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.

Exploring the effects of COVID-19 on family planning: results from a qualitative study in rural Uganda following COVID-19 lockdown.

BACKGROUND: The COVID-19 pandemic has likely affected the already high unmet need for family planning in low- and middle-income countries. This qualitative study used Andersen's Behavioral Model of Health Service Use as a theoretical framework to explore the possible ways in which the COVID-19 pandemic, including the impact of a 3-month government mandated lockdown, might affect family planning outcomes in rural Uganda. A secondary aim was to elicit recommendations to improve family planning service delivery in the context of COVID-19. METHODS: Between June and October 2020, we conducted four focus group discussions with men and women separately (N = 26) who had an unmet need for family planning, and 15 key-informant interviews with community leaders and family planning stakeholders. Data were analyzed using thematic analysis. RESULTS: We identified a significant disruption to the delivery of family planning services due to COVID-19, with potential negative effects on contraceptive use and risk for unintended pregnancy. COVID-19 had a negative effect on individual enabling factors such as family income, affecting service access, and on community enabling factors, such as transportation barriers and the disruption of community-based family planning delivery through village health teams and mobile clinics. Participants felt COVID-19 lockdown restrictions exacerbated existing contextual predisposing factors related to poverty and gender inequity, such as intimate partner violence and power inequities that diminish women's ability to refuse sex with their husband and their autonomy to use contraceptives. Recommendations to improve family planning service delivery in the context of COVID-19 centered on emergency preparedness, strengthening community health systems, and creating new ways to safely deliver contractive methods directly to communities during future COVID-19 lockdowns. CONCLUSIONS: This study highlights the consequences of COVID-19 lockdown on family planning distribution, as well as the exacerbation of gender inequities that limit women's autonomy in pregnancy prevention measures. To improve family planning service uptake in the context of COVID-19, there is a need to strengthen emergency preparedness and response, utilize community structures for contraceptive delivery, and address the underlying gender inequities that affect care seeking and service utilization.

This study explored the potential impact of the COVID-19 pandemic and a 3-month government mandated lockdown on barriers to accessing family planning services in rural Uganda, and recommendations to improve service delivery in the event of future COVID-19 restrictions. Data were collected from four focus group discussions with men and women separately (N = 26) who had an unmet need for family planning, and 15 interviews with community leaders and family planning stakeholders. The delivery of family planning services was disrupted due to COVID-19, negatively affecting community members' ability to access services, such as by reducing their income. COVID-19 also disrupted community and health system distribution of services, such as through a transportation ban and the suspension of all community-based family planning delivery through village health teams and mobile clinics. Participants felt that COVID-19 lockdown restrictions worsened intimate partner violence, and with men at home more, limited women's ability to use contraceptives without their partner's knowledge and resulted in more sex between partners without women being able to refuse. Taken together, these consequences were thought to increase women's risk of unintended pregnancy. Recommendations to improve family planning service delivery in the context of COVID-19 centered on measures to improve the health system's response to emergencies and to safely deliver contraceptive methods directly to communities during future COVID-19 lockdowns. The successful implementation of community-based family planning will depend on efforts to increase men's acceptance of family planning, while addressing underlying gender inequities that diminish women's ability to time and space pregnancy.

Validity of the Personal Impact of Epilepsy Scale (PIES) in patients with epilepsy in Uganda.

PURPOSE: We sought to address the construct validity and reliability of the Personal Impact of Epilepsy Scale (PIES), an epilepsy-specific quality-of-life measure, in patients with epilepsy in Uganda. We also sought to assess the applicability of the scale across three languages: English, Luganda, and Runyankole. METHODS: Patients with epilepsy (N = 626) were recruited at the time of care seeking from Mulago National Referral Hospital (MNRH), Butabika National Referral Mental Hospital (BNRMH), and Mbarara Regional Referral Hospital (MRRH), and were given the English, Runyankole, and Luganda versions of the PIES as a part of a larger interview. Reliability, internal consistency specifically, was assessed using three parameters: Cronbach's alpha, McDonald's Omega, and composite reliability. Construct validity (internal structure) was evaluated with principal component analysis (PCA) for three factors, as well as confirmatory factor analysis (CFA) for a three-factor structure of the scale. We also assessed correlations between the three PIES subscales and the seizure severity question in the Liverpool Seizure Severity Scale (LSSS) and reported seizure frequency. RESULTS: The three-factor model of the PIES had adequate reliability, with Cronbach's Alpha, McDonald's Omega, and composite reliability values over 0.7, except for the Cronbach's Alpha and McDonald's Omega values for the second factor, which was slightly lower than 0.7 in the full sample as well as when stratified by study language. The PCA and CFA models for the scale demonstrated adequate fit with the Tucker-Lewis index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA), with TLI and CFI values above 0.9 and RMSEA values less than 0.08. However, the model demonstrated inadequate fit with the Chi-square indicator, which yielded a significant p-value. Individual factor loadings ranged from 0.50 to 0.95 in the full sample, 0.45 to 0.98 in the English sample, and 0.45 to 0.93 in the Luganda sample. Finally, the three PIES subscales aligned with reported seizure frequency and the seizure severity question from the LSSS. CONCLUSIONS: This study presents the first Luganda and Runyankole versions of the PIES, and the first validation of this scale in English and Luganda with patients with epilepsy in Uganda. The PIES was found to have acceptable psychometric properties for reliability and validity parameters. Thus, the scale is recommended for use and for further investigation in patients with epilepsy in Uganda. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Epilepsy beliefs and misconceptions among patient and community samples in Uganda.

OBJECTIVE: The objective of the study was to characterize and compare the attitudes, beliefs, and perceptions about epilepsy across community and patient cohorts in Uganda. METHODS: This was a descriptive study utilizing two samples: a randomly selected, national survey community sample and a hospital-based patient sample of people with epilepsy (PWE) and their caregivers attending clinic settings in Kampala and Mbarara, Uganda for epilepsy care. Both samples were surveyed about their beliefs about epilepsy, its treatment, and people who have the illness. Multivariate linear regression was used to examine group differences and variables associated with specific beliefs. RESULTS: Among the 15,818 community survey participants who participated in this study, 435 study participants reported symptoms suggestive of recurrent seizures, and all 626 subjects in the hospital-based sample had confirmed epilepsy. Results revealed significant differences across groups in their endorsement of epilepsy as a contagion; 37% of people in the community unaffected by epilepsy, and 39% of people with suspected epilepsy who did not seek care believed that epilepsy was contagious by touch, in contrast to 8% of PWE or their caregivers attending regular hospital-based care. Higher educational attainment and income, and seeking regular hospital-based medical care were associated with less endorsement of epilepsy as a contagion, while age, education, income, area of residence, and presence of seizure symptoms, were significant predictors of support or belief in the basic rights of PWE. Study participants within the community who screened negative for seizures placed the most restrictions on rights for PWE. To varying degrees, the samples all endorsed the effectiveness of allopathic, traditional, and religious providers, and the use of pharmaceutical drugs, traditional rituals and herbs, and prayer. CONCLUSIONS: People with epilepsy who are attending biomedical care for routine epilepsy care think differently about epilepsy, its treatment, and the rights of those with the disease than the general population. Within the community setting, more erroneous beliefs and negative attitudes about epilepsy and PWE persist, and they not only contribute to stigma but also interfere with the patients' health-seeking behavior. Further confounding the care of PWE, the pluralistic healthcare system in Uganda is evident in endorsements spanning biomedical, traditional, and religious treatment methods. Focused awareness campaigns utilizing local epilepsy societies are needed to promote epilepsy health literacy, to favorably impact acceptance and opportunities for PWE in Uganda, and to facilitate efficient uptake of biomedical care. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Barriers to biomedical care for people with epilepsy in Uganda: A cross-sectional study.

OBJECTIVE: Epilepsy, a neurological disorder with effective biomedical treatment, remains largely untreated in Uganda. Potential reasons for this treatment gap (TG) include limited access to trained providers and clinics, social stigmata of seizures, cultural beliefs, or lack of public understanding of epilepsy as a treatable condition. The current study aimed to formally evaluate barriers faced by people with epilepsy (PWE) in Uganda when seeking biomedical care. METHODS: In a cross-sectional study, 435 participants drawn from a community prevalence study were enrolled. We included participants reporting a history of recurrent seizures suggestive of epilepsy, who completed a survey about barriers to obtaining care for their symptoms. Principal axis factor analysis (PFA) using a promax rotation was conducted for data reduction. Frequencies of barrier factors were compared across those who did not seek care for epilepsy (n = 228), those who sought care from biomedical facilities (n = 166), and those who sought care from a traditional or pastoral healer (n = 41). RESULTS: The PFA yielded a five-factor solution: 1) logistical and actual costs; 2) treatment effectiveness; 3) influence of the opinion of others; 4) doctors' care; and 5) contextual factors impacting decision-making. Variables related to logistical and actual costs were most endorsed. Comparison of groups by care sought did not reveal a difference in endorsement of factors, with the exception that those who sought biomedical care were more likely to endorse factors related to doctors' care compared with those that sought care from traditional or pastoral healers (P = .005). CONCLUSIONS: People with repetitive seizures in Uganda report several barriers to obtaining biomedical care in Uganda, with those related to practical and actual costs endorsed the most. It is imperative that interventions developed to reduce the TG in Uganda consider these practical issues to improve access to effective epilepsy care. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda.

Pluralistic and singular causal attributions for epilepsy in Uganda.

OBJECTIVE: In Uganda, causal attributions for epilepsy reflect a variety of beliefs and impact care-seeking behavior, perpetuate stigma, and undermine the effectiveness of interventions to narrow the epilepsy treatment gap. The objective of this study was to characterize beliefs about seizure etiology to gain a better understanding of how epilepsy is conceptualized in the community in order to inform culturally appropriate educational policies and interventions. METHODS: In a community-based study, 15,383 participants were surveyed about beliefs related to 15 potential causes for epilepsy. Principal axis factor analysis (PFA) was performed to identify causative factors and then utilized to classify singular versus pluralistic belief systems related to epilepsy etiology. Analysis of variance (ANOVA) and Mann-Whitney U-tests were conducted to examine the differences in background characteristics across the etiology belief groups. RESULTS: Three main causative factors emerged from the PFA: biological, sociospiritual, and biospiritual. Among those endorsing at least one factor (n = 13,036), the biological factor was endorsed most frequently as a potential cause for epilepsy (88.0%), followed by the sociospiritual (63.4%), then biospiritual (47.6%). Review of the patterns of endorsement found that only 22.2% endorsed the biological factor alone, 6.7% the sociospiritual factor alone, and 2.8% the biospiritual factor alone (total 31.7%). The remainder endorsed a combination of two or all three factors as being potentially causal, and most (65.7%) endorsed a pluralistic combination inclusive of a biological etiology. Group comparisons showed that endorsing only the biological factor was associated with the highest levels of education (p < 0.01), the pluralistic group had the highest ratio of people in the household who needed assistance to those that could provide aid (p < 0.01), and there were significant differences in income across specific groups (p < 0.01). CONCLUSIONS: Pluralistic attributions for epilepsy are common in Uganda, with the majority of community members drawing from biomedical and traditional concepts to construct complex explanations for seizures that transcend discrete belief categories traditionally depicted in the literature. These findings emphasize the need to understand cultural beliefs about epilepsy in order to design contextually specific interventions and education programs, which respect the fundamental beliefs and values of the community. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Hospital-based epilepsy care in Uganda: A prospective study of three major public referral hospitals.

OBJECTIVE: This study sets out to describe the current demographics of people with epilepsy (PWE) attending hospital-based care in Uganda and the epilepsy treatment practices within three of the largest Ugandan public referral hospitals. METHODS: In a six-month prospective cohort study, 626 children and adults attending epilepsy clinics at Mulago National Referral Hospital, Butabika National Referral Mental Hospital and Mbarara Regional Referral Hospital were enrolled. Using a study questionnaire, data were collected at baseline and at 3 weeks, 3 months, and 6 months following enrollment. Specific data surrounding individual patient demographics, clinical characteristics and severity of epilepsy, and treatment of epilepsy with antiepileptic drugs (AEDs) were collected. RESULTS: Female patients totaled to 50.8%, with a nearly equal gender distribution at each hospital. There was no statistical difference in gender or age between sites. The majority of PWE had completed primary school, with less than 15% of patients completing more than a secondary education. Seizure severity was high, with most patients having multiple seizures per week at the initial onset of epilepsy, and greater than 90% of patients reporting a loss of consciousness with seizures. The majority of patients (54.95%) also reported a developmental or learning delay. Most patients were on 1 AED (46.01%) or 2 AEDs (36.90%), with carbamazepine being the most frequently prescribed AED. There was a trend towards improved seizure severity over the follow-up period, as assessed by the corresponding Personal Impact of Epilepsy Scale (PIES) subscale. CONCLUSIONS: People with epilepsy attending hospital-based care in Uganda tend to have severe forms of epilepsy requiring management with AEDs. Current hospital-based practices show a positive trend for seizure burden and quality of life of PWE in Uganda. Further interventions to improve overall access to biomedical care are required to continue to advance the management of PWE across all communities. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Neural tube defects in Uganda: follow-up outcomes from a national referral hospital.

OBJECTIVE: Children with neural tube defects (NTDs) require timely surgical intervention coupled with long-term management by multiple highly trained specialty healthcare teams. In resource-limited settings, outcomes are greatly affected by the lack of coordinated care. The purpose of this study was to characterize outcomes of spina bifida patients treated at Mulago National Referral Hospital (MNRH) through follow-up phone surveys. METHODS: All children presenting to MNRH with NTDs between January 1, 2014, and August 31, 2015, were eligible for this study. For those with a documented telephone number, follow-up phone surveys were conducted with the children's caregivers to assess mortality, morbidity, follow-up healthcare, and access to medical resources. RESULTS: Of the 201 patients, the vast majority (n = 185, 92%) were diagnosed with myelomeningocele. The median age at presentation was 6 days, the median length of stay was 20 days, and the median time to surgery was 10 days. Half of the patients had documented surgeries, with 5% receiving multiple procedures (n = 102, 51%): 80 defect closures (40%), 32 ventriculoperitoneal shunts (15%), and 1 endoscopic third ventriculostomy (0.5%). Phone surveys were completed for 53 patients with a median time to follow-up of 1.5 years. There were no statistically significant differences in demographics between the surveyed and nonrespondent groups. The 1-year mortality rate was 34% (n = 18). At the time of survey, 91% of the survivors (n = 30) have received healthcare since their initial discharge from MNRH, with 67% (n = 22) returning to MNRH. Hydrocephalus was diagnosed in 29 patients (88%). Caregivers reported physical deficits in 39% of patients (n = 13), clubfoot in 18% (n = 6), and bowel or bladder incontinence in 12% (n = 4). The surgical complication rate was 2.5%. Glasgow Outcome Scale-Extended pediatric revision scores were correlated with upper good recovery in 58% (n = 19) of patients, lower good recovery in 30% (n = 10), and moderate disability in 12% of patients (n = 4). Only 5 patients (15%) reported access to home health resources postdischarge. CONCLUSIONS: This study is the first to characterize the outcomes of children with NTDs that were treated at Uganda's national referral hospital. There is a great need for improved access to and coordination of care in antenatal, perioperative, and long-term settings to improve morbidity and mortality.

Burden of Surgical Conditions in Uganda: A Cross-sectional Nationwide Household Survey.

OBJECTIVE: To quantify the burden of surgical conditions in Uganda. BACKGROUND: Data on the burden of disease have long served as a cornerstone to health policymaking, planning, and resource allocation. Population-based data are the gold standard, but no data on surgical burden at a national scale exist; therefore, we adapted the Surgeons OverSeas Assessment of Surgical Need survey and conducted a nation-wide, cross-sectional survey of Uganda to quantify the burden of surgically treatable conditions. METHODS: The 2-stage cluster sample included 105 enumeration areas, representing 74 districts and Kampala Capital City Authority. Enumeration occurred from August 20 to September 12, 2014. In each enumeration area, 24 households were randomly selected; the head of the household provided details regarding any household deaths within the previous 12 months. Two household members were randomly selected for a head-to-toe verbal interview to determine existing untreated and treated surgical conditions. RESULTS: In 2315 households, we surveyed 4248 individuals: 461 (10.6%) reported 1 or more conditions requiring at least surgical consultation [95% confidence interval (CI) 8.9%-12.4%]. The most frequent barrier to surgical care was the lack of financial resources for the direct cost of care. Of the 153 household deaths recalled, 53 deaths (34.2%; 95% CI 22.1%-46.3%) were associated with surgically treatable signs/symptoms. Shortage of time was the most frequently cited reason (25.8%) among the 11.6% household deaths that should have, but did not, receive surgical care (95% CI 6.4%-16.8%). CONCLUSIONS: Unmet surgical need is prevalent in Uganda. There is an urgent need to expand the surgical care delivery system starting with the district-level hospitals. Routine surgical data collection at both the health facility and household level should be implemented.

Geospatial Analysis of Unmet Surgical Need in Uganda: An Analysis of SOSAS Survey Data.

BACKGROUND: Globally, a staggering five billion people lack access to adequate surgical care. Sub-Saharan Africa represents one of the regions of greatest need. We sought to understand how geographic factors related to unmet surgical need (USN) in Uganda. METHODS: We performed a geographic information system analysis of a nationwide survey on surgical conditions performed in 105 enumeration areas (EAs) representing the national population. At the district level, we determined the spatial autocorrelation of the following study variables: prevalence of USN, hub distance (distance from EA to the nearest surgical center), area of coverage (geographic catchment area of each center), tertiary facility transport time (average respondent-reported travel time), and care availability (rate of hospital beds by population and by district). We then used local indicators of spatial association (LISA) and spatial regression to identify any significant clustering of these study variables among the districts. RESULTS: The survey enumerated 4248 individuals. The prevalence of USN varied from 2.0-45 %. The USN prevalence was highest in the Northern and Western Regions. Moran's I bivariate analysis indicated a positive correlation between USN and hub distance (p = 0.03), area of coverage (p = 0.02), and facility transport time (p = 0.03). These associations were consistent nationally. The LISA analysis showed a high degree of clustering among sets of districts in the Northern Sub-Region. CONCLUSIONS: This study demonstrates a statistically significant association between USN and the geographic variables examined. We have identified the Northern Sub-Region as the highest priority areas for financial investment to reduce this unmet surgical disease burden.

Quantifying the pediatric surgical need in Uganda: results of a nationwide cross-sectional, household survey.

PURPOSE: Little is known about the prevalence of pediatric surgical conditions in low- and middle-income countries. Many children never seek medical care, thus the true prevalence of surgical conditions in children in Uganda is unknown. The objective of this study was to determine the prevalence of surgical conditions in children in Uganda. METHODS: Using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey, we enumerated 4248 individuals in 2315 households in 105 randomly selected clusters throughout Uganda. Children aged 0-18 were included if randomly selected from the household; for those who could not answer for themselves, parents served as surrogates. RESULTS: Of 2176 children surveyed, 160 (7.4 %) reported a currently untreated surgical condition. Lifetime prevalence of surgical conditions was 14.0 % (305/2176). The predominant cause of surgical conditions was trauma (48.4 %), followed by wounds (19.7 %), acquired deformities (16.2 %), and burns (12.5 %). Of 90 pediatric household deaths, 31.1 % were associated with a surgically treatable proximate cause of death (28/90 deaths). CONCLUSION: Although some trauma-related surgical burden among children can be adequately addressed at district hospitals, the need for diagnostics, human resources, and curative services for more severe trauma cases, congenital deformities, and masses outweighs the current capacity of hospitals and trained pediatric surgeons in Uganda.

Understanding sexual and reproductive health needs of adolescents: evidence from a formative evaluation in Wakiso district, Uganda.

INTRODUCTION: Adolescents are frequently reluctant to seek sexual and reproductive health services (SRH). In Uganda, adolescent health and development is constrained by translation of the relevant policies to practice. Recent studies done in central Uganda have shown that there is need for a critical assessment of adolescent friendly services (AFS) to gain insights on current practice and inform future interventions. This study aimed to assess the sexual reproductive health needs of the adolescents and explored their attitudes towards current services available. METHODS: A qualitative study was conducted in Wakiso district, central Uganda in September 2013.Twenty focus group discussions (FGDs) stratified by gender (10 out-of-school, and 10 in-school), were purposefully sampled. We used trained research assistants (moderator and note taker) who used a pretested FGD guide translated into the local language to collect data. All discussions were audio taped, and were transcribed verbatim before analysis. Thematic areas on; adolescent health problems, adolescent SRH needs, health seeking behaviour and attitudes towards services, and preferred services were explored. Data was analysed using atlas ti version 7 software. RESULTS: Our results clearly show that adolescents have real SRH issues that need to be addressed. In and out-of-school adolescents had sexuality problems such as unwanted pregnancies, sexually transmitted infections (STIs), defilement, rape, substance abuse. Unique to the females was the issue of sexual advances by older men and adolescents. We further highlight RH needs which would be solved by establishing adolescent friendly clinics with standard recommended characteristics (sexuality information, friendly health providers, a range of good clinical services such as post abortion care etc.). With regard to health seeking behaviour, most adolescents do not take any action at first until disease severity increase. CONCLUSIONS: Adolescents in Uganda have multiple sexual and reproductive health needs that require special focus through adolescent friendly services. This calls for resource support in terms of health provider training, information education and communication materials as well as involvement of key stakeholders that include parents, teachers and legislators.

Effects of a community-based, multi-level family planning intervention on theoretically grounded intermediate outcomes for couples in rural Uganda: Results from a mixed methods pilot evaluation.

OBJECTIVES: This study tested the theoretically grounded conceptual model of a multi-level intervention, Family Health = Family Wealth (FH = FW), by examining FH = FW's effect on intermediate outcomes among couples in rural Uganda. FH = FW is grounded in the social-ecological model and the social psychological theory of transformative communication. DESIGN: A pilot quasi-experimental controlled trial. METHODS: Two matched clusters (communities) were randomly allocated to receive the FH = FW intervention or an attention/time-matched water, sanitation and hygiene intervention (N = 140, 35 couples per arm). Quantitative outcomes were collected through interviewer-administered questionnaires at baseline, 7-months and 10-months follow-up. Focus group discussions (n = 39) and semi-structured interviews (n = 27) were conducted with subsets of FH = FW participants after data collection. Generalized estimated equations tested intervention effects on quantitative outcomes, and qualitative data were analysed through thematic analysis-these data were mixed and are presented by level of the social-ecological model. RESULTS: The findings demonstrated an intervention effect on family planning determinants across social-ecological levels. Improved individual-level family planning knowledge, attitudes and intentions, and reduced inequitable gender attitudes, were observed in intervention versus comparator, corroborated by the qualitative findings. Interpersonal-level changes included improved communication, shared decision-making and equitable relationship dynamics. At the community level, FH = FW increased perceived acceptance of family planning among others (norms), and the qualitative findings highlighted how FH = FW's transformative communication approach reshaped definitions of a successful family to better align with family planning. CONCLUSIONS: This mixed methods pilot evaluation supports FH = FW's theoretically grounded conceptual model and ability to affect multi-level drivers of a high unmet need for family planning.

"The burden is upon your shoulders to feed and take care of your children, not religion or culture": qualitative evaluation of participatory community dialogues to promote family planning's holistic benefits and reshape community norms on family success in rural Uganda.

BACKGROUND: Family planning has significant health and social benefits, but in settings like Uganda, is underutilized due to prevalent community and religious norms promoting large family size and gender inequity. Family Health = Family Wealth (FH = FW) is a multi-level, community-based intervention that used community dialogues grounded in Campbell and Cornish's social psychological theory of transformative communication to reshape individual endorsement of community norms that negatively affect gender equitable reproductive decision-making among couples in rural Uganda. METHODS: This study aimed to qualitatively evaluate the effect of FH = FW's community dialogue approach on participants' personal endorsement of community norms counter to family planning acceptance and gender equity. A pilot quasi-experimental controlled trial was implemented in 2021. This paper uses qualitative, post-intervention data collected from intervention arm participants (N = 70) at two time points: 3 weeks post-intervention (in-depth interviews, n = 64) and after 10-months follow-up (focus group discussions [n = 39] or semi-structured interviews [n = 27]). Data were analyzed through thematic analysis. RESULTS: The community dialogue approach helped couples to reassess community beliefs that reinforce gender inequity and disapproval of family planning. FH = FW's inclusion of economic and relationship content served as key entry points for couples to discuss family planning. Results are presented in five central themes: (1) Community family size expectations were reconsidered through discussions on economic factors; (2) Showcasing how relationship health and gender equity are central to economic health influenced men's acceptance of gender equity; (3) Linking relationship health and family planning helped increase positive attitudes towards family planning and the perceived importance of shared household decision-making to family wellness; (4) Program elements to strengthen relationship skills helped to translate gender equitable attitudes into changes in relationship dynamics and to facilitate equitable family planning communication; (5) FH = FW participation increased couples' collective family planning (and overall health) decision-making and uptake of contraceptive methods. CONCLUSION: Community dialogues may be an effective intervention approach to change individual endorsement of widespread community norms that reduce family planning acceptance. Future work should continue to explore innovative ways to use this approach to increase gender equitable reproductive decision-making among couples in settings where gender, religious, and community norms limit reproductive autonomy. Future evaluations of this work should aim to examine change in norms at the community-level. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04262882).

Perspectives of female sex workers on HIV pre-exposure prophylaxis delivery in Uganda: A qualitative study.

Background: HIV pre-exposure prophylaxis (PrEP) is underutilized by cisgender female sex workers (FSW) despite its proven effectiveness. This study aimed to understand the experiences of FSW with PrEP services in Uganda to inform HIV programming for this key population. Methods: We conducted qualitative interviews with 19 FSW between June and July 2022 at the Most at Risk Populations Initiative clinic, Mulago Hospital, Kampala, to explore experiences with accessing PrEP Indepth interviews explored: (1) descriptions of where and how PrEP was obtained; (2) perspectives on current approaches for accessing PrEP; and (3) individual encounters with PrEP services. Data were analyzed through inductive thematic analysis. Results: Three key themes emerged for FSW perspectives on PrEP service delivery. FSW highlighted the positive impact of a welcoming clinic environment, which motivated FSW to initiate PrEP and fostered a sense of connectedness within their community. They also reported feeling accepted, secure, and free from prejudice when accessing PrEP through facility-based services. The second explores the obstacles faced by FSW, such as lengthy wait times at clinics, inadequate provider support, and lack of sensitivity training which hindered their access to PrEP The third sheds light on how HIV-related stigma negatively impacted the delivery of community-based PrEP for FSW. While community-based distribution offered convenience and helped mitigate stigma, clinic-based care provided greater anonymity and was perceived as offering higher-quality care. Overall, FSWs emphasized the critical role of friendly healthcare providers, social support, and non-stigmatizing environments in promoting successful utilization of PrEP. Conclusion: The study findings offer insights that can support HIV programs in optimizing PrEP delivery for FSW. Establishing easily accessible drug pick-up locations, prioritizing privacy, addressing and improving health workers' attitudes, and providing regular reminders could enhance PrEP access for FSW and decrease HIV acquisition.

A pilot quasi-experimental controlled trial of a community-based, multilevel family planning intervention for couples in rural Uganda: evidence of feasibility, acceptability, and effect on contraceptive uptake among those with an unmet need for family planning.

OBJECTIVES: Effective interventions to reduce the unmet need for family planning in low-income settings are limited. This study aimed to establish the feasibility, acceptability, and preliminary effects of Family Health=Family Wealth (FH=FW), a multilevel intervention aimed to increase high-efficacy contraceptive uptake among couples wanting to delay pregnancy. STUDY DESIGN: A pilot quasi-experimental controlled trial was conducted in rural Uganda, with 70 couples wanting to delay pregnancy but not using contraceptives (n = 140). Two matched clusters (communities) were randomly allocated to receive FH=FW or a comparator intervention via coin toss. FH=FW included health system strengthening elements and four facilitated group sessions. Interviewer-administered questionnaires were conducted at baseline and at ∼7-month and ∼10-month follow-up, and process data gathered feasibility/acceptability outcomes. RESULTS: Of 121 households visited in the intervention community, 63 couples were screened, and 35 enrolled. In the comparator, 61 households were visited, 45 couples screened, and 35 enrolled. Intervention attendance was 99%, fidelity was 96%, and 100% of participants reported being satisfied with the intervention. From no use at baseline, there was 31% more high efficacy contraceptive uptake at 7 months and 40% more at 10 months in intervention versus comparator couples (adjusted odds ratio = 1.68, 95% confidence interval = 0.78-3.62, p = 0.19). A decline in fertility desires was observed in intervention versus comparator participants from baseline (Wald χ2 = 9.87, p = 0.007; Cohen's d: 7 months, 0.06; 10 months, 0.49). CONCLUSIONS: FH=FW is a feasible and acceptable intervention with strong promise in its effect on contraceptive uptake to be established in a future trial. IMPLICATIONS: The FH=FW intervention addresses multilevel family planning barriers through four group dialogs with couples paired with efforts to reduce health system barriers. A quasi-experimental controlled trial provides preliminary support for its feasibility, acceptability, contraceptive uptake and fertility desire effects, and success in engaging both women and men.

International stakeholder perspectives on One Health training and empowerment: a needs assessment for a One Health Workforce Academy.

BACKGROUND: One Health is defined as an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems; this approach attracts stakeholders from multiple sectors, academic disciplines, and professional practices. The diversity of expertise and interest groups is frequently and simultaneously framed as (1) a strength of the One Health approach in the process of understanding and solving complex problems associated with health challenges such as pathogen spillovers and pandemics and (2) a challenge regarding consensus on essential functions of One Health and the sets of knowledge, skills, and perspectives unique to a workforce adopting this approach. Progress in developing competency-based training in One Health has revealed coverage of various topics across fundamental, technical, functional, and integrative domains. Ensuring that employers value the unique characteristics of personnel trained in One Health will likely require demonstration of its usefulness, accreditation, and continuing professional development. These needs led to the conceptual framework of a One Health Workforce Academy (OHWA) for use as a platform to deliver competency-based training and assessment for an accreditable credential in One Health and opportunities for continuing professional development. METHODS: To gather information about the desirability of an OHWA, we conducted a survey of One Health stakeholders. The IRB-approved research protocol used an online tool to collect individual responses to the survey questions. Potential respondents were recruited from partners of One Health University Networks in Africa and Southeast Asia and international respondents outside of these networks. Survey questions collected demographic information, measured existing or projected demand and the relative importance of One Health competencies, and determined the potential benefits and barriers of earning a credential. Respondents were not compensated for participation. RESULTS: Respondents (N = 231) from 24 countries reported differences in their perspectives on the relative importance of competency domains of the One Health approach. More than 90% of the respondents would seek to acquire a competency-based certificate in One Health, and 60% of respondents expected that earning such a credential would be rewarded by employers. Among potential barriers, time and funding were the most cited. CONCLUSION: This study showed strong support from potential stakeholders for a OHWA that hosts competency-based training with opportunities for certification and continuing professional development.

The "Family Health = Family Wealth" intervention: study protocol for a pilot quasi-experimental controlled trial of a multi-level, community-based family planning intervention for couples in rural Uganda.

BACKGROUND: Uganda has one of the highest fertility rates globally, but only 30% of women report using an effective method of contraception. Community-based, multi-level interventions are needed to help couples in rural Uganda overcome barriers to contraceptive use. METHODS: This study will pilot test the Family Health = Family Wealth intervention, a multi-level, community-based intervention employing transformative community dialogues, which use facilitated discussion to reshape community norms that influence family planning acceptance, to alter individual attitudes and the perception of community norms that discourage family planning. Community dialogues are delivered to groups of couples over 4 sessions (two gender-segregated and two gender-mixed). Sessions simultaneously address individual and interpersonal-level determinants of family planning and link couples to family planning services. At the health system level, a refresher training will be conducted with health workers in the intervention community's health center to address gaps in contraceptive knowledge and skills as identified from a needs assessment. The intervention will be evaluated through a pilot quasi-experimental trial paired with a mixed methods process evaluation. Participants include 70 couples (N=140) randomized by community to the Family Health = Family Wealth intervention (n=35 couples) or to an attention-matched water, sanitation, and hygiene (WASH) intervention (n=35 couples). Participants include sexually active, married couples who are age 18 (or an emancipated minor) to 40 for women and age 18 (or an emancipated minor) to 50 for men, not pregnant, at least one person in the couple reports wanting to avoid pregnancy for at least a year, and not currently using a method of contraception or using a low-efficacy or ineffective method of contraception. The primary aims of the study are to (1) assess the feasibility of the intervention trial procedures, (2) the acceptability and feasibility of the intervention content and structure, and (3) explore the intervention's preliminary effectiveness at increasing contraceptive use and affecting related outcomes among couples. DISCUSSION: Filling the unmet need for family planning has important public health implications, including reductions in pregnancy-related health risks and deaths, and infant mortality. This pilot intervention trial will gather preliminary evidence on the acceptability, feasibility, and potential effect of a novel, multi-level, community-based intervention to increase contraceptive use among couples with an unmet need for family planning in rural Uganda. We aim to use the findings of this pilot study to refine the trial procedures and intervention content for a future, larger cluster randomized controlled trial to establish the intervention's efficacy. TRIAL REGISTRATION: ClinicalTrials.gov NCT04262882; registered on February 10, 2020.

Costs and Cost Drivers of Providing Option B+ Services to Mother-Baby Pairs for PMTCT of HIV in Health Centre IV Facilities in Jinja District, Uganda.

BACKGROUND: In 2013, the World Health Organization (WHO) revised the 2012 guidelines on use of antiretroviral drugs (ARVs) for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). The new guidelines recommended lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women irrespective of CD4 count or clinical stage (also referred to as Option B+). Uganda started implementing Option B+ in 2012 basing on the 2012 WHO guidelines. Despite the impressive benefits of the Option B+ strategy, implementation challenges, including cost burden and mother-baby pairs lost to follow-up, threatened its overall effectiveness. The researchers were unable to identify any studies conducted to assess costs and cost drivers associated with provision of Option B+ services to mother-baby pairs in HIV care in Uganda. Therefore, this study determined costs and cost drivers of providing Option B+ services to mother-baby pairs over a two-year period (2014-2015) in selected health facilities in Jinja district, Uganda. METHODS: The estimated costs of providing Option B+ to mother-baby pairs derived from the provider perspective were evaluated at four health centres (HC) in Jinja district. A retrospective, ingredient-based costing approach was used to collect data for 2014 as base year using a standardized cost data capture tool. All costs were valued in United States dollars (USD) using the 2014 midyear exchange rate. Costs incurred in the second year (2015) were obtained by inflating the 2014 costs by the ratio of 2015 and 2014 USA Gross Domestic Product (GDP) implicit price deflator. RESULTS: The average total cost of Option B+ services per HC was 66,512.7 (range: 32,168.2-102,831.1) USD over the 2-year period. The average unit cost of Option B+ services per mother-baby pair was USD 441.9 (range: 422.5-502.6). ART for mothers was the biggest driver of total mean costs (percent contribution: 62.6%; range: 56.0%-65.5%) followed by facility personnel (percent contribution: 8.2%; range: 7.7%-11.6%), and facility-level monitoring and quality improvement (percent contribution: 6.0%; range: 3.2%-12.3%). Conclusions and Recommendations. ART for mothers was the major cost driver. Efforts to lower the cost of ART for PMTCT would make delivery of Option B+ affordable and sustainable.

Road traffic injuries in Uganda: pre-hospital care time intervals from crash scene to hospital and related factors by the Uganda Police.

A cross-sectional survey was conducted to collect primary data prospectively on pre-hospital care time intervals of Road Traffic Crash (RTC) victims that had been rescued by the Uganda police and to determine what factors were related to those intervals. The survey was conducted between 1 May 2015 and 31 May 2015. The Police responses to 96 RTCs were recorded, but only 74 of them were considered serious enough to warrant hospital transfer, and those 74 are the subject of the analysis. Pre-hospital care time ranged between 10 and 220 min. Seventy-two per cent of the calls were completed within 1 h of call initiation. The scene to hospital transport interval was the longest with a mean of 19.07 min (SD 10.11). Activation time was the shortest interval with a mean of 4.58 min (SD 5.67). Key factors for delays included: understaffing, lack of skills and long distances. A toll-free Universal Access Number, a law mandating provision of free basic emergency medical services at every health facility and gazetting of lanes for emergency services and might decrease on pre-hospital care time and could reduce on the notification and transport time interval respectively.