"Here, your only relative is money " why slum social networks do not facilitate neighborhood community development: insights through a sanitation lens.

INTRODUCTION: Though social networks which are deemed vehicles of community development exist in slum areas, underdevelopment still persists in these areas. We explored the nature and role of social networks in facilitating community development in the slums of Kampala through a sanitation lens. METHODS: Qualitative Social Network Analysis (SNA) was done to understand the nature of slum social networks primarily through the analysis of sanitation behavior. Data were collected through six Focus Group Discussions (FGD), six In-depth Interviews (IDIs), and 18 Key Informant Interviews (KII) with Government, civil society and private stakeholders. We used both inductive and deductive thematic analysis. RESULTS: Four themes emerged in our analysis; i); Unsupportive environments, uncooperative neighbours and uncertainty of tenure: participants reported slums as unsupportive of community development due to a shortage of space, poverty and unplanned services. Tenants perceived landlords as exploitative and predatory and wished the tables are turned. This notion of cyclic exploitation did not encourage collective action for community good. Short-term economic survival trumped long-term community interests ii) Patronage and poor service delivery: varying degrees of patronage led to multiple forms of illegalities and violations such as tax evasion. Due to vested interests and corruption among public officials, the slum population was lethargic. iii) Intersecting realities of poverty and unemployment: slum dwellers lived on the margins daily. Hence, poor living conditions were a secondary concern. iv) Social relations for personal development: Slum social networks were driven by individual interests rather than community good. Slum dwellers prioritized connections with people of common socio-economic interests. As such social networks were instrumental only if they 'added value'. CONCLUSION: Social networks in slums are only concerned about survival needs. Slums require responses that address the complexity of slum formation and broader livelihood challenges, as well as re-assessing the meaning of community. We posit that more needs to be done in understanding the meaning and workings of a sociology beyond physical societies. Poverty is a modifier of social systems and processes and should be a concern for all stakeholders involved in slum development.

"After all, we are all sick": multi-stakeholder understanding of stigma associated with integrated management of HIV, diabetes and hypertension at selected government clinics in Uganda.

BACKGROUND: Integrated care is increasingly used to manage chronic conditions. In Uganda, the integration of HIV, diabetes and hypertension care has been piloted, to leverage the advantages of well facilitated and established HIV health care provision structures. This qualitative study aimed to explore HIV stigma dynamics whilst investigating multi-stakeholder perceptions and experiences of providing and receiving integrated management of HIV, diabetes and hypertension at selected government clinics in Central Uganda.  METHODS: We adopted a qualitative-observational design. Participants were purposively selected. In-depth interviews were conducted with patients and with health care providers, clinical researchers, policy makers, and representatives from international nongovernmental organizations (NGOs). Focus group discussions were conducted with community members and leaders. Clinical procedures in the integrated care clinic were observed. Data were managed using Nvivo 12 and analyzed thematically. RESULTS: Triangulated findings revealed diverse multi-stakeholder perceptions around HIV related stigma. Integrated care reduced the frequency with which patients with combinations of HIV, diabetes, hypertension visited health facilities, reduced the associated treatment costs, increased interpersonal relationships among patients and healthcare providers, and increased the capacity of health care providers to manage multiple chronic conditions. Integration reduced stigma through creating opportunities for health education, which allayed patient fears and increased their resolve to enroll for and adhere to treatment. Patients also had an opportunity to offer and receive psycho-social support and coupled with the support they received from healthcare worker. This strengthened patient-patient and provider-patient relationships, which are building blocks of service integration and of HIV stigma reduction. Although the model significantly reduced stigma, it did not eradicate service level challenges and societal discrimination among HIV patients. CONCLUSION: The study reveals that, in a low resource setting like Uganda, integration of HIV, diabetes and hypertension care can improve patient experiences of care for multiple chronic conditions, and that integrated clinics may reduce HIV related stigma.

Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial.

BACKGROUND: Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up 'one-stop' integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. METHODS: The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner's ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). RESULTS: Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. CONCLUSIONS: Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. TRIAL REGISTRATION NUMBER: ISRCTN43896688.

Re-conceptualizing sustainable urban sanitation in Uganda: why the roots of 'Slumification' must be dealt with.

BACKGROUND: Country-wide urbanization in Uganda has continued amidst institutional challenges. Previous interventions in the water and sanitation sector have not addressed the underlying issues of a poorly managed urbanization processes. Poor urbanisation is linked to low productivity, urban poverty, unemployment, limited capacity to plan and offer basic services as well as a failure to enforce urban standards. METHODS: This ethnographic study was carried out in three urban centres of Gulu, Mbarara and Kampala. We explored relationships between urban livelihoods and sustainable urban sanitation, using the economic sociology of urban sanitation framework. This framework locates the urbanization narrative within a complex system entailing demand, supply, access, use and sustainability of slum sanitation. We used both inductive and deductive thematic analysis. RESULTS: More than any other city in Uganda, Kampala was plagued with poor sanitation services characterized by a mismatch between demand and the available capacity for service provision. Poor slum sanitation was driven by; the need to escape rural poverty through urban migration, urban governance deficits, corruption and the survival imperative, poor service delivery and lack of capacity, pervasive (urban) informality, lack of standards: 'to whom it may concern' attitudes and the normalization of risk as a way of life. Amidst a general lack of affordability, there was a critical lack of public good conscience. Most urbanites were trapped in poverty, whereby economic survival trumped for the need for meeting desirable sanitation standards. CONCLUSIONS: Providing sustainable urban livelihoods and meeting sanitation demands is nested within sustainable livelihoods. Previous interventions have labored to fix the sanitation problem in slums without considering the drivers of this problem. Sustainable urban livelihoods are critical in reducing slums, improving slum living and curtailing the onset of slumification. Urban authorities need to make urban centres economically vibrant as an integral strategy for attaining better sanitation standards.

'When will the doctor be around so that I come by?!' Geo-socio effects on health care supply, access and utilisation: experiences from Kalangala Islands, Uganda.

BACKGROUND: The study set out to give an in-depth intersection of geo, eco-socio exposition of the factors relating to geography, healthcare supply and utilization in an island setting. This analysis is informed by what has emerged to be known as social epidemiology. We provide in-depth explanation of context to health care access, utilization and outcomes. We argue that health care delivery has multiple intersections that are experientially complex, multi-layered and multi-dimensional to the disadvantage of vulnerable population segments of society in the study area. METHODS: We used a cross-sectional qualitative exploratory design. Qualitative methods facilitated an in-depth exploration and understanding of this island dispersed and peripheral setting. Data sources included a review of relevant literature and an ethnographic exploration of the lived experiences of community members while seeking and accessing health care. Data collection methods included in-depth interviews (IDI) from selected respondents, observation, focus group discussions (FGDs) and key informant interviews (KII). RESULTS: We report based on the health care systems model which posits that, health care activities are diverse but interconnected in a complex way. The identified themes are; the role of geography, access (geographical and financial) to health services, demand and utilization, Supplies, staffing and logistical barriers and a permissive and transient society. When and how to travel for care was beyond a matter of having a health need/ being sick and need arising. A motivated workforce is as critical as health facilities themselves in determining healthcare outcomes. CONCLUSION: Geography doesn't work and affect health outcomes in isolation. Measures that target only individuals will not be adequate to tackle health inequalities because aspects of the collective social group and physical environment may also need to be changed in order to reduce health variations.

Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda.

INTRODUCTION: Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease. METHODS AND ANALYSIS: This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension. ETHICS AND DISSEMINATION: The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications. TRIAL REGISTRATION NUMBER: ISRCTN15319595.

Why don't adolescent girls in a rural Uganda district initiate or complete routine 2-dose HPV vaccine series: Perspectives of adolescent girls, their caregivers, healthcare workers, community health workers and teachers.

INTRODUCTION: Vaccination with the 2-dose HPV vaccine series among adolescent girls in Uganda remains low after almost 5 years since the vaccine was included into the routine national immunization program and barriers are not well understood. OBJECTIVE: We explored barriers that prevent eligible girls from initiating or completing the recommended 2-dose HPV vaccine series in Oyam District, Northern Uganda. METHODS: A qualitative study was conducted in Oyam District, Northern Uganda. Forty interviews were conducted with adolescent girls, their caregivers, Village Health Team Members, health workers and school administrators involved in HPV vaccination. All interviews were audio recorded and transcribed. NVivo version 11 was used for data management and content thematic approach for analysis guided by the Social Ecological Model. RESULTS: At individual level, low levels of knowledge about the vaccine, girls' frequent mobility between vaccine doses, school absenteeism and drop out, fear of injection pain and discouragement from caregivers or peers were key barriers. At the health facilities level, reported barriers included: few healthcare workers, inadequate knowledge about HPV vaccine, limited social mobilization and community engagement to promote the vaccine, limited availability of the HPV vaccine, unreliable transportation, lack of reminder strategies after the first dose of the vaccine, lack of vaccination strategy for out-of-school girls and un-friendly behaviour of some healthcare workers. Concerns about safety and efficacy of the vaccine, negative religious and cultural beliefs against vaccination, rumors and misconceptions about the vaccine, mistrust in government intentions to introduce the new vaccine targeting girls, busy schedules and the gendered nature of care work were key community level barriers. CONCLUSION: Our study revealed an interplay of barriers at individual, health facility and community levels, which prevent initiation and completion of HPV vaccination among adolescent girls. Strengthening HIV vaccination programs and ensuring high uptake requires providing appropriate information to the girls plus the community, school and health facility stakeholders; addressing cold chain challenges as well as adequate training of vaccinators to enable them respond to rumors about HPV vaccination.