Understanding women's and men's perspectives on cervical cancer screening in Uganda: a qualitative study.

BACKGROUND: Cervical cancer remains a significant but preventable threat to women's health throughout much of the developing world, including Uganda. Cervical cancer screening and timely treatment of pre-cancerous lesions is a cost-effective means of mitigating cervical cancer morbidity and mortality. However, only 5% of women in Uganda have ever been screened. Barriers to screening, such as social stigma and access to safe conditions, have been previously identified, but insights into the role of male spouses in encouraging or discouraging screening have been limited. To our knowledge, no studies have compared barriers and facilitators among women who had or had not yet been screened and male partners of screened and unscreened women. METHODS: To resolve this gap, we conducted 7 focus groups- 3 among women who had been screened, 3 among those who had not been screened, and 1 among men whose female partners had or had not been screened. We performed qualitative thematic analysis on the focus group data. RESULTS: We identified several important factors impacting screening and the decision to screen among women, ranging from stigma, availability of screening, false beliefs around the procedure and side effects, and the role of spousal support in screening promotion. Male spousal perspectives for screening ranged from full support to hesitancy around male-performed exams and possible prolonged periods without intercourse. CONCLUSION: This exploratory work demonstrates the importance of dialogue both among women and their male partners in enhancing screening uptake. Efforts to address screening uptake are necessary given that it is an important means of mitigating the burden of cervical cancer. Interventions along these lines need to take these barriers and facilitators into account in order to drive up demand for screening.

Enhanced Oral Pre-exposure Prophylaxis (PrEP) Implementation for Ugandan Fisherfolk: Pilot Intervention Outcomes.

Mobile populations such as fisherfolk show high HIV incidence and prevalence. We pilot-tested implementation strategies to enhance pre-exposure prophylaxis (PrEP) uptake and adherence in the context of healthcare outreach events in two mainland fisherfolk communities on Lake Victoria, Uganda from September 2021 to February 2022. The implementation strategies included PrEP adherence supporters (selected from PrEP users' social networks), community workshops (to address misconceptions and stigma, and empower PrEP advocacy), and check-in calls (including refill reminders). PrEP medical records data were collected from 6-months pre-intervention to 6-months post-intervention. Qualitative interviews with 20 PrEP users (10 who continued, 10 who discontinued), 9 adherence supporters, and 7 key partners (providers, community leaders) explored acceptability. Percentages of PrEP initiators (of those eligible) were significantly higher during the intervention (96.5%) than 6-months before the intervention (84.5%), p < 0.0001; percentages of PrEP users who persisted (i.e., possessed a refill) 6-months post-initiation (47.9% vs. 6.7%) and had at least 80% PrEP coverage (based on their medication possession ratio) from the initiation date to 6-months later (35.9% vs. 0%) were higher during versus pre-intervention, p < 0.0001. A comparison fisherfolk community with better healthcare access had lower uptake (78.3%; p < 0.0001) and persistence at 6-months (34.0%; p < 0.001), but higher coverage during the intervention period (70.4%; p < 0.0001). Qualitative data suggested the strategies promoted PrEP use through reduced stigma and misconceptions. The intervention bundle cost was $223.95, $172.98, and $94.66 for each additional person for PrEP initiation, persistence, and coverage, respectively. Enhanced community-based PrEP implementation that fosters a supportive community environment can improve PrEP use in mobile populations without easy access to healthcare. (NCT05084716).

Associations Between Alcohol Use, Antiretroviral Therapy Use, and Viral Load Suppression Among People Living with HIV in Rural Central Uganda.

Alcohol use among people living with HIV (PWH) is common and may negatively affect engagement in HIV care. We evaluated the relationships between alcohol use, ART use, and viral suppression among PWH in Uganda. PATH/Ekkubo was a trial evaluating a linkage to HIV care intervention in four Ugandan districts, Nov 2015-Sept 2021. Our analytical sample included: (1) baseline data from individuals not enrolled in the intervention trial (previously diagnosed HIV+); and 12-month follow-up data from the control group (newly diagnosed or previously diagnosed, but not in care). Level of alcohol use was categorized using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C): none (AUDIT-C = 0), low (women = 1-2, men = 1-3), medium (women = 3-5, men = 4-5), high/very high (6-12). Multivariable logistic regression models evaluated associations between alcohol use, ART use and viral suppression (a viral load of < 20); we also stratified by gender. Among 931 PWH, medium (OR: 0.43 [95% CI 0.25-0.72]) and high/very high (OR: 0.22 [95% CI 0.11-0.42]) levels of alcohol use were associated with lower odds of being on ART. In a sub-sample of 664, medium use (OR: 0.63 [95% CI 0.41-0.97]) was associated with lower odds of viral suppression. However, this association was not statistically significant when restricting to those on ART, suggesting the relationship between alcohol use and viral suppression is explained by ART use. Among men, high/very high, and among women, medium alcohol use levels were associated with lower odds of being on ART and being virally suppressed. Interventions for PWH who use higher levels of alcohol may be needed to optimize the benefits of Uganda's Universal Test and Treat strategy.

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.

Barriers and facilitators of cervical cancer screening literacy among rural women with HIV attending rural public health facilities in East Central Uganda: a qualitative study using the integrated model of health literacy.

BACKGROUND: Several rural public health facilities in East Central Uganda have sub-optimal, below 50%, levels of uptake of cervical cancer screening services among women with HIV. This is attributed to low cervical cancer screening literacy: limited ability to access, understand, appraise, and apply cervical cancer screening information. This research identified multi-level (health facility, community, interpersonal and individual) barriers, and facilitators of accessing, understanding, and applying cervical cancer screening information among rural women with HIV attending rural public health facilities in East Central Uganda to inform interventions. METHODS: We conducted ten Focus Group Discussions with rural women aged 25-49 years with HIV attending four selected rural public health facilities: thirty women who had ever screened for cervical cancer and thirty women who had never screened for cervical cancer across different age categories. Data was collected using a guide based on the Integrated model of health literacy. Thematic analysis was used for analysis. Competences (accessing, understanding and applying cervical cancer screening information) and categories of factors (health system, community, interpersonal and individual factors) of the integrated model of health literacy were deductively derived whereas barriers and facilitators were deductively derived from women's statements. RESULTS: Lack of communication materials and inability to access information were health facility and individual barriers of accessing cervical cancer screening information respectively. Facilitators of accessing information were access to information at health facility, community, and interpersonal levels and women's ability to access information. Barriers and facilitators of understanding cervical cancer information were related to communication materials, provision of health education and women's concentration during health education. Barriers and facilitators of applying cervical cancer screening information were related to communication and provision of cervical cancer screening services at health facility level, and interpersonal level from peers, partners and other family members as well as women's ability to: understand information and access to cervical cancer screening services at individual level. CONCLUSIONS: This study emphasizes the influence of multi-level factors on cervical cancer screening literacy among rural women with HIV attending rural public health facilities in East Central Uganda. Improving uptake of cervical cancer screening services among these women requires multi-level interventions.

Linkages between the Sustainable Development Goals and health in Somalia.

BACKGROUND: The Sustainable Development Goals (SDGs) adopted in 2015 compromises 17 universal and indivisible goals for sustainable development, however the interactions between the SDGs in Somalia is not known which is vital for understanding potential synergies and trad-offs between the SDGs. Hence, this study aims to identify and classify the linkages between the SDGs with a focus on health and well-being (SDG 3) in Somalia. METHODS: Following the SDG Synergies approach, 35 leading experts from the public and private sectors as well as academia and civil society gathered for a 2-day workshop in Mogadishu and scored the interactions between the individual SDGs on a seven point-scale from - 3 to + 3. From this, a cross-impact matrix was created, and network models were used to showcase the direct and indirect interactions between the SDGs with a focus on SDG 3 (good health and well-being). RESULTS: Many promoting and a few restricting interactions between the different SDGs were found. Overall, SDG 16 (peace, justice, and strong institutions) influenced the other SDGs the most. When second-order interactions were considered, progress on SDG 16 (peace, justice, and strong institutions) showed the largest positive impact on SDG 3 (good health and well-being). SDG 3 (good health and well-being) was heavily influenced by progress on other SDGs in Somalia and making progress on SDG 3 (good health and well-being) positively influenced progress on all other SDGs. CONCLUSION: The findings revealed that in Somalia, the interactions between the SDGs are mostly synergistic and that SDG 16 (peace, justice, and strong institutions) has a strong influence on progress on other SDGs as well as progress on SDG 3 (good health and well-being). This study highlights the need for a multisectoral strategy to accelerate progress on the SDGs in Somalia in general, and particularly SDG 3 (good health and well-being).

Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area.

BACKGROUND: Hand hygiene is known to reduce healthcare-associated infections. However, it remains suboptimal among healthcare providers. In this study, we used the Behaviour-centered Design approach to explore the facilitators and deterrents to hand hygiene among healthcare providers in the Kampala Metropolitan area, Uganda. METHODS: We conducted a formative qualitative study as part of a cluster randomised trial in 19 healthcare facilities (HCFs). The study used 19 semi-structured and 18 key informant interviews to collect data on hand hygiene status and facilitators and deterrents of hand hygiene. Research assistants transcribed verbatim and used a thematic framework aided by Nvivo 14.0. to undertake analysis. We used thick descriptions and illustrative quotes to enhance the credibility and trustworthiness of our findings. RESULTS: About 47.4% of the HCFs had sufficient hand hygiene infrastructure, and 57.9% did not report total compliance with hand hygiene during patient care. The physical facilitator for hand hygiene was the presence of constant reminders such as nudges, while the biological included the frequency of patient contact and the nature of clinical work. The only biological deterrent was the heavy workload in HCFs. The executive brain facilitators included knowledge of workplace health risks, infection prevention and control (IPC) guidelines, and a positive attitude. A negative attitude was the executive brain deterrent to hand hygiene. Recognition, rewards, and fear of infections were the only motivated brain facilitators. Behavioural setting facilitators included proximity to functional hand hygiene infrastructure, the existence of active IPC committees, good leadership, and the availability of a budget for hand hygiene supplies. Behavioural setting deterrents included the non-functionality and non-proximity to hand hygiene infrastructure and inadequate supplies. CONCLUSIONS: The study revealed low compliance with hand hygiene during the critical moments of patient care and inadequacy of hand hygiene infrastructure. The deterrents to hand hygiene included a heavy workload, negative attitude, inadequate supplies, non-functionality, and long distance to hand washing stations. Facilitators included constant reminders, fear of infections, frequency of patient contact and nature of clinical work, positive attitude, knowledge of IPC guidelines, recognition and reward, good leadership, availability of budgets for hand hygiene supplies, availability and proximity to hand hygiene supplies and infrastructure and active IPC committees. TRIAL REGISTRATION: ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

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.

Mediators and moderators of the effect of the game changers for cervical cancer prevention intervention on cervical cancer screening among previously unscreened social network members in Uganda.

INTRODUCTION: Cervical cancer (CC) rates are high in Uganda, yet CC screening rates are very low. Our peer advocacy group intervention, Game Changers for Cervical Cancer Prevention (GC-CCP), was shown to increase CC screening uptake among social network members. In this secondary analysis, we examined mediators and moderators of this effect to better understand how and for whom the intervention was most successful in promoting CC screening. METHODS: We conducted a pilot randomized controlled trial of GC-CCP in Namayingo district, Eastern Uganda between September 2021 and April 2022. Forty adult women who had screened for CC in the past year (index participants) enrolled at baseline: 20 were randomized to receive the 7-session intervention to empower women to engage in CC prevention advocacy, and 20 were assigned to the waitlist control; from these index participants, 103 unscreened social network members (alters) also enrolled. All participants were assessed at baseline and month 6 follow-up. Change in cognitive and behavioral CC-related constructs from baseline to month 6 were examined as mediators, using multivariate linear regression analysis. Index and alter demographics and index CC treatment status were examined as moderators. RESULTS: Increased alter engagement in CC prevention advocacy fully mediated the intervention effect on alter uptake of CC screening, and was associated with an increased likelihood of alter CC screening. CC treatment status of the index participant was the sole moderator of the intervention effect, as those in the intervention group who had screened positive and received treatment for pre-cancerous lesions were more likely to have alters who got screened for CC by month 6. CONCLUSION: The effect of GC-CCP on alter CC screening is greater when the alter reports increased engagement in her own advocacy for CC prevention with others. The intervention effects on increased engagement in CC prevention advocacy among both index and alter participants suggest a diffusion of advocacy, which bodes well for dissemination of knowledge and screening activation throughout a network and the larger community.

Integrated malaria prevention in low- and middle-income countries: a systematic review.

BACKGROUND: As many countries aim to eliminate malaria, use of comprehensive approaches targeting the mosquito vector and environment are needed. Integrated malaria prevention advocates the use of several malaria prevention measures holistically at households and in the community. The aim of this systematic review was to collate and summarize the impact of integrated malaria prevention in low- and middle-income countries on malaria burden. METHODS: Literature on integrated malaria prevention, defined as the use of two or more malaria prevention methods holistically, was searched from 1st January 2001 to 31st July 2021. The primary outcome variables were malaria incidence and prevalence, while the secondary outcome measures were human biting and entomological inoculation rates, and mosquito mortality. RESULTS: A total of 10,931 studies were identified by the search strategy. After screening, 57 articles were included in the review. Studies included cluster randomized controlled trials, longitudinal studies, programme evaluations, experimental hut/houses, and field trials. Various interventions were used, mainly combinations of two or three malaria prevention methods including insecticide-treated nets (ITNs), indoor residual spraying (IRS), topical repellents, insecticide sprays, microbial larvicides, and house improvements including screening, insecticide-treated wall hangings, and screening of eaves. The most common methods used in integrated malaria prevention were ITNs and IRS, followed by ITNs and topical repellents. There was reduced incidence and prevalence of malaria when multiple malaria prevention methods were used compared to single methods. Mosquito human biting and entomological inoculation rates were significantly reduced, and mosquito mortality increased in use of multiple methods compared to single interventions. However, a few studies showed mixed results or no benefits of using multiple methods to prevent malaria. CONCLUSION: Use of multiple malaria prevention methods was effective in reducing malaria infection and mosquito density in comparison with single methods. Results from this systematic review can be used to inform future research, practice, policy and programming for malaria control in endemic countries.

A Psychometric Evaluation and a Framework Test of the HIV Stigma Mechanisms Scale Among a Population-Based Sample of Men and Women Living with HIV in Central Uganda.

HIV stigma is a critical barrier to HIV prevention and care. This study evaluates the psychometric properties of the HIV Stigma Mechanisms Scale (HIV-SMS) among people living with HIV (PLHIV) in central Uganda and tests the underlying framework. Using data from the PATH/Ekkubo study, (n = 804 PLHIV), we assessed the HIV-SMS' reliability and validity (face, content, construct, and convergent). We used multiple regression analyses to test the HIV-SMS' association with health and well-being outcomes. Findings revealed a more specific (5-factor) stigma structure than the original model, splitting anticipated and enacted stigmas into two subconstructs: family and healthcare workers (HW). The 5-factor model had high reliability (α = 0.92-0.98) and supported the convergent validity (r = 0.12-0.42, p < 0.01). The expected relationship between HIV stigma mechanisms and health outcomes was particularly strong for internalized stigma. Anticipated-family and enacted-family stigma mechanisms showed partial agreement with the hypothesized health outcomes. Anticipated-HW and enacted-HW mechanisms showed no significant association with health outcomes. The 5-factor HIV-SMS yielded a proper and nuanced measurement of HIV stigma in central Uganda, reflecting the importance of family-related stigma mechanisms and showing associations with health outcomes similar to and beyond the seminal study.

Effects of M-DEPTH Model of Depression Care on Maternal HIV Viral Suppression and Adherence to the PMTCT Care Continuum Among HIV-Infected Pregnant Women in Uganda: Results from a Cluster Randomized Controlled Trial at Pregnancy Completion.

Perinatal depression has been shown to impede adherence to antiretroviral therapy (ART) and the prevention of mother-to-child transmission (PMTCT) care continuum; therefore, treating perinatal depression may result in increased viral suppression and PMTCT adherence. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on depression, maternal viral suppression and adherence to PMTCT care processes in an ongoing cluster-randomized controlled trial of 391 HIV-infected pregnant women (200 usual care; 191 intervention) with at least mild depressive symptoms enrolled across 8 antenatal care clinics in Uganda. At baseline, 68.3% had clinical depression and 41.7% had detectable HIV viral load. Adjusted repeated-measures multivariable regression models found that the intervention group was nearly 80% less likely to be clinically depressed [Adjusted OR (95% CI) 0.22 (0.05, 0.89)] at the 2-month post-pregnancy assessment, compared to the control group. However, the intervention and control groups did not differ meaningfully on maternal viral suppression, ART adherence, and other PMTCT care processes and outcomes. In this sample of women who were mostly virally suppressed and ART adherent at baseline, the depression care model had a strong effect on depression alleviation, but no downstream effects on viral suppression or other PMTCT care processes.Trial Registration NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Spread and seasonality of COVID-19 pandemic confirmed cases in sub-Saharan Africa: experience from Democratic Republic of Congo, Nigeria, Senegal, and Uganda.

BACKGROUND: The COVID-19 pandemic has impacted the world negatively with huge health and socioeconomic consequences. This study estimated the seasonality, trajectory, and projection of COVID-19 cases to understand the dynamics of the disease spread and inform response interventions. METHOD: Descriptive analysis of daily confirmed COVID-19 cases from January 2020 to 12th March 2022 was conducted in four purposefully selected sub-Saharan African countries (Nigeria, Democratic Republic of Congo (DRC), Senegal, and Uganda). We extrapolated the COVID-19 data from (2020 to 2022) to 2023 using a trigonometric time series model. A decomposition time series method was used to examine the seasonality in the data. RESULTS: Nigeria had the highest rate of spread (ß) of COVID-19 (ß = 381.2) while DRC had the least rate (ß = 119.4). DRC, Uganda, and Senegal had a similar pattern of COVID-19 spread from the onset through December 2020. The average doubling time in COVID-19 case count was highest in Uganda (148 days) and least in Nigeria (83 days). A seasonal variation was found in the COVID-19 data for all four countries but the timing of the cases showed some variations across countries. More cases are expected in the 1st (January-March) and 3rd (July-September) quarters of the year in Nigeria and Senegal, and in the 2nd (April-June) and 3rd (October-December) quarters in DRC and Uganda. CONCLUSION: Our findings show a seasonality that may warrant consideration for COVID-19 periodic interventions in the peak seasons in the preparedness and response strategies.

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.

Development of a multi-level family planning intervention for couples in rural Uganda: key findings & adaptations made from community engaged research methods.

BACKGROUND: Uganda has among the highest fertility rates in the world and multi-level barriers contribute to the low contraceptive use. OBJECTIVE: The objective of this study was to develop a culturally and socially relevant, community-based intervention to increase contraceptive use among couples in rural Uganda through community-engaged research methods. This study reports on the community-engaged research that informed the intervention's content and structure and the final content of the intervention; the evaluation of the pilot intervention will be reported upon completion. METHODS: An intervention steering committee of community stakeholders reviewed the initially proposed intervention content and approach. Four (4) gender-segregated focus groups were conducted with twenty-six (26) men and women who had an unmet need for family planning. Fifteen key-informant interviews were conducted with community leaders and family planning stakeholders. Finally, the 4-session intervention was pilot tested with a cohort of couples (N = 7) similar in demographics to the target sample of the future pilot intervention trial. Qualitative data were analyzed thematically. RESULTS: Findings included the identification of community beliefs to reshape in order to increase family planning acceptance, as well as strategies to engage men, acceptable approaches for community leader involvement in the intervention to endorse family planning, and methods for managing gender dynamics and minimizing risk of unintended negative consequences of participation. The findings were used to inform the ideal structure and format of the intervention, including the distribution of contraceptives directly during group sessions, and identified the need to strengthen health worker capacity to provide Long-Acting Reversable Contraceptives (LARCs) as part of the intervention. CONCLUSIONS: These findings were used to refine an intervention before a larger scale pilot test of its feasibility, acceptability, and potential efficacy. They can inform other multi-level family planning interventions in similar settings and the methods can be adopted by others to increase the feasibility, acceptability, and cultural relevance of interventions.

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.

Effects of a peer advocacy intervention on cervical cancer screening among social network members: results of a randomized controlled trial in Uganda.

Cervical cancer (CC) is the most common cancer among women in Uganda, yet lifetime CC screening is as low as 5%. Training women who have screened for CC to engage in peer advocacy could increase uptake of CC screening in social networks. We conducted a randomized controlled trial of a peer-facilitated, manualized, 7-session group intervention to train women to engage in CC prevention advocacy. Forty women recently screened for CC (index participants) enrolled and were assigned to receive the intervention (n = 20) or wait-list control (n = 20). Each index was asked to recruit up to three female social network members (alters) who had not been screened for CC (n = 103 enrolled alters). All index and alter participants were assessed at baseline and month-6 follow-up. All but one (n = 39; 98%) index and 98 (95%) alter participants completed the month 6 assessment. In multivariate regression models controlling for baseline outcome measures and demographic covariates, intervention alters were more likely to have been screened for CC at month 6 [67% vs. 16%; adjusted OR (95% CI) = 12.13 (4.07, 36.16)], compared to control alters. Data also revealed significant increased engagement in CC prevention advocacy, among both index and alter participants in the intervention group at month 6, compared to the control group. The intervention was highly effective in increasing CC screening uptake among social network members, and engagement in CC prevention advocacy among not only intervention recipients, but also targets of advocacy, suggesting the potential for wide dissemination of CC knowledge.Trial Registration. NIH Clinical Trial Registry NCT04960748 ( clinicaltrials.gov ).

Increased Knowledge Mediates the Effect of Game Changers for Cervical Cancer Prevention on Diffusion of Cervical Cancer Screening Advocacy Among Social Network Members in a Pilot Trial.

BACKGROUND: Game Changers for Cervical Cancer Prevention (GC-CCP), a peer-led, group advocacy training intervention, increased cervical cancer (CC) prevention advocacy not only among intervention recipients, but also their social network members (referred to as "alters") who were targeted with advocacy in a pilot randomized controlled trial. We examined mediators and moderators of this effect on alter advocacy, to understand how and for whom the intervention had such an effect. METHOD: Forty women (index participants) who had recently screened for CC enrolled and were randomly assigned to receive the GC-CCP intervention (n = 20) or the wait-list control (n = 20). Up to three alters from each participant (n = 103) were surveyed at baseline and month 6. Measures of CC-related cognitive constructs (knowledge, enacted stigma, and risk management self-efficacy), as well as extent of advocacy received from index participants, were assessed as mediators of the intervention effect on alter advocacy using multivariate regression analyses. Alter characteristics were examined as moderators. RESULTS: Increased CC-related knowledge partially mediated the intervention effect on increased alter engagement in CC prevention advocacy; those with greater gains in knowledge reported greater engagement in advocacy. No moderators of the intervention effect were identified. CONCLUSION: The effect of GC-CCP on alter CC prevention advocacy is enhanced by increased alter knowledge pertaining to CC prevention, causes, and treatment and suggests this may be key for diffusion of intervention effects on increased CC prevention advocacy throughout a social network. TRIAL REGISTRATION: NCT04960748 (registered on clinicaltrials.gov , 7/14/2021).

Stressors and Maladaptive Coping Mechanisms Associated with Elevated Perinatal Depressive Symptoms and Suicidality Among Women Living with HIV in Uganda.

BACKGROUND: Perinatal depression is highly prevalent among women living with HIV and contributes to nonadherence to the PMTCT (prevention of mother-to-child transmission) care continuum. We examined correlates of elevated depressive symptoms and suicidality in this population. METHOD: Baseline data from 391 Ugandan women enrolled in a cluster randomized controlled trial of a depression care intervention were analyzed. Adult women with confirmed sero-positive HIV status were eligible if their gestation period was ≤ 32 weeks, and they had a Patient Health Questionnaire (PHQ-9) score ≥ 5. Correlates of elevated depressive symptoms (PHQ-9 > 9) and moderate-to-severe suicidal ideation (more than half of the days in the prior 2 weeks) were assessed using bivariate and multivariate logistic regression models, controlling for clustering within study sites by using a random effects specification (with study site as the random effect), as well as age and education. RESULTS: The mean PHQ-9 score was 12.7 (SD = 5.1); 267 (68.3%) participants had elevated depressive symptoms, and 51 (13.0%) reported moderate-to-severe suicidality. In multiple logistic regression analysis, perceived provider stigma of childbearing [OR (95% CI) = 1.81 (1.16, 2.84)], greater use of negative problem-solving [OR (95% CI) = 1.09 (1.04, 1.15)], and lower general social support [OR (95% CI) = 0.50 (0.30, 0.82)] were correlated with elevated depression symptoms, while moderate-to-severe suicidal ideation was correlated with greater experience of physical interpersonal violence (IPV) and greater use of negative problem-solving. CONCLUSIONS: Programs aimed at improving provider support for the childbearing needs of persons living with HIV, supporting women who are experiencing IPV, and helping women to develop effective problem-solving skills and social supports may reduce symptoms of perinatal depression and help optimize PMTCT care outcomes. TRIAL REGISTRATION: Clinicaltrials.gov NCT03892915 (registered March 21, 2019).