Barriers to contraceptive use in humanitarian settings: Experiences of South Sudanese refugee women living in Adjumani district, Uganda; an exploratory qualitative study.

INTRODUCTION: Contraceptive use can be lifesaving, empowering and cost-effective for women and girls. Access to contraception is still challenging to female refugees due to several barriers including language, low educational level, lack of information, influence by family members, limited income, cultural and religious norms. This study explored barriers to contraceptive use among South Sudanese refugee women living in Adjumani district, Uganda. METHODS: An exploratory study design using qualitative methods were employed involving women of reproductive age (15-49 years). Purposive sampling was used to select participants for Focus Group Discussions (FGDs) and In-depth Interviews (IDIs) from three settlements in Adjumani district. We conducted four FGDs, each consisting of 8 participants. We also conducted fourteen in-depth interviews (IDIs) with women of reproductive age. The IDI and FGD guides were translated into local languages before they were used to collect data. The interviews were recorded, transcribed verbatim and translated into English. Audio recordings were labeled before being translated back to English. Deductive, team-based coding was implemented, and a codebook developed. Transcripts were entered, and data coded using Atlas ti version 14. Data were analyzed using content analysis to produce the final outputs for the study. RESULTS: The study found several challenges to contraceptive use. These included gender dynamics, socially constructed myths on contraceptive use, cultural norms, limited knowledge about contraceptives, men's negative attitudes, antagonism of contraceptive use by leaders and reprisal of women who use contraception. CONCLUSION: The study concluded that there is need for community strategies to break down the barriers to contraception utilization among refugee women. Such strategies should involve men and women alongside gatekeepers to enhance sustainability.

Ethnicity, gender, and migration status: Applying intersectionality methodology to explore barriers to equitable health systems for maternal and newborn health among immigrant populations in Masindi, Uganda.

Globally, 298,000 women die due to pregnancy related causes and half of this occurs in Africa. In Uganda, maternal mortality has marginally reduced from 526 to 336 per 100,000 live births between 2001 and 2016. Health facility delivery is an important factor in improving maternal and neonatal outcomes. However, the concept of using a skilled birth attendant is not popular in Uganda. An earlier intervention to mobilize communities in the Masindi region for maternal and newborn health services discovered that immigrant populations used maternal health services less compared to the indigenous populations. The aim of this qualitative study was therefore to better understand why immigrant populations were using maternal health services less and what the barriers were in order to suggest interventions that can foster equitable access to maternal health services. Five focus group discussions (FGDs) (three among women; 2 with men), 8 in-depth interviews with women, and 7 key informant interviews with health workers were used to better understand the experiences of immigrants with maternal and newborn services. Interviews and FGDs were conducted from July to September 2016. Data were analyzed using content analysis and intersectionality. Results were based on the following thematic areas: perceived discrimination based on ethnicity as a barrier to access, income, education and gender. Immigrant populations perceived they were discriminated against because they could not communicate in the local dialect, they were poor casual laborers, and/or were not well schooled. Matters of pregnancy and childbearing were considered to be matters for women only, while financial and other decisions at the households are a monopoly of men. The silent endurance of labor pains was considered a heroic action. In contrast, care-seeking early during the onset of labor pains attracted ridicule and was considered frivolous. In this context, perceived discrimination, conflicting gender roles, and societal rewards for silent endurance of labor pains intersect to create a unique state of vulnerability, causing a barrier to access to maternal and newborn care among immigrant women. We recommend platforms to demystify harmful cultural norms and training of health workers on respectful treatment based on the 12 steps to safe and respectful mother baby-family care.

Identifying cholera "hotspots" in Uganda: An analysis of cholera surveillance data from 2011 to 2016.

BACKGROUND: Despite advance in science and technology for prevention, detection and treatment of cholera, this infectious disease remains a major public health problem in many countries in sub-Saharan Africa, Uganda inclusive. The aim of this study was to identify cholera hotspots in Uganda to guide the development of a roadmap for prevention, control and elimination of cholera in the country. METHODOLOGY/PRINCIPLE FINDINGS: We obtained district level confirmed cholera outbreak data from 2011 to 2016 from the Ministry of Health, Uganda. Population and rainfall data were obtained from the Uganda Bureau of Statistics, and water, sanitation and hygiene data from the Ministry of Water and Environment. A spatial scan test was performed to identify the significantly high risk clusters. Cholera hotspots were defined as districts whose center fell within a significantly high risk cluster or where a significantly high risk cluster was completely superimposed onto a district. A zero-inflated negative binomial regression model was employed to identify the district level risk factors for cholera. In total 11,030 cases of cholera were reported during the 6-year period. 37(33%) of 112 districts reported cholera outbreaks in one of the six years, and 20 (18%) districts experienced cholera at least twice in those years. We identified 22 districts as high risk for cholera, of which 13 were near a border of Democratic Republic of Congo (DRC), while 9 districts were near a border of Kenya. The relative risk of having cholera inside the high-risk districts (hotspots) were 2 to 22 times higher than elsewhere in the country. In total, 7 million people were within cholera hotspots. The negative binomial component of the ZINB model shows people living near a lake or the Nile river were at increased risk for cholera (incidence rate ratio, IRR = 0.98, 95% CI: 0.97 to 0.99, p < .01); people living near the border of DRC/Kenya or higher incidence rate in the neighboring districts were increased risk for cholera in a district (IRR = 0.99, 95% CI: 0.98 to 1.00, p = .02 and IRR = 1.02, 95% CI: 1.01 to 1.03, p < .01, respectively). The zero inflated component of the ZINB model yielded shorter distance to Kenya or DRC border, higher incidence rate in the neighboring districts, and higher annual rainfall in the district were associated with the risk of having cholera in the district. CONCLUSIONS/SIGNIFICANCE: The study identified cholera hotspots during the period 2011-2016. The people located near the international borders, internationally shared lakes and river Nile were at higher risk for cholera outbreaks than elsewhere in the country. Targeting cholera interventions to these locations could prevent and ultimately eliminate cholera in Uganda.

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.

A decade of nutrition research in Africa: assessment of the evidence base and academic collaboration.

OBJECTIVE: Malnutrition in Africa has not improved compared with other regions in the world. Investment in the build-up of a strong African research workforce is essential to provide contextual solutions to the nutritional problems of Africa. To orientate this process, we reviewed nutrition research carried out in Africa and published during the last decade. DESIGN: We assessed nutrition research from Africa published between 2000 and 2010 from MEDLINE and EMBASE and analysed the study design and type of intervention for studies indexed with major MeSH terms for vitamin A deficiency, protein-energy malnutrition, obesity, breast-feeding, nutritional status and food security. Affiliations of first authors were visualised as a network and power of affiliations was assessed using centrality metrics. SETTING: Africa. SUBJECTS: Africans, all age groups. RESULTS: Most research on the topics was conducted in Southern (36%) and Western Africa (34%). The intervention studies (9%; n 95) mainly tested technological and curative approaches to the nutritional problems. Only for papers on protein-energy malnutrition and obesity did lead authorship from Africa exceed that from non-African affiliations. The 10% most powerfully connected affiliations were situated mainly outside Africa for publications on vitamin A deficiency, breast-feeding, nutritional status and food security. CONCLUSIONS: The development of the evidence base for nutrition research in Africa is focused on treatment and the potential for cross-African networks to publish nutrition research from Africa remains grossly underutilised. Efforts to build capacity for effective nutrition action in Africa will require forging a true academic partnership between African and non-African research institutions.

Is antenatal care preparing mothers to care for their newborns? A community-based cross-sectional study among lactating women in Masindi, Uganda.

BACKGROUND: Neonatal mortality has remained resistant to change in the wake of declining child mortality. Suboptimal newborn care practices are predisposing factors to neonatal mortality. Adherence to four ANC consultations is associated with improved newborn care practices. There is limited documentation of this evidence in sub-Saharan Africa where suboptimal newborn care practices has been widely reported. METHODS: Structured interviews were held with 928 women having children under-five months old at their homes in Masindi, Uganda, from October-December 2011. Four/more ANC consultations (sufficient ANC) was considered the exposure variable. Three composite variables (complete cord care, complete thermal care and complete newborn vaccination status) were derived by combining related practices from a list of recommended newborn care practices. Logistic regression models were used to assess for associations. RESULTS: One in five women 220(23.7%) were assessed to practice complete cord care. Less than ten percent 57(6.1%) were considered to practice complete thermal care and 611(65.8%) were assessed to have complete newborn vaccination status. Application of substance on the cord 744 (71.6%) and early bathing 816 (87.9%) were main drivers of sub-optimal newborn care practices. Multivariable logistic models did not demonstrate significant association between four/more ANC consultations and complete cord care, complete thermal care or complete newborn vaccination status. Secondary or higher education was associated with complete cord care [adjusted Odds Ratio (aOR): 2.72; 95% CI: 1.63-4.54] and complete newborn vaccination [aOR: 1.37; 95% CI: 1.04-1.82]. Women who reported health facility delivery were more likely to report complete thermal care [aOR: 3.63; 95% CI: 2.21-5.95] and newborn vaccination [aOR: 1.84; 95% CI: 1.23-2.75], but not complete cord care. Having the first baby was associated with complete thermal care [aOR: 2.00; 95% CI: 1.24-3.23]. CONCLUSION: Results confirm suboptimal newborn care practices in Masindi. Despite being established policy, adherence to four or more ANC consultations was not associated with complete cord care, complete thermal care or complete newborn vaccination. This finding has important implications for the implementation of focused ANC to improve newborn care practices. Future ANC interventions should focus on addressing application of substance on the cord and early bathing of the baby during the immediate neonatal period.

How can the operating environment for nutrition research be improved in sub-Saharan Africa? The views of African researchers.

Optimal nutrition is critical for human development and economic growth. Sub-Saharan Africa is facing high levels of food insecurity and only few sub-Saharan African countries are on track to eradicate extreme poverty and hunger by 2015. Effective research capacity is crucial for addressing emerging challenges and designing appropriate mitigation strategies in sub-Saharan Africa. A clear understanding of the operating environment for nutrition research in sub-Saharan Africa is a much needed prerequisite. We collected data on the barriers and requirements for conducting nutrition research in sub-Saharan Africa through semi-structured interviews with 144 participants involved in nutrition research in 35 countries in sub-Saharan Africa. A total of 133 interviews were retained for coding. The main barriers identified for effective nutrition research were the lack of funding due to poor recognition by policymakers of the importance of nutrition research and under-utilisation of research findings for developing policy, as well as an absence of research priority setting from within Africa. Current research topics were perceived to be mainly determined by funding bodies from outside Africa. Nutrition researchers argued for more commitment from policymakers at national level. The low capacity for nutrition research was mainly seen as a consequence of insufficient numbers of nutrition researchers, limited skills and a poor research infrastructure. In conclusion, African nutrition researchers argued how research priorities need to be identified by African stakeholders, accompanied by consensus building to enable creating a problem-driven national research agenda. In addition, it was considered necessary to promote interactions among researchers, and between researchers and policymakers. Multidisciplinary research and international and cross-African collaboration were seen as crucial to build capacity in sub-Saharan nutrition research.