maternal and newborn health (MNH)-related needs of women with walking disabilities in Kibuku District Uganda. METHODS: We carried out a qualitative study in September 2017 in three sub-counties of Kibuku district. Four In-depth Interviews (IDIs) among purposively selected women who had walking disabilities and who had given birth within two years from the study date were conducted. Trained research assistants used a pretested IDI guide translated into the local language to collect data. All IDIs were audio recorded and transcribed verbatim before analysis. The thematic areas explored during analysis included psychosocial, mobility, health facility and personal needs of women with walking disabilities. Data was analyzed manually using framework analysis. RESULTS: We found that women with walking disabilities had psychosocial, mobility, special services and personal needs. Psychosocial needs included; partners', communities', families' and health workers' acceptance. Mobility needs were associated with transport unsuitability, difficulty in finding transport and high cost of transport. Health facility needs included; infrastructure, and responsive health services needs while personal MNH needs were; personal protective wear, basic needs and birth preparedness items. CONCLUSIONS: Women with walking disabilities have needs addressable by their communities and the health system. Communities, and health workers need to be sensitized on these needs and policies to meet and implement health system-related needs of women with disability.

Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda.

In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care - through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh's Model of Diffusion to reflect on these projects' approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.

Health systems readiness to provide geriatric friendly care services in Uganda: a cross-sectional study.

BACKGROUND: As ageing emerges as the next public health threat in Africa, there is a paucity of information on how prepared its health systems are to provide geriatric friendly care services. In this study, we explored the readiness of Uganda's public health system to offer geriatric friendly care services in Southern Central Uganda. METHODS: Four districts with the highest proportion of old persons in Southern Central Uganda were purposively selected, and a cross-section of 18 randomly selected health facilities (HFs) were visited and assessed for availability of critical items deemed important for provision of geriatric friendly services; as derived from World Health Organization's Age-friendly primary health care centres toolkit. Data was collected using an adapted health facility geriatric assessment tool, entered into Epi-data software and analysed using STATA version 14. Kruskal-Wallis and Dunn's post hoc tests were conducted to determine any associations between readiness, health facility level, and district. RESULTS: The overall readiness index was 16.92 (SD ±4.19) (range 10.8-26.6). This differed across districts; Lwengo 17.91 (SD ±3.15), Rakai 17.63 (SD ±4.55), Bukomansimbi 16.51 (SD ±7.18), Kalungu 13.74 (SD ±2.56) and facility levels; Hospitals 26.62, Health centers four (HCIV) 20.05 and Health centers three (HCIII) 14.80. Low readiness was due to poor scores concerning; leadership (0%), financing (0%), human resources (1.7%) and health management information systems (HMIS) (11.8%) WHO building blocks. Higher-level HFs were statistically significantly friendlier than lower-level HFs (p = 0.015). The difference in readiness between HCIIIs and HCIVs was 2.39 (p = 0.025). CONCLUSION: There is a low readiness for public health facilities to provide geriatric friendly care services in Uganda. This is due to gaps in all of the health system building blocks. There is a need for health system reforms in Uganda to adequately cater for service provision for older adults if the 2020 global healthy ageing goal is to be met.

Elements for harnessing participatory action research to strengthen health managers' capacity: a critical interpretative synthesis.

BACKGROUND: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers' capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers' capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter. METHODS: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers' capacity. The critical interpretive synthesis method's approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104-111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains. RESULTS: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers' capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning. CONCLUSIONS: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers' capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.

A structural equation analysis on the relationship between maternal health services utilization and newborn health outcomes: a cross-sectional study in Eastern Uganda.

BACKGROUND: Neonatal and maternal health services have a bearing on neonatal mortality. Direct and indirect factors affecting neonatal health outcomes therefore require understanding to enable well-targeted interventions. This study, therefore, assessed the interrelationship between newborn health outcomes and maternal service utilization factors. METHODS: We investigated maternal health utilization factors using health facility delivery and at least four Antenatal Care (ANC) visits; and newborn health outcomes using newborn death and low birth weight (LBW). We used data from a household cross-sectional survey that was conducted in 2015 in Kamuli, Pallisa and Kibuku districts. We interviewed 1946 women who had delivered in the last 12 months. The four interrelated (Endogenous) outcomes were ANC attendance, health facility delivery, newborn death, and LBW. We performed analysis using a structural equation modeling technique. RESULTS: A history of newborn death (aOR = 12.64, 95% CI 5.31-30.10) and birth of a LBW baby (aOR = 3.51, 95% CI 1.48-8.37) were directly related to increased odds of newborn death. Factors that reduced the odds of LBW as a mediating factor for newborn death were ANC fourth time attendance (aOR = 0.62, 95% CI 0.45-0.85), having post-primary level education (aOR = 0.68, 95% CI 0.46-0.98) compared to none and being gravida three (aOR = 0.49, 95% CI 0.26-0.94) compared to being gravida one. Mother's age group, 20-24 (aOR = 0.24, 95% CI 0.08-0.75) and 25-29 years (aOR = 0.20, 95% CI 0.05-0.86) compared to 15-19 years was also associated with reduced odds of LBW. Additionally, ANC visits during the first trimester (aOR = 2.04, 95% CI 1.79-2.34), and village health teams (VHTs) visits while pregnant (aOR = 1.14, 95% CI 1.01-1.30) were associated with increased odds of at least four ANC visits, which is a mediating factor for health facility delivery, LBW and newborn death. Surprisingly, newborn death was not significantly different between health facility and community deliveries. CONCLUSIONS: Attending ANC at least four times was a mediating factor for reduced newborn death and low birth weight. Interventions in maternal health and newborn health should focus on factors that increase ANC fourth time attendance and those that reduce LBW especially in resource-limited settings. Targeting women with high-risk pregnancies is also crucial for reducing newborn deaths.

A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda.

BACKGROUND: Many approaches to improving health managers' capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers' capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers' capacity in Eastern Uganda. METHODS: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers' capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus. RESULTS: The findings indicate that the participatory action research approach enhanced health managers' capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness. CONCLUSIONS: Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers' capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers' capacity.

Building a competent health manager at district level: a grounded theory study from Eastern Uganda.

BACKGROUND: Health systems in low-income countries are often characterized by poor health outcomes. While many reasons have been advanced to explain the persistently poor outcomes, management of the system has been found to play a key role. According to a WHO framework, the management of health systems is central to its ability to deliver needed health services. In this study, we examined how district managers in a rural setting in Uganda perceived existing approaches to strengthening management so as to provide a pragmatic and synergistic model for improving management capacity building. METHODS: Twenty-two interviews were conducted with district level administrative and political managers, district level health managers and health facility managers to understand their perceptions and definitions of management and capacity building. Kathy Charmaz's constructive approach to grounded theory informed the data analysis process. RESULTS: An interative, dynamic and complex model with three sub-process of building a competent health manager was developed. A competent manager was understood as one who knew his/her roles, was well informed and was empowered to execute management functions. Professionalizing health managers which was viewed as the foundation, the use of engaging learning approaches as the inside contents and having a supportive work environment the frame of the model were the sub-processes involved in the model. The sub-processes were interconnected although the respondents agreed that having a supportive work environment was more time and effort intensive relative to the other two sub-processes. CONCLUSIONS: The model developed in our study makes four central contributions to enhance the WHO framework and the existing literature. First, it emphasizes management capacity building as an iterative, dynamic and complex process rather than a set of characteristics of competent managers. Second, our model suggests the need for professionalization of health managers at different levels of the health system. Third, our model underscores the benefits that could be accrued from the use of engaging learning approaches through prolonged and sustained processes that act in synergy. Lastly, our model postulates that different resource investments and a varied range of stakeholders could be required at each of the sub-processes.

The neonatal mortality and its determinants in rural communities of Eastern Uganda.

BACKGROUND: In Uganda, neonatal mortality rate (NMR) remains high at 27 deaths per 1000 live births. There is paucity of data on factors associated with NMR in rural communities in Uganda. The objective of this study was to determine NMR as well as factors associated with neonatal mortality in the rural communities of three districts from eastern Uganda. METHODS: Data from a baseline survey of a maternal and newborn intervention in the districts of Pallisa, Kibuku and Kamuli, Eastern Uganda was analyzed. A total of 2237 women who had delivered in the last 12 months irrespective of birth outcome were interviewed in the survey. The primary outcome for this paper was neonatal mortality. The risk ratio (RR) was used to determine the factors associated with neonatal mortality using log-binomial model. RESULTS: The neonatal mortality was found to be 34 per 1000 live births (95% CI = 27.1-42.8); Kamuli 31.9, Pallisa 36.5 and Kibuku 30.8. Factors associated with increased neonatal deaths were parity of 5+ (adj. RR =2.53, 95% CI =1.14-5.65) relative to parity of 4 and below, newborn low birth weight (adj. RR = 3.10, 95% CI = 1.47-6.56) and presence of newborn danger signs (adj. RR = 2.42, 95% CI = 1.04-5.62). Factors associated with lower risk of neonatal death were, home visits by community health workers' (CHW) (adj. RR =0.13, 95% CI = 0.02-0.91), and attendance of at least 4 antenatal visits (adj. RR = 0.65, 95% CI = 0.43-0.98). CONCLUSIONS: Neonatal mortality in rural communities is higher than the national average. The use of CHW's to mobilize and sensitize households on appropriate maternal and newborn care practices could play a key role in reducing neonatal mortality.

Determinants and processes of HIV status disclosure to HIV--infected children aged 4 to 17 years receiving HIV care services at Baylor College of Medicine Children's Foundation Tanzania, Centre of Excellence (COE) in Mbeya: a cross-sectional study.

BACKGROUND: Disclosure of HIV sero-status to HIV-infected children is associated with reduced risk of death and better adherence to antiretroviral drugs. However, caregivers find it difficult to determine when and how they should disclose the HIV sero-positive status to HIV-infected children. In this study, we assessed the determinants and processes of HIV status disclosure to HIV-infected children aged 4 to 17 years receiving HIV care services at the Baylor College of Medicine Children's Foundation Tanzania, Centre of Excellence (COE) in Mbeya. METHODS: This was a cross-sectional study conducted among 334 caregivers of HIV positive children attending the Baylor COE in Mbeya, Tanzania. Data were collected using quantitative and qualitative research methods. Quantitative data were collected on socio-demographic characteristics of children and caregivers using an interviewer-administered questionnaire. Data were entered into Epi-Info version 3.5.1 and analyzed using STATA version 10. Univariable and multivariable logistic regression analyses were conducted to obtain odds ratios (OR) and 95% confidence intervals (95% CI) associated with disclosing HIV positive status to HIV-infected children. Qualitative data were collected on the processes used in accomplishing the HIV status disclosure event using case histories and key informant interviews and analyzed manually using latent analysis techniques. RESULTS: About one-third of the caregivers (32.6%) disclosed the children's HIV sero-positive status to them. Disclosure was more likely among children 10 years or older (adjusted OR [AOR] = 8.8; 95% CI: 4.7, 16.5), caregivers with knowledge about HIV disclosure (AOR = 5.7; 95% CI: 2.3, 13.7) and those earning more than Tsh 99,999 (US $62.5) per month (AOR = 2.4; 95% CI: 1.3, 4.5). Qualitative findings showed that caregivers used a diversity of approaches to complete the HIV status disclosure event including direct, third-party, event-driven and use of drawings. CONCLUSIONS: Our study shows that disclosure is common among older children and is largely driven by the caregivers' knowledge about HIV status disclosure and monthly earnings. HIV status disclosure was accomplished through a variety of approaches. These findings suggest a need to provide caregivers with knowledge about HIV status disclosure approaches to improve HIV status disclosure to HIV-infected children.

Utilization of research findings for health policy making and practice: evidence from three case studies in Bangladesh.

BACKGROUND: In striving to contribute towards improved health outcomes, health research institutions generate and accumulate huge volumes of relevant but often underutilized data. This study explores activities undertaken by researchers from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), an international research institution that promotes the utilization of their findings in the policymaking processes in Bangladesh. METHODS: The study used an exploratory case study design and employed qualitative methods to explore activities implemented to promote research utilization and the extent to which researchers felt that their findings contributed to the policymaking process. Data were collected between September and December 2011 through key informant interviews, focus group discussions with study investigators, and database and document reviews. We reviewed findings from 19 reproductive health studies conducted and completed by icddr,b researchers between 2001 and 2011. We interviewed 21 key informants, including 13 researchers, two policy makers, and six programme implementers. Data were entered into Microsoft Word and analyzed manually following a thematic framework approach. Following the World Health Organization/Turning Research into Practice (WHO/TRIP) framework, three case studies of how research findings were utilized in the policymaking processes in Bangladesh were documented. RESULTS: Activities implemented to promote research utilization included conducting dissemination workshops, publishing scientific papers, developing policy briefs, providing technical assistance to policymakers and programme implementers, holding one-on-one meetings, and joining advocacy networks. The majority of the researchers (12 of 13) reported that their study findings were utilized to influence policymaking processes at different levels. However, some researchers reported being unaware of whether and how their findings were utilized. As regards actual utilization of research findings, the evidence from the three case studies indicate that research findings can be utilized instrumentally, conceptually and symbolically, and at different stages within the policymaking process, including agenda setting and policy formulation and implementation. CONCLUSIONS: The results show that research findings from icddr,b were promoted and utilized in health policymaking processes in Bangladesh using a variety of utilization approaches. These results suggest a need for using multiple approaches to promote utilization of research findings in health policymaking processes.

Financial interventions and movement restrictions for managing the movement of health workers between public and private organizations in low- and middle-income countries.

BACKGROUND: Health workers move between public and private organizations in both urban and rural areas during the course of their career. Depending on the proportion of the population served by public or private organizations in a particular setting, this movement may result in imbalances in the number of healthcare providers available relative to the population receiving care from that sector. However, both public and private organizations are needed as each sector has unique contributions to make to the effective delivery of health services. OBJECTIVES: To assess the effects of financial incentives and movement restriction interventions to manage the movement of health workers between public and private organizations in low- and middle-income countries. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (10 November 2012); EMBASE (7 June 2011); LILACS (9 June 2011); MEDLINE (10 November 2012); CINAHL (13 August 2012); and the British Nursing Index (13 August 2012). SELECTION CRITERIA: Randomized controlled trials and non-randomized controlled trials; controlled before-and-after studies if pre- and post-intervention periods for study and control groups were the same and there were at least two units included in both the intervention and control groups; uncontrolled and controlled interrupted time series studies if the point in time when the intervention occurred was clearly defined and there were at least three or more data points before and after the intervention. Interventions included payment of special allowances, increasing salaries, bonding health workers, offering bursary schemes, scholarships or lucrative terminal benefits, and hiring people on contract basis. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the criteria for inclusion and exclusion of studies to the titles and abstracts of all articles obtained from the search. The same two review authors independently screened the full reports of the selected citations. At each stage, we compared the results and resolved discrepancies through discussion with a third review author. MAIN RESULTS: We found no studies that were eligible for inclusion in this review. AUTHORS' CONCLUSIONS: We identified no rigorous studies on the effects of interventions to manage the movement of health workers between public and private organizations in low- and middle-income countries. Health worker availability is a key obstacle in delivery of health services. Interventions to make the health sector more responsive to the expectations of populations by having more health workers in the sector that serves most people would contribute to the more efficient use of the health workforce. More research is needed to assess the effect of increase in salaries, offering scholarships or bonding on movement of health workers in one sector compared with another.