Cultural beliefs and practices on perinatal death: a qualitative study among the Lango community in Northern Uganda.

BACKGROUND: Perinatal death has profound psychosocial effects on women and their families. Sociocultural contexts influence the burden, rituals and bereaved's support. Little is known about cultural beliefs and practices related to perinatal death. This study explored the cultural perspectives of the Lango community on perinatal death. METHODS: This study utilised a focused ethnographic design anchored on a symbolic interactionist framework to understand the meanings attached to beliefs and practices on stillbirth or neonatal death among the Lango community in Lira District, Northern Uganda. Participants were sampled purposively for FGD while key informants were identified through snowballing technique. Data were audio recorded in Lango, transcribed, and later translated, a codebook was developed and data entered into Atlas. ti version 8.4.26 and then coded. It was analysed both deductively and inductively into themes. RESULTS: Stillbirth and early neonatal death both attract similar rituals as would an older child. Burial is not rushed and is attended by family members and close friends. Stillbirths and children that die before naming are buried without names. Bereaved families are comforted and encouraged about future pregnancies. Currently, Lango associates the deaths to biomedical explanations such as teenage pregnancies, inadequate pregnancy care, health system challenges and poor health-seeking behaviour, unlike previously when they were attributed to consequences of unacceptable social behaviours, superstitious beliefs and witchcraft. Antenatal care and health facility childbirths are currently preferred over traditional practices for good pregnancy outcomes. CONCLUSION: Stillbirth or early neonatal death is viewed as the death of a child, different from other settings. Thus, rituals are performed to honour, create memory, and maintain the connection with deceased babies. Bereaved parents are supported. Health care workers need to provide culturally sensitive support to parents after perinatal loss. The prevailing beliefs of perinatal death cause in terms of biomedical explanations consistent with known determinants and preference for health facility care for prevention creates an opportunity for improving perinatal health.

Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda.

BACKGROUND: Transwomen (also known as transgender women) are disproportionately affected by all forms of gender-based violence (GBV). The high prevalence of physical, sexual and emotional violence not only predisposes transwomen to HIV infection but also limits the uptake/access to HIV prevention, care, and treatment services. Despite the high prevalence of HIV infection and GBV among transwomen, there is limited evidence on how GBV affects the uptake and utilisation of HIV prevention, care, and treatment services. Therefore, this qualitative study explored how GBV affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area (GKMA), Uganda. METHODS: This participatory qualitative study was conducted among transwomen in the GKMA. A total of 20 in-depth interviews, 6 focus group discussions, and 10 key informant interviews were conducted to explore how GBV affects the uptake and utilisation of HIV prevention, treatment, and care services among transwomen. Data were analysed using a thematic content analysis framework. Data were transcribed verbatim, and NVivo version 12 was used for coding. RESULTS: At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy (ART). Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level led to fear among transwomen traveling to healthcare facilities. Emotional violence suffered by transwomen in healthcare settings led to the limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. The fear of emotional violence also made it difficult for transwomen to approach healthcare providers. Fear of physical violence such as being beaten while in healthcare settings made transwomen shun healthcare facilities. CONCLUSION: The effects of GBV on the uptake and utilisation of HIV prevention, care, and treatment services were observed in individual, community, and healthcare settings. Across all levels, physical, emotional, and sexual violence suffered by transwomen led to the shunning of healthcare facilities, denial of healthcare services, delays in receiving appropriate care, and the low utilisation of post-exposure prophylaxis, and HIV testing services. Given its effects on HIV transmission, there is a need to develop and implement strategies/ interventions targeting a reduction in GBV. Interventions should include strategies to sensitize communities to accept transwomen. Healthcare settings should provide an enabling environment for transwomen to approach any healthcare provider of their choice without fear of experiencing GBV.

"It's just like a blood transfusion": perceptions on the use of donated breast milk in selected hospitals in central Uganda: a qualitative study.

BACKGROUND: Breast milk is crucial for the nutritional and developmental milestones in the first two years of life. Uganda has recognized the need for a human milk bank as an opportunity that offers reliable and healthy milk to babies who lack access to their mothers. However, there is little information on the perceptions towards donated breast milk in Uganda. This study aimed to explore the perceptions of mothers, fathers, and health workers on the use of donated breast milk at Nsambya and Naguru hospitals in Kampala district, central Uganda. METHODS: A qualitative descriptive study was conducted at Nsambya and Naguru hospitals in central Uganda. The study consisted of 8 focus group discussions (FGDs) of 6 participants each and 19 key informant interviews (KIIs) among mothers, fathers, and health workers. Participants were purposively selected. Data collected were transcribed, translated from Luganda to English, and analyzed using thematic analysis. All data were organized and managed in Nvivo version 12.0. RESULTS: A total of 67 participants were involved in the study. Two main themes were identified: positive perceptions and negative perceptions. Participants linked donated breast milk to blood transfusion, believed it had nutrients comparable to the biological mother's milk, and thought it was an opportunity to avoid formula or cow milk and help babies that cannot access breast milk. However, the notable negative perceptions were; the feeling that donated breast milk is disgusting, could result in acquiring non-parental genes and traits, and that it was unsafe. Participants also feared that donated breast milk could be expensive and affect the bond between mother and child. CONCLUSION: In summary, participants had positive perceptions about donated breast milk but were concerned about the potential side effects. Health workers should take extra precautions to ensure that donated breast milk is safe. The development of appropriate information and communication programs to sensitize the public about the benefits of donated breast milk will improve the uptake. Further research should focus on understanding the social-cultural beliefs regarding donated breast milk.

Help-seeking and challenges faced by transwomen following exposure to gender-based violence; a qualitative study in the Greater Kampala Metropolitan Area, Uganda.

BACKGROUND: The high prevalence of gender-based violence (GBV) among transwomen is a human rights and public health challenge. Nonetheless, there is limited evidence of sources of GBV support services and the challenges faced by transwomen while help-seeking, especially in transphobic settings like Uganda. This study explored the sources of GBV support services and the challenges faced by transwomen in the Greater Kampala Metropolitan Area during help-seeking. METHODS: A qualitative study design involving 60 transwomen and 10 key informants was conducted. Respondents were recruited using snowball sampling. An in-depth interview (IDI), and a focus group discussion guide were used to collect data from 20 IDI respondents and six focus group discussants. Each focus group discussion averaged six participants. A key informant interview guide was used for key informant interviews. Data were transcribed verbatim and analysed following a thematic framework, informed by the socio-ecological model. Data were organised into themes and subthemes using NVivo 12.0. RESULTS: The sources of support following exposure to GBV included key population-friendly healthcare facilities and civil society organisations (CSOs), and friends and family. Friends and family provided emotional support while key population-friendly healthcare facilities offered medical services including HIV post-exposure prophylaxis. Key population CSOs provided shelter, nutritional support, and legal advice to GBV victims. Lack of recognition of transgender identity; long distances to healthcare facilities; discrimination by healthcare providers and CSO staff, inappropriate questioning of the trans-gender identity by police officers and healthcare providers, and the lack of trans-competent healthcare providers and legal personnel hindered help-seeking following exposure to GBV. CONCLUSION: The immediate sources of GBV support services included key population-friendly healthcare facilities and CSOs, police, and friends and family. However, a significant number of transwomen did not report incidences of GBV. Transwomen were discriminated against at some key population healthcare facilities and CSOs, and police, which hindered help-seeking following exposure to GBV. This study highlights the need to tackle internalized stigma and discrimination against transwomen at the existing sources of GBV support. There is also a need to train law enforcers and legal personnel on the right to access healthcare among transwomen in Uganda.

"Your heart keeps bleeding": lived experiences of parents with a perinatal death in Northern Uganda.

BACKGROUND: Worldwide, two million babies are stillborn and 1.8 million babies die before completing seven days of life. Approximately 4% of pregnant women in Uganda experience perinatal death. The response following a perinatal death tends to be socio-culturally constructed. Investigating the unique personal experiences of parents from a low-income setting with unique cultural beliefs and practices is crucial for the design and implementation of appropriate interventions. OBJECTIVE: To describe the lived experiences of parents following perinatal death in Lira district, Northern Uganda. METHODS: A qualitative study was carried out drawing on the tenets of descriptive phenomenology. We conducted 32 in-depth interviews in Lira district, Northern Uganda between August 2019 and September 2020 with 18 women and 14 men who had experienced a stillbirth or an early neonatal death within the preceding 2 years. Participants were selected from different families and interviewed. A local IRB approved the study. All in-depth interviews were audio-recorded, transcribed, translated, and data were analysed using a content thematic approach. Key findings were discussed based on Worden's Four Tasks of Mourning theory. RESULTS: The themes that emerged from the analyses included reaction to the perinatal loss and suggestions for support. The participants' immediate reactions were pain, confusion, and feelings of guilt which were aggravated by the unsupportive behaviour of health care providers. Men cumulatively lost financial resources in addition to facing multiple stressful roles. Delayed reactions such as pain and worries were triggered by the sight of similar-age-babies, subsequent pregnancy losses, and marital challenges. Participants recommended emotional support and management of postnatal complications for parents faced with perinatal loss. CONCLUSION: Losing a baby during the perinatal period in a resource-constrained setting negatively affected both gender. In addition, men suffered the loss of financial resources and the burden of multiple stressful roles. Acknowledging the pain and offering support to the grieving parents reinforce their coping with a perinatal loss. In addition to family and community members, health care providers need to provide emotional support and postnatal care to parents who experience perinatal death.

Factors associated with uptake of contraceptives among HIV positive women on dolutegravir based anti-retroviral treatment-a cross sectional survey in urban Uganda.

BACKGROUND: In May 2018, following the preliminary results of a study in Botswana that reported congenital anomalies in babies born to HIV-positive women taking dolutegravir drug, the WHO issued a teratogenicity alert. However, there are scarce data on the impact of this guidance on contraceptive uptake among women taking dolutegravir. We assessed the uptake of contraceptives in HIV-positive women of reproductive age on dolutegravir regimens. METHODS: We conducted a cross-sectional survey from April 2019 to July 2019 in five government health facilities in central Uganda, where dolutegravir-based regimens were offered as the preferred first-line antiretroviral treatment. We randomly selected 359 non-pregnant women aged 15-49 years taking dolutegravir-based regimens and interviewed them using semi-structured interviewer-administered questionnaires. We collected data on demographics, contraceptive use, individual, social, and health system factors. We described patients' characteristics using descriptive statistics and assessed factors associated with contraceptive uptake using a modified Poisson regression model. RESULTS: A total of 359 women were included in the study. The mean age was 37 years (standard deviation = 6.8) and overall contraceptive uptake was 38.4%. The most utilized method was injectable method at 58.4% followed by condoms (15%), intrauterine device (10.7%), pills (6.4%), implants (5.4%), and sterilization (0.7%). Predictors for contraceptive uptake were parity of 3-4 children (Adjusted Prevalence Ratio (APR) = 1.48, 95% confidence interval (CI): 1.14, 1.92) in reference to those with 1-2 children. There was reduced contraceptive uptake in women of the age range 40-49 years (APR = 0.45, CI: 0.21-0.94) compared to those aged 15-24 years. Unemployed women were less likely to use contraceptives (APR: 0.6, CI: 0.42- 0.94) than the formally employed. Contraceptive uptake was lower among women who did not discuss family planning with their partners (APR = 0.39, CI: 0.29-0.52) than those who discussed family planning with their partners and women who did not receive family planning counseling (APR = 0.56, CI: 0.34-0.92) than those who received family planning counselling. CONCLUSION: We observed a low-level uptake of contraceptives, with injectables as the most used method. Family planning counseling and partner discussion on family planning were associated with contraceptive uptake among the women who used dolutegravir-based regimens. There is a need for more strategies to integrate FP services and increase male involvement in HIV care programs.

"I felt very small and embarrassed by the health care provider when I requested to be tested for syphilis": barriers and facilitators of regular syphilis and HIV testing among female sex workers in Uganda.

BACKGROUND: Periodic testing of female sex workers (FSW) for sexually transmitted infections (STIs) is a core component of global and national responses to achieve population-level STI elimination. We conducted a qualitative study to explore barriers and facilitators of regular syphilis and HIV testing among FSW in Uganda. METHODS: Within a quasi-experimental study among 436 FSW to assess the effect of peer education and text message reminders on uptake of regular STI and HIV testing among FSW, we conducted 48 qualitative interviews in four cities in Uganda from August-December 2018. We purposively selected FSW who tested for syphilis and HIV every 3-6 months; 12 FSW were interviewed in each city. Sex worker interviews explored: 1) reasons for periodic syphilis and HIV testing; 2) barriers and facilitators of testing; 3) experiences of testing; and 4) challenges faced while seeking testing services. Data were analyzed using thematic content analysis. RESULTS: Thematic analysis revealed individual- and health system-level barriers and facilitators of testing. For syphilis, barriers were a) interpersonal stigma, low perceived severity of syphilis and testing misconceptions (individual); and b) judgmental provider attitudes, paucity of facilities offering syphilis testing, stockouts of test kits and high cost (health system). Facilitators were c) desire to remain healthy, get married and have children, knowing the benefits of early treatment, influence of male partners/clients and normative testing behaviors (individual); and d) sex worker clinics offering dual syphilis/HIV testing (health system). For HIV, barriers included: a) internalized stigma (individual); and b) unfavorable clinic hours, stigma, discrimination, and unfriendly provider (health system). Facilitators were a) motivations to stay healthy and attract clients, habitual testing, self-efficacy, doubts about accuracy of negative test results, and use of post-exposure prophylaxis (individual); and d) availability of testing facilities (health system). Syphilis and HIV had similar testing barriers and facilitators. CONCLUSIONS: HIV programs are likely to be important entry points for syphilis testing among FSW. Multi-level interventions to address testing barriers should consider focusing on these service delivery points. Extending the dual syphilis and HIV testing approach to FSW may improve testing uptake for both infections at public health facilities and decrease population-level incidence.

Text message reminders and peer education increase HIV and Syphilis testing among female sex workers: a pilot quasi-experimental study in Uganda.

BACKGROUND: Globally, female sex workers (FSW) are disproportionately affected by HIV and other sexually transmitted infections (STIs). However, uptake of STI and HIV testing services among FSW in sub-Saharan Africa remains low. We aimed to assess the effect of FSW-led peer education and text message reminders on 3-monthly syphilis and HIV testing among FSW in Uganda. METHODS: Between September 2019 and February 2020, we implemented weekly peer education sessions and bi-monthly SMS reminders for FSW in Mbarara (intervention city). Peer education sessions were implemented by 20 FSW, who received five days of basic training as peer educators. We held monthly meetings with peer educators throughout the six-month implementation period. FSW in Mbale (control city) continued to receive standard of care consisting of HIV testing outreach campaigns, and facility-based testing. Using a quasi-experimental design in one intervention city, and one control city, we conducted pre- and post- questionnaire-based surveys on recent syphilis and HIV testing behavior among FSW in July-October 2018, and March 2020. We compared proportions and prevalence ratios at baseline and follow-up using chi-square tests and negative binomial regression. RESULTS: We conducted 436 interviews (200 before/236 after) with FSW. At baseline similar proportions reported taking an HIV test (57 % vs. 54 %; p = 0.72), and a syphilis serology test (35 % vs. 39 %; p = 0.67) in the intervention and control cities, respectively, in the prior three months. After the intervention, this proportion increased to 82 % (95 % confidence interval [CI] 74.0-88.2) for HIV, and 81 % (95 % CI: 73.0-87.0) for syphilis in the intervention city. Relative to baseline in the control city, the proportion testing for HIV was unchanged (52 %) but decreased for syphilis (26 %). CONCLUSIONS: Bi-monthly text message reminders with weekly peer education sessions increased uptake of 3-monthly syphilis and HIV testing in a Ugandan female sex work population and could help increase sex worker engagement in HIV/STI services in line with World Health Organization recommendations.

HIV and syphilis testing behaviors among heterosexual male and female sex workers in Uganda.

BACKGROUND: In Sub-Saharan Africa where HIV disproportionately affects women, heterosexual male sex workers (HMSW) and their female clients are at risk of acquiring or transmitting HIV and other STIs. However, few studies have described HIV and STI risk among HMSW. We aimed to assess and compare recent HIV and syphilis screening practices among HMSW and female sex workers (FSW) in Uganda. METHODS: Between August and December 2019, we conducted a cross-sectional study among 100 HMSW and 240 female sex workers (FSW). Participants were enrolled through snowball sampling, and an interviewer-administered questionnaire used to collect data on HIV and syphilis testing in the prior 12 and 6 months respectively. Integrated change model constructs were used to assess intentions, attitudes, social influences, norms and self-efficacy of 3-monthly Syphilis and 6-monthly HIV testing. Predictors of HIV and syphilis recent testing behaviors were estimated using negative binomial regression. RESULTS: We enrolled 340 sex workers of whom 100 (29%) were HMSW. The median age was 27 years [interquartile range (IQR) 25-30] for HMSW and 26 years [IQR], (23-29) for FSW. The median duration of sex work was 36 and 30 months for HMSW and FSW, respectively. HMSW were significantly less likely than FSW to have tested for HIV in the prior 12 months (50% vs. 86%; p = 0.001). For MSW, non-testing for HIV was associated with higher education [adjusted prevalence ratio (aPR) 1.66; 95% confidence interval (CI) 1.09-2.50], poor intention to seek HIV testing (aPR 1.64; 95% CI 1.35-2.04), perception that 6-monthly HIV testing was not normative (aPR 1.33; 95% CI 1.09-1.67) and low self-efficacy (aPR 1.41; 95% CI 1.12-1.79). Not testing for syphilis was associated with low intention to seek testing (aPR 3.13; 95% CI 2.13-4.55), low self-efficacy (aPR 2.56; 95% CI 1.35-4.76), negative testing attitudes (aPR 2.33; 95% CI 1.64-3.33), and perception that regular testing was not normative (aPR 1.59; 95% CI 1.14-2.22). CONCLUSIONS: Non-testing for HIV and syphilis was common among HMSW relative to FSW. Future studies should evaluate strategies to increase testing uptake for this neglected sub-population of sex workers.

Health providers' experiences, perceptions and readiness to provide HIV services to men who have sex with men and female sex workers in Uganda - a qualitative study.

BACKGROUND: Access to HIV services among men who have sex with men (MSM) and female sex workers (FSWs) remains suboptimal globally. While the reasons for this dismal performance have been documented, limited evidence exists on the experiences, perceptions and readiness of health providers to provide HIV services to MSM and FSWs. METHODS: This analysis uses data collected from 48 key informants (health providers in public and private health facilities) as part of a larger study conducted in 12 districts of Uganda between October and December 2013. Data were collected on health providers' experiences and readiness to provide HIV services to MSM and FSWs and their perceptions on the effect of existing legislation on HIV services provision to MSM and FSWs. Data were captured verbatim, transcribed and analyzed following a thematic framework approach. RESULTS: All health providers reported that they had ever provided HIV services to FSWs and a majority of them were comfortable serving them. However, no health provider had ever served MSM. When asked if they would be willing to serve MSM, nearly three-quarters of the health providers indicated that they would be bound by the call of duty to serve them. However, some health providers reported that they "would feel very uncomfortable" handling MSM because they engage in "a culture imported into our country". A majority of the health providers felt that they did not have adequate skills to effectively serve MSM and called for specific training to improve their clinical skills. There were mixed reactions as to whether existing criminal laws would affect MSM or FSWs access to HIV services but there was agreement that access to HIV services, under the existing laws, would be more constrained for MSM than FSWs since society "does not blame FSWs [as much as it does] with MSM". CONCLUSION: A majority of the health providers were generally comfortable serving FSWs but there were strong homophobic tendencies towards MSM. A majority of the health providers lacked skills in how to handle MSM. Interventions aimed at improving health providers' skills in handling MSM while minimizing the negative attitude towards them are urgently needed.

Perspectives on male partner notification and treatment for syphilis among antenatal women and their partners in Kampala and Wakiso districts, Uganda.

BACKGROUND: Syphilis screening can be successfully integrated into antenatal clinics, and potentially avert significant morbidity and mortality to unborn infants. A minority of male partners report for testing and treatment, increasing the likelihood of reinfection. We conducted a qualitative study to understand factors influencing male partners to seek treatment after syphilis notification by their pregnant partners. METHODS: A purposeful sample of 54 adults who participated in the STOP (Syphilis Treatment of Partners) study was stratified by gender (24 women, 30 male partners) and enrolled for in-depth interviews which were audio recorded, transcribed, and analyzed using the thematic approach. RESULTS: The participants' median age (IQR) was 32 years (25-44), 87% were married, and 57.4% (31/74) had attained secondary education. Fourteen of 22 (63%) female participants reported that they sometimes experienced domestic violence. Male participant's knowledge of syphilis and their perception of their valued role as responsible fathers of an unborn baby facilitated return. Female's fear of partner's violence and poor communication between partners, were barriers against delivery of the notification forms to partners and subsequent treatment of partners. For men, fear of injection pain, perceptions of syphilis as a genetic disease and as a woman's problem, busy work schedules, poor access to good STD services, shared facilities with women in clinics, as well as HIV-related stigma were important barrier factors. CONCLUSIONS: The return to the clinic for treatment of male partners after partner notification by infected pregnant women, was low due to limited knowledge about syphilis, fear of painful injection, fears of domestic violence, lack of communication skills (individual characteristics) and syphilis disease characteristics such as signs and symptoms. This, combined with health services characteristics such as structural barriers that hinder male partner treatment, low access, low capacity, work/time challenges, inadequate laboratory services and low clinic personnel capacity; threatens efforts to eliminate mother-to-child infection of syphilis. Improved public messaging about syphilis, better services, legal and policy frameworks supporting STD notification and treatment in resource-constrained settings are needed for effective STD control. TRIAL REGISTRATION: Clinicaltrials.gov NCT02262390 ., Date Registered October 8 2014.

Psychosocial correlates of regular syphilis and HIV screening practices among female sex workers in Uganda: a cross-sectional survey.

BACKGROUND: Limited data are available regarding correlates of regular sexually transmitted infections (STIs) and HIV screening among female sex workers (FSW) in Sub-Saharan Africa. In this study, we aimed to assess the frequency of regular syphilis and HIV screening and the psychosocial correlates associated with screening among FSW in Uganda. METHODS: This cross-sectional correlational study was conducted among 441 FSW, aged 17-49 years. We enrolled FSW through peer referrals and ascertained self-reported data on number of serological tests for HIV, syphilis and other STIs in the prior 12 months using an interviewer-administered questionnaire. In addition, we assessed attitudes, norms, social influences and self-efficacy towards 3-monthly Syphilis and 6-monthly HIV testing. We estimated the correlates of regular STI and HIV testing using negative binomial regression. RESULTS: Of the respondents 420 (95.2%) reported to have ever taken an HIV test with 297 (67.4%) testing two or more times in the prior 12 months. Over half of the respondents (59%) reported ever taking a syphilis test with only 62 (14.1%) reporting testing three or more times in the prior 12 months. After adjusting for socio-demographics, attitude and norms, high perceived self-efficacy was associated with a 33% increase in the likelihood of repeated HIV testing [prevalence ratio (PR), 1.33, 95% confidence interval (CI) 1.15-1.53] while low perceived confidence was associated with a 25% decrease in the likelihood of repeated HIV testing (PR, 0.75, 95% CI 0.63-0.89). Similarly low attitudes and norms were associated with a decrease of 52.6% (PR, 0.47, 95% CI 0.37-0.61) and 47% (PR, 0.53, 95% CI 0.41-0.69) in the likelihood of repeated syphilis testing respectively. CONCLUSION: Compared to HIV, uptake of repeated syphilis testing was very low. Correlates of HIV testing include; perceived self-efficacy amidst barriers and perceived confidence for HIV and low attitudes and accepting norms for syphilis. Health campaigns should emphasize overcoming barriers to HIV testing while promoting attitudes and norms including integration of serological syphilis testing and other STIs into HIV services.

Dietary patterns and practices in rural eastern Uganda: Implications for prevention and management of type 2 diabetes.

BACKGROUND: The burden of type 2 diabetes in Sub-Saharan Africa is projected to double by 2040, partly attributable to rapidly changing diets. In this paper, we analysed how community members in rural Uganda understood the concept of a healthy or unhealthy diet, food preparation and serving practices to inform the process of facilitating knowledge and skill necessary for self-management and care for type 2 diabetes. This was a qualitative study involving 20 focus group discussions and eight in-depth interviews among those at risk, patients with type 2 diabetes and the general community members without diabetes mellitus. Data was coded and entered into Atlas ti version 7.5.12 and interpreted using thematic analysis. We identified three main themes, which revealed, the perceptions on food and diet concerning health; the social dimensions of food and influence on diet practices; and food as a gendered activity. Participants noted that eating and cooking practices resulted in unhealthy diets. Their practices were affected by beliefs, poverty and food insecurity. Women determined which foods to prepare, but men prepared only some of the foods such as delicacies like a rice dish "pilau." New commercial and processed foods were increasingly available and consumed even in rural areas. Participants linked signs and symptoms of illness to diet as they narrated changes from past to current food preparation behaviours. Their view of overweight and obesity was also gendered and linked to social status. Participants' perception of disease influenced by diet was similar among those with and without type 2 diabetes, and those at risk. People described what is a healthy diet was as recommended by the health workers, but stated that their practices differed greatly from their knowledge. There was high awareness about healthy and balanced diets, but food is entrenched within social and gendered paradigms, which are slowly changing. Social and gender dimensions of food will need to be addressed through interventions in communities to promote change on a society level.

"When they know that you are a sex worker, you will be the last person to be treated": Perceptions and experiences of female sex workers in accessing HIV services in Uganda.

BACKGROUND: HIV prevalence among female sex workers (FSWs) in high burden countries in sub-Saharan Africa varies between 24 and 72%, however their access to HIV services remains limited. This study explored FSWs' perspectives of the barriers and opportunities to HIV service access in Uganda. METHODS: The cross-sectional qualitative study was conducted between October and December 2013. Twenty-four focus group discussions were conducted with 190 FSWs in 12 districts. Data were analysed using manifest content analysis, using Atlas.ti software, based on the socio-ecological model. RESULTS: FSWs indicated that HIV services were available and these included condoms, HIV testing and treatment, and management of sexually transmitted infections. However, access to HIV services was affected by several individual, societal, structural, and policy related barriers. Individual level factors included limited awareness of some prevention services, fears, and misconceptions while societal stigma was prominent. Structural and policy level barriers included inconvenient hours of operation of the clinics, inflexible facility based distribution of condoms, interuptions in the supply of condoms and other commodities, and limited package of services with virtually no access to lubricants, HIV pre- and post-exposure prophylaxis, and support following client perpetrated violence. Policies such as partner testing and involvement at antenatal care, and using only one facility for antiretroviral drug refills hindered HIV service uptake and retention in care. FSWs had major concerns with the quality of services especially discrimination and rude remarks from providers, denial or delay of services, and potential for breach of confidentiality. However, some FSWs reported positive experiences including interface with friendly providers and participated in formal and informal FSW groups, which supported them to access health services. CONCLUSION: Despite availability of services, FSWs faced major challenges in access to services. Comprehensive multilevel interventions targeting individual, societal, structural and policy level barriers are required to increase access to HIVservices among FSWs in Uganda. Policy and institutional adjustments should emphasize quality friendly services and expanding the package of services to meet the needs of FSWs.

Use of mobile phone consultations during home visits by Community Health Workers for maternal and newborn care: community experiences from Masindi and Kiryandongo districts, Uganda.

BACKGROUND: Home visits by Community Health Workers [In Uganda Community Health Workers are given the collective term of Village Health Teams (VHTs). Hereafter referred to as VHTs] is recommended to improve maternal and newborn care. We investigated perceived maternal and newborn benefits of home visits made by VHTs, combined with mobile phone consultations with professional health workers for advice. METHODS: A qualitative study was conducted in Masindi and Kiryandongo districts, Uganda, in December-2013 to March-2014. Study participants were drawn from the intervention arm of a randomised community-intervention trial. In-depth interviews were conducted with 20 prenatal and 16 postnatal women who were visited by VHTs; 5 group discussions and 16 key informant interviews were held with VHTs and 10 Key Informant Interviews with professional health workers. Data were analysed using latent content analysis techniques. RESULTS: Majority women and VHTs contend that the intervention improved access to maternal and newborn information; reduced costs of accessing care and facilitated referral. Women, VHTs and professional health workers acknowledged that the intervention induced attitudinal change among women and VHTs towards adapting recommended maternal and newborn care practices. Mobile phone consultations between VHTs and professional health workers were considered to reinforce VHT knowledge on maternal newborn care and boosted the social status of VHTs in community. A minority of VHTs perceived the implementation of recommended maternal and newborn care practices as difficult. Some professional health workers did not approve of the transfer of promotional maternal and newborn responsibility to VHTs. For a range of reasons, a number of professional health workers were not always available on phone or at the health centre to address VHT concerns. CONCLUSIONS: Results suggest that home visits made by VHTs for maternal and newborn care are reasonably well accepted. Our study highlights potential benefits of combining home visits with phone consultations between VHTs and professional health workers. However, the challenge of attitudinal change among VHTs towards certain strongly culturally-embedded behavioural post-partum practices, resistance from part of the professional health workforce to collaborate with VHTs and the problematic availability of professional health workers are important systemic problems that need to be addressed. TRIAL REGISTRATION: Current Controlled Trials NCT02084680. Registered 14 March 2014.

Understanding cervical cancer: an exploration of lay perceptions, beliefs and knowledge about cervical cancer among the Acholi in northern Uganda.

BACKGROUND: Cervical cancer is the most common cancer affecting women in Uganda; yet community understanding of the disease is limited. We explored community perceptions, beliefs and knowledge about the local names, causes, symptoms, course, treatment, and prognosis of cervical cancer in order to inform targeted interventions to promote early help-seeking. METHODS: Twenty four focus group discussions (FGD) with men and women aged 18 - 59 years and ten key informant interviews with persons aged ≥ 60 years were conducted at two sites in Gulu district between May and June 2012. A semi-structured interview guide informed by Kleinman's illness explanatory model and literature on community awareness of cervical cancer was used to collect data. Data analysis was supported with use of ATLAS.ti 6.1 in coding, organizing and tracking data segments. We used content analysis technique in data analysis and organised data into a structured format under distinct themes and categories. RESULTS: Cervical cancer was known by the local name "two remo", meaning "an illness that manifests with bleeding." Respondents believed that early onset of sexual activity, multiple male sexual partners and multi-parity cause cervical cancer. Respondents in half of FGDs also reported that use of condoms and family planning pills and injections cause cervical cancer. Symptoms of cervical cancer reported included vaginal bleeding, watery vaginal discharge and lower abdominal and waist pain. Respondents in most of the FGDs and key informants perceived cervical cancer as a chronic illness and that it can be treated with both modern and traditional medicines. The majority thought that cervical cancer treatment was supportive; the illness is not curable. CONCLUSIONS: While some lay beliefs about the causes of cervical cancer suggest some understanding of aetiology of the disease, other perceived causes particularly those related to use of family planning and condoms are potentially hurtful to public health. Awareness campaigns to promote early help-seeking for cervical cancer symptoms need to be culturally-sensitive and context-specific; and include messages on symptoms, risk factors, course, treatment and prognoses.

'Change means sacrificing a good life': perceptions about severity of type 2 diabetes and preventive lifestyles among people afflicted or at high risk of type 2 diabetes in Iganga Uganda.

BACKGROUND: Interventions for prevention of type 2 diabetes ought to be acceptable to target communities. We assessed perceptions about type 2 diabetes and lifestyle change among people afflicted or at high risk of this disease in a low income setting in Iganga Uganda. METHODS: Twelve focus group discussions (FGDs) of eight participants each were conducted, balancing rural and peri-urban (near the Municipality) residence and gender. The FGDs involved people with suspected type 2 diabetes (based on fasting plasma glucose (FPG), people with suspected pre-diabetes and obese people with normal FPG. Content analysis was conducted. RESULTS: Diabetes was perceived to be a very severe disease. Its severity was attributed to its incurability and its numerous health effects. Men were also concerned about reduced sexual performance. However, participants' strong concerns about the severity of diabetes were not reflected in their perceptions about the risk factors and lifestyles associated with it. While people with diabetes perceive obesity as 'sickness', those without diabetes perceive it as a sign of 'success'. Although participants are willing to change their diet, they mention numerous barriers including poverty, family size, and access to some foods. Because of their good taste, reduction of high risk foods like sugar and fried food is perceived as 'sacrificing a good life'. Increments in physical activity were said to be feasible, but only in familiar forms like domestic work. An over-arching theme emerged that 'lifestyle changes are viewed as sacrificing a good life'. CONCLUSIONS: Health promotion should target both community norms and individual awareness regarding obesity, physical activity and diet, and should address the notion that obesity and unhealthy foods represent a good life. Health educators should plan with clients on how to overcome barriers and misconceptions to lifestyle change, leveraging the pervasive perception of type 2 diabetes as a severe disease to motivate change.

Urban settings do not ensure access to services: findings from the immunisation programme in Kampala Uganda.

BACKGROUND: Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda. METHODS: Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Survey data underwent descriptive statistical analysis. Latent content analysis was used for qualitative data. RESULTS: Of the 821 respondents in the survey, 96% (785/821) were mothers with a mean age of 26 years (95% CI 24-27). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents (24%, 95% CI 21-27). This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3-6 hours before receipt of services although this was more common at public facilities. Only 33% (95% CI 30-37) of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% (95% CI 27-34) of the survey respondents utilised these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. Charges ranged from US$ 0.2 to US$4 and these were more commonly reported at private (70%, 95% CI 65-76) than at public (58%, 95% CI 54-63) facilities. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities. CONCLUSIONS: Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, governments should strengthen health systems to cater for increasing urban populations.

Correction: Prevention and management of type 2 diabetes mellitus in Uganda and South Africa: Findings from the SMART2D pragmatic implementation trial.

[This corrects the article DOI: 10.1371/journal.pgph.0000425.].