Expectations of clients, insurers, and providers: a qualitative responsiveness assessment among private health insurance sector in Kampala-Uganda.

BACKGROUND: There is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda's proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness. METHODS: This study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes. RESULTS: Client-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service. CONCLUSION: Health care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda's proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships.

Use and non-adherence to antiretroviral therapy among Refugee HIV positive pregnant mothers aged 18-49 years in Kyangwali Refugee Camp, Western Uganda.

Introduction: Refugee HIV positive mothers experience significant obstacles in accessing, utilizing and adhering to antiretroviral therapy (ART). Identifying ART non-adherence can help enforce interventions aimed at improving adherence and subsequently effectiveness of ART among the refugee mothers. We describe the use and the factors associated with non-adherence to ART among Refugee HIV positive pregnant mothers aged 18-49 years in Kyangwali Refugee Camp, Uganda. Methods: We conducted a cross-sectional study among HIV positive pregnant mothers aged 18-49 years in Kyangwali refugee camp between May and June 2023. Using a structured questionnaire, we collected data on use, and factors associated with non-adherence to ART. We used modified Poisson regression analysis to determine factors associated with non-adherence to ART. Results: Of the 380 participants enrolled, 192 (50.5%) were married, mean age 32.1 years. Overall, 98.7; 95% CI [97.5-99.8%] were using ART and 27.4; 95% CI [22.9-31.9%] were non-adherent. Non-adherence was associated with; Initiating PMTCT care in the third trimester of pregnancy (aPR: 2.06; 95% CI: 1.27-3.35), no need to get permission to seek PMTCT services aPR 1.61; 95% CI [1.07-2.42] and poor attitude of PMTCT providers aPR 1.90; 95% CI [1.20-3.01]. Conclusion and recommendations: Non-adherence to ART was generally high; therefore limiting the effectiveness of the PMTCT program in this setting. Refugee context specific education interventional programs aimed at early initiation into HIV care, strong social and psychological support from families, communities and health care providers are vital to improve adherence this setting.

Factors associated with willingness to take Pre-Exposure Prophylaxis (PrEP) among high-risk adolescent boys and young men in Masese fishing community, Uganda.

Pre-Exposure Prophylaxis (PrEP) is a known HIV prevention strategy for high-risk populations however, some high-risk communities have not yet fully embraced it. We sought to determine willingness to take PrEP and the associated factors among high-risk adolescent boys and young men (ABYM) in Masese fishing community, Jinja district, Eastern Uganda. We conducted a cross-sectional study, between October and November 2020, using a semi-structured questionnaire among ABYM aged 10-24 years in Masese fishing community, Eastern Uganda. We surveyed 479 participants, who had two or more sexual partners with inconsistent or no condom use. We carried out modified Poisson regression analysis to determine factors associated with willingness to take PrEP.Of 479 high-risk ABYM, 86.4% (n = 414) were willing to take PrEP. Confidence in PrEP safety (adj.PR = 1.56; 95%CI: 1.55, 2.24), availability of PrEP in areas easily accessible by ABYM (adj.PR = 1.40; 95%CI: 1.25, 1.57), and perceiving oneself as being at a very high risk of HIV infection (adj.PR = 1.11; 95%CI: 1.03, 1.20) were positively associated with willingness to take PrEP. On the other hand, being unmarried (adj.PR = 0.92; 95%CI: 0.87, 0.98) and earning more than USD 27 a month (adj.PR = 0.92; 95%CI: 0.87, 0.97) were negatively associated with willingness to take PrEP. There was high willingness to take PrEP among adolescent boys and young men in Masese fishing community. Confidence in PrEP safety, access to PrEP in their community and self-perception to be at high risk for HIV acquisition had a positive bearing on willingness to take PrEP while being unmarried and earning more than USD27 had a negative bearing on willingness to take PrEP. These findings suggest a need for target-specific interventions for unmarried men and those earning >USD27.

Men's late presentation for HIV care in Eastern Uganda: The role of masculinity norms.

INTRODUCTION: In Uganda, adult men living with HIV are more likely to present late for care; with a CD4 cell count below 350 cells/µl compared to women. Understanding why adult men present late for HIV care is important in improving early linkage to care. Studies across countries in Sub-Saharan Africa emphasize the role of masculinity norms; defined as social expectations about appropriate roles and behavior for men, in men's health behaviours particularly, in HIV care engagement. This study therefore explored how masculinity norms influence men's late presentation for HIV care. METHODS: This was a qualitative study undertaken in Jinja District, Eastern Uganda between October and November 2020. We conducted 20 In-Depth Interviews (IDIs) with men living with HIV who had presented late for care at Family Hope Centre. We also conducted four Focus Group Discussions (FGDs) with HIV negative men and women in selected communities of Katende and Walukuba. Conventional content analysis approach was used to identify themes across the collected data. RESULTS: A total of 20 men participated in the In-depth Interviews (IDIs), with majority being married 15/20 (75%) and primary level holders 7/15 (46.7%). Nineteen (19) women participated in two FGDs, with a mean age of 29.5 years. Nineteen (19) men also participated in other two FGDs, with a mean age of 28.2 years. Conventional content analysis results indicated that men's late presentation for HIV care in Jinja district is greatly related to their concerns of loss of respect and the need to preserve their reputation and maintain a sense of normality in their families and society as proposed by Wilson's (1969) respectability-reputation theoretical model. Respectability was endorsed by 'the wider society', while reputation was endorsed almost entirely by men and some women. CONCLUSION: Findings show that the explanations for men's late presentation arise from the masculinity norms in Jinja District, Eastern Uganda.

Factors Influencing the Uptake of Voluntary Medical Male Circumcision Among Boda-Boda Riders Aged 18-49 Years in Hoima, Western Uganda.

Introduction: We asseSssed factors influencing the uptake of voluntary medical male circumcision (VMMC) among boda-boda riders aged 18-49 years in Hoima, western Uganda. Despite high levels of awareness about availability and benefits of VMMC, uptake was still low. Methods: We employed the convergent parallel mixed methods design among boda-boda riders in Hoima district between August and September 2020. We administered a structured questionnaire to 316 boda-boda riders to determine factors associated with uptake of VMMC. We also conducted eight focus group discussions (FGDs) and six key informant interviews (KIIs) to explore perceptions of VMMC. To determine factors associated with VMMC, we conducted modified Poisson regression analysis at 5% level of significance. We identified sociocultural barriers and facilitators for VMMC using thematic content analysis. Results: Uptake of VMMC was at 33.9% (95% CI 28.6-39.1) and was associated with higher level of education, adjusted prevalence ratio (APR) 1.63, (95% CI 1.12-2.40); concern about being away from work, APR 0.66 (95% CI 0.49-0.88); and the belief that VMMC does not diminish sexual performance, APR 1.78 (95% CI 1.08-2.9). Facilitators of uptake of VMMC were health education and awareness creation, improved penile hygiene, and perceived sexual functioning; and reduced chances of HIV and sexually transmitted infections (STIs). On the other hand, the barriers to uptake were fear of pain and compulsory HIV testing, healing duration, financial loss during the healing period, fear of sexual misbehavior after circumcision, interruption of God's creation, and fear of loss of male fertility. Conclusion: Although VMMC is largely perceived as protective against HIV and other STIs, deliberate measures using multiple strategies should be put in place to address the barriers to its uptake among this key population.

Using Population-Based Structures to Actively Monitor AEFIs during a Mass Immunization Campaign-A Case of Measles-Rubella and Polio Vaccines.

Active vaccine pharmacovigilance complements the standard passive or spontaneous surveillance system, which suffers from low reporting rates. This study aimed at utilizing population-based structures to report and profile adverse events following immunization (AEFI) with the measles and rubella vaccine (MR), or MR in combination with the bivalent oral polio vaccine (bOPV 1&3) (MR & bOPV), during mass vaccination in Uganda. Caretakers of children at home (less than 5 years) and schoolgoing children were followed up on and encouraged to report any AEFIs on day one, 2-3 days, 10 days, and 14 days after vaccination at school by their teachers and at-home, community-based village health teams. Out of 9798 children followed up on, 382 (3.9%) reported at least one AEFI, and in total, 517 AEFIs were reported. For MR, high temperature (21%), general feeling of weakness (19.3%), and headache (13%) were the most reported AEFIs, though there were variations on the days when they were reported. For the combination dose of MR & bOPV, high temperature (44%), rash (17%), general feeling of weakness (13%), and diarrhoea (8%) were the most common adverse events following immunization reported by caretakers. All 382 children cleared the AEFIs within 2 days, with 343 (90%) children reporting mild or moderate AEFIs and only 39 (10%) reporting severe AEFIs. The reported AEFIs are known and are mentioned in the vaccine leaflets with similar severity classification. Rates of AEFIs differed with the number of days after receiving the immunization. Conclusion: Active surveillance for AEFIs provides additional important information to national vaccine regulatory bodies. It reassures the public that vaccines are safe and that their safety is being taken seriously in Uganda, which would improve vaccine acceptability and confidence in the health system. Piggybacking on existing structures such as village health team members (for children at home) and teachers (for schoolgoing children) facilitates reaching vaccine recipients and increases reporting rates. Therefore, studies using active reporting of AEFIs should be conducted at regular intervals to report the overall incidence of AEs and to monitor trends and changes.