Health Workers' Practices in Assessment and Management of Children with Respiratory Symptoms in Primary Care Facilities in Uganda: A FRESH AIR Descriptive Study.

INTRODUCTION: Globally, acute lower respiratory infections are the leading cause of mortality among children under 5 years. Following World Health Organization primary care guidelines, pneumonia is diagnosed based on cough/difficult breathing and fast breathing. We aimed to describe the practices of healthcare workers in primary care health facilities in Uganda in the management of young children with respiratory symptoms especially regarding asthma as opposed to pneumonia. METHODS: Health workers were observed during clinical consultations with children 1-59 months of age presenting with cough and/or difficult breathing at recruitment. Afterward, an exit interview with the caregiver was conducted. Health center availability of clinical guidelines, equipment and supplies for management of children with respiratory symptoms was assessed systematically. RESULTS: A total of 218 consultations with 50 health workers at six health centers were included. Median consultation time was 4 min. Health workers asked history relevant to distinguishing asthma from pneumonia in 16% of consultations. The respiratory rate was counted in 10%. Antibiotics were prescribed to 32% of all the children and to 39% of children diagnosed with pneumonia. Caregivers reported being informed of findings and possible diagnosis in 5% of cases. Medicine and equipment needed for diagnosing and treating asthma were generally unavailable. CONCLUSION: Clinical practices among Ugandan health workers in primary care are insufficient to distinguish between main causes of respiratory symptoms, especially asthma as opposed to pneumonia, in children under five. Irrational use of antibiotics is widespread. Clear communication with caregivers is lacking. This could be due to lack of relevant competencies, medicines, time and supplies. LAY SUMMARY: Globally, the most frequent cause of death for children under five is infections in the lower airways. The World Health Organization recommends that in local health clinics this is defined as cough/difficult breathing and fast breathing. This article focuses on the practices of local health workers in Uganda and how they in practice diagnose and treat children under five with these symptoms. In addition, we try to estimate how much the caregivers of the children understand from the consultation. This is done by observing the healthcare workers (HCWs) and by interviewing the caregivers. In general, we found that the consultations were too short, that too few of the health workers looked for important signs for lower airways disease such as fast breathing and that antibiotics were prescribed in too many of the consultations. Also, the length and quality of the consultations and the supplies at the local health clinics were not sufficient to diagnose and treat asthma, which can often be mistaken for an infection. We believe that it is an important problem that too few children with asthma are being diagnosed correctly and that antibiotics are being prescribed too frequently, the latter being an important cause of antibiotic resistance. Relevant action must be taken to improve this.

Fetal heart rate monitoring practices at a public hospital in Northern Uganda - what health workers document, do and say.

Background: In Uganda, perinatal mortality is 38 per 1000 pregnancies. One-third of these deaths are due to birth asphyxia. Adequate fetal heart rate (FHR) monitoring during labor may detect birth asphyxia but little is known about monitoring practices in low resource settings.Objective: To explore FHR monitoring practices among health workers at a public hospital in Northern Uganda.Methods: A sequential explanatory mixed methods study was conducted by reviewing 251 maternal records and conducting 11 interviews and two focus group discussions with health workers complemented by observations of 42 women in labor until delivery. Quantitative data were summarized using frequencies and percentages. Content analysis was used for qualitative data.Results: FHR was assessed in 235/251 (93.6%) of records at admission. Health workers documented the FHR at least once in 175/228 (76.8%) of cases during the first stage of labor compared to observed 17/25 (68.0%) cases. Median intervals between FHR monitoring were 30 (IQR 30-120) minutes in patients' records versus 139 (IQR 87-662) minutes according to observations. Observations suggested no monitoring of FHR during the second stage of labor but records indicated monitoring in 3.2% of cases. Reported barriers to adequate FHR monitoring were inadequate number of staff and monitoring devices, institutional challenges such as few beds, documentation problems and perceived non-compliant women not reporting for repeated checks during the first stage of labor. Health workers demonstrated knowledge of national FHR monitoring guidelines and acknowledged that practice was different.Conclusions: When compared to national and international guidelines, FHR monitoring is sub-optimal in the studied setting. Approximately one in four women was not monitored during the first stage of labor. Barriers to appropriate FHR monitoring included shortage of staff and devices, institutional challenges and mother's negative attitudes. These barriers need to be addressed in order to reduce neonatal mortality.

Determinants of Health Facility Utilization at Birth in South Sudan.

South Sudan has a high maternal mortality ratio estimated at 800 deaths per 100,000 live births. Birth in health facilities with skilled attendants can lower this mortality. In this cross-sectional study, we determined the level and determinants of health facility utilization and skilled birth attendance in Jubek State, South Sudan. Mothers of children aged less than two years were interviewed in their homes. Multivariable regression analysis was performed to determine factors associated with health facility births. Only a quarter of the mothers had given birth at health facilities, 209/810 (25.8%; 95% CI 18.2-35.3) and 207/810 had a skilled birth attendant (defined as either nurse, midwife, clinical officer, or doctor). Factors positively associated with health facility births were four or more antenatal visits (adjusted odds ratio (AOR) 19; 95% CI 6.2, 61), secondary or higher education (AOR 7.9; 95% CI 3, 21), high socio-economic status (AOR 4.5; 95% CI 2.2, 9.4), and being primipara (AOR 2.9; 95% CI 1.5, 5.4). These findings highlight the need for efforts to increase health facility births in South Sudan.

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda.

BACKGROUND: Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. METHODS: Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. RESULTS: Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. CONCLUSIONS: MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

Exclusive breastfeeding promotion and neuropsychological outcomes in 5-8 year old children from Uganda and Burkina Faso: Results from the PROMISE EBF cluster randomized trial.

BACKGROUND: The beneficial effects from exclusive breastfeeding (EBF) have been widely acknowledged. We assessed the effect of exclusive breastfeeding promotion by peer counsellors in Uganda and Burkina Faso, on cognitive abilities, social emotional development, school performance and linear growth among 5-8 years old children. METHODS: Children in the PROMISE EBF trial (2006-2008) were re-enrolled in the follow-up PROMISE Saving Brains (SB) study (2013-2015). Caretaker interviews captured sociodemographic characteristics and social emotional development using the parent version of the Strengths and Difficulties Questionnaire (SDQ). Overall cognition and working memory were assessed using the Kaufman Assessment Battery for Children, second edition (KABC2), cognitive flexibility was measured with the Child Category Test (CCT), and attention with the Test of Variables of Attention (T.O.V.A), while school performance was measured by a standardized test on arithmetic and reading. Country-pooled, age adjusted z-scores from each of the above outcomes were entered into a linear regression model controlling for confounders. RESULTS: The number of children re-enrolled in the intervention and control arms were: 274/396 (69.2%) and 256/369 (69.4%) in Uganda and 265/392 (67.6%) and 288/402 (71.6%) in Burkina Faso. Assessment of cognitive ability showed small and no significant differences, of which general cognition (z-scores, 95% CI) showed the largest mean difference: -0.17 (-0.40; 0.05). Social emotional symptoms were similar across arms. There were no differences in school performance or linear growth for age detected. CONCLUSION: Peer promotion for exclusive breastfeeding in Burkina Faso and Uganda was not associated with differences at 5-8 years of age in a range of measures of child development: cognitive abilities, emotion-behaviour-social symptoms or linear growth. This study from sub Saharan Africa did not reconfirm findings elsewhere that have shown an association between exclusive breastfeeding and cognitive performance. This might be due to a number of methodological limitations inherent in the current study. For example since the majority of the children were breastfed, the benefits of the intervention could have been diluted. Other factors such as the mental and HIV status of the mothers (which were not assessed in the current study) could have affected our results. Hence regarding the effect of exclusive breastfeeding on measures of child neurocognitive development in sub Saharan Africa, the jury is still out. TRIAL REGISTRATION: ClinicalTrials.gov NCT01882335.

Factors associated with delayed initiation of breastfeeding: a survey in Northern Uganda.

BACKGROUND: Initiation of breastfeeding later than 1 hour after birth is associated with increased neonatal morbidity and mortality. OBJECTIVE: To determine the prevalence and factors associated with delayed initiation of breastfeeding. METHODS: We conducted a survey in 2016 of 930 children under the age of 2 years in Lira district, northern Uganda. Mothers of the children were interviewed and data was collected on mobile phones using Open Data Kit software ( https://opendatakit.org ). Multivariable logistic regression was used to determine factors associated with delayed initiation of breastfeeding. RESULTS: Almost half [48.2%, 95% confidence interval (CI) (44.3-52.1)] of the mothers delayed initiation of breastfeeding. Factors significantly associated with delayed initiation of breastfeeding in multivariable analysis included caesarean delivery [Adjusted Odds Ratio (AOR) 11.10 95% CI (3.73-33.04)], discarding initial breast milk [AOR 2.02 95% CI (1.41-2.88)], home delivery [AOR 1.43 95% CI (1.04-1.97)] and mother being responsible for initiating breastfeeding as compared to a health worker or relative [AOR 1.73 95% CI (1.33-2.26)]. Mothers having a secondary education were less likely [AOR 0.54 95% CI (0.30-0.96)] to delay initiation of breastfeeding as compared to those with no education. CONCLUSION: About half the mothers delayed initiation of breastfeeding until after 1 hour after birth. Programs to promote, protect and support breastfeeding in this post conflict region are urgently needed.

Impact of a peer-counseling intervention on breastfeeding practices in different socioeconomic strata: results from the equity analysis of the PROMISE-EBF trial in Uganda.

BACKGROUND: Undernutrition is highly prevalent among infants in Uganda. Optimal infant feeding practices may improve nutritional status, health, and survival among children. OBJECTIVE: Our study evaluates the socioeconomic distribution of exclusive breastfeeding (EBF) and growth outcomes among infants included in a trial, which promoted EBF by peer counselors in Uganda. DESIGN: Twenty-four clusters comprising one to two communities in Uganda were randomized into intervention and control arms, including 765 mother-infant pairs (PROMISE-EBF trial, 200608, ClinicalTrials.gov no. NCT00397150). Intervention clusters received the promotion of EBF by peer counselors in addition to standard care. Breastfeeding and growth outcomes were compared according to wealth quintiles and intervention/control arms. Socioeconomic inequality in breastfeeding and growth outcomes were measured using the concentration index 12 and 24 weeks postpartum. We used the decomposition of the concentration index to identify factors contributing to growth inequality at 24 weeks. RESULTS: EBF was significantly concentrated among the poorest in the intervention group at 24 weeks postpartum, concentration index -0.060. The control group showed a concentration of breastfeeding among the richest part of the population, although not statistically significant. Stunting, wasting, and underweight were similarly significantly concentrated among the poorest in the intervention group and the total population at 24 weeks, but showing non-significant concentrations for the control group. CONCLUSION: This study shows that EBF can be successfully promoted among the poor. In addition, socioeconomic inequality in growth outcomes starts early in infancy, but the breastfeeding intervention was not strong enough to counteract this influence.

Cost-Effectiveness of Peer Counselling for the Promotion of Exclusive Breastfeeding in Uganda.

BACKGROUND: Community based breastfeeding promotion programmes have been shown to be effective in increasing breastfeeding prevalence. However, there is limited data on the cost-effectiveness of these programmes in sub-Saharan Africa. This paper evaluates the cost-effectiveness of a breastfeeding promotion intervention targeting mothers and their 0 to 6 month old children. METHODS: Data were obtained from a community randomized trial conducted in Uganda between 2006-2008, and supplemented with evidence from several studies in sub-Saharan Africa. In the trial, peer counselling was offered to women in intervention clusters. In the control and intervention clusters, women could access standard health facility breastfeeding promotion services (HFP). Thus, two methods of breastfeeding promotion were compared: community based peer counselling (in addition to HFP) and standard HFP alone. A Markov model was used to calculate incremental cost-effectiveness ratios between the two strategies. The model estimated changes in breastfeeding prevalence and disability adjusted life years. Costs were estimated from a provider perspective. Uncertainty around the results was characterized using one-way sensitivity analyses and a probabilistic sensitivity analysis. FINDINGS: Peer counselling more than doubled the breastfeeding prevalence as reported by mothers, but there was no observable impact on diarrhoea prevalence. Estimated incremental cost-effectiveness ratios were US$68 per month of exclusive or predominant breastfeeding and U$11,353 per disability adjusted life year (DALY) averted. The findings were robust to parameter variations in the sensitivity analyses. CONCLUSIONS: Our strategy to promote community based peer counselling is unlikely to be cost-effective in reducing diarrhoea prevalence and mortality in Uganda, because its cost per DALY averted far exceeds the commonly assumed willingness-to-pay threshold of three times Uganda's GDP per capita (US$1653). However, since the intervention significantly increases prevalence of exclusive or predominant breastfeeding, it could be adopted in Uganda if benefits other than reducing the occurrence of diarrhoea are believed to be important.

Infant feeding survival and Markov transition probabilities among children under age 6 months in Uganda.

Infant feeding studies are typically presented as single-event models, without considering the dynamic nature of feeding. We analyzed the determinants of infant feeding duration using both single- and multiple-event Cox regression models. The Cox model was compared with parametric survival models, which were used to estimate feeding-state transition probabilities. Data were taken from a community randomized trial promoting exclusive breastfeeding (EBF) in Uganda from 2005 to 2008. Peer counselors visited intervention mothers once antenatally and 4 times after birth. Results showed that children in the control group were more likely to be switched from exclusive breastfeeding (EBF)/predominant breastfeeding (PBF) to mixed feeding (MF)/replacement feeding (RF). Children in intervention clusters (hazard ratio = 0.33, 95% confidence interval: 0.26, 0.42) and rural areas (hazard ratio = 0.79, 95% confidence interval: 0.63, 0.99) had a lower risk of EBF/PBF cessation. Based on the Akaike Information Criterion, parametric models were better fitted than the Cox model. The analytical approach to assessing infant feeding duration used in this study takes into account transitions between feeding categories, allowing for multiple events. This will enhance understanding of infant feeding practices and give policy-makers a better picture of the versatility of infant feeding.

Cost of individual peer counselling for the promotion of exclusive breastfeeding in Uganda.

BACKGROUND: Exclusive breastfeeding (EBF) for 6 months is the recommended form of infant feeding. Support of mothers through individual peer counselling has been proved to be effective in increasing exclusive breastfeeding prevalence. We present a costing study of an individual peer support intervention in Uganda, whose objective was to raise exclusive breastfeeding rates at 3 months of age. METHODS: We costed the peer support intervention, which was offered to 406 breastfeeding mothers in Uganda. The average number of counselling visits was about 6 per woman. Annual financial and economic costs were collected in 2005-2008. Estimates were made of total project costs, average costs per mother counselled and average costs per peer counselling visit. Alternative intervention packages were explored in the sensitivity analysis. We also estimated the resources required to fund the scale up to district level, of a breastfeeding intervention programme within a public health sector model. RESULTS: Annual project costs were estimated to be US$56,308. The largest cost component was peer supporter supervision, which accounted for over 50% of total project costs. The cost per mother counselled was US$139 and the cost per visit was US$26. The cost per week of EBF was estimated to be US$15 at 12 weeks post partum. We estimated that implementing an alternative package modelled on routine public health sector programmes can potentially reduce costs by over 60%. Based on the calculated average costs and annual births, scaling up modelled costs to district level would cost the public sector an additional US$1,813,000. CONCLUSION: Exclusive breastfeeding promotion in sub-Saharan Africa is feasible and can be implemented at a sustainable cost. The results of this study can be incorporated in cost effectiveness analyses of exclusive breastfeeding promotion programmes in sub-Saharan Africa.

Faecal calprotectin concentrations in apparently healthy children aged 0-12 years in urban Kampala, Uganda: a community-based survey.

BACKGROUND: Calprotectin is a calcium and zinc binding protein, abundant in neutrophils and is extremely stable in faeces. Faecal calprotectin is used as a non-specific marker for gastrointestinal inflammation. It has a good diagnostic precision to distinguish between irritable bowel syndrome and inflammatory bowel disease. Studies have established normal concentrations in healthy children; all these studies have been performed in high-income countries. The objective of this study was to determine the concentration of faecal calprotectin in apparently healthy children aged 0-12 years in urban Kampala, Uganda. METHOD: We tested 302 apparently healthy children aged, age 0-12 years (162 female, 140 male) in urban Kampala, Uganda. The children were recruited consecutively by door-to-door visits. Faecal calprotectin was analyzed using a quantitative enzyme-linked immunosorbent assay. Faeces were also tested for Helicobacter pylori (H. pylori) antigen, for growth of enteropathogens and microscopy was performed to assess protozoa and helminths. A short standardized interview with socio-demographic information and medical history was obtained to assess health status of the children. RESULTS: In the different age groups the median faecal calprotectin concentrations were 249 mg/kg in 0 < 1 year (n = 54), 75 mg/kg in 1 < 4 years (n = 89) and 28 mg/kg in 4 < 12 years (n = 159). There was no significant difference in faecal calprotectin concentrations and education of female caretaker, wealth index, gender, habits of using mosquito nets, being colonized with H. pylori or having other pathogens in the stool. CONCLUSION: Concentrations of faecal calprotectin among healthy children, living in urban Ugandan, a low-income country, are comparable to those in healthy children living in high-income countries. In children older than 4 years, the faecal calprotectin concentration is low. In healthy infants faecal calprotectin is high. The suggested cut-off concentrations in the literature can be used in apparently healthy Ugandan children. This finding also shows that healthy children living under poor circumstances do not have a constant inflammation in the gut. We see an opportunity to use this relatively inexpensive test for further understanding and investigations of gut inflammation in children living in low-income countries.

An up-date on the prevalence of sickle cell trait in Eastern and Western Uganda.

BACKGROUND: The first survey on sickle cell disease (SCD) done in Uganda in 1949, reported the district of Bundibugyo in Western Uganda to have the highest sickle cell trait (SCT) prevalence (45%). This is believed to be the highest in the whole world. According to the same survey, the prevalence of SCT in the districts of Mbale and Sironko in the East was 20-28%, whilst the districts of Mbarara and Ntungamo in the West had 1-5%. No follow-up surveys have been conducted over the past 60 years. SCA accounts for approximately 16.2% of all pediatric deaths in Uganda. The pattern of SCT inheritance, however, predicts likely changes in the prevalence and distribution of the SCT. The objective of the study therefore was to establish the current prevalence of the SCT in Uganda. METHODS: This study was a cross sectional survey which was carried out in the districts of Mbale and Sironko in the Eastern, Mbarara/Ntungamo and Bundibugyo in Western Uganda. The participants were children (6 months-5 yrs). Blood was collected from each subject and analyzed for hemoglobin S using cellulose acetate Hb electrophoresis. RESULTS: The established prevalence of the SCT (As) in Eastern Uganda was 17.5% compared to 13.4% and 3% in Bundibugyo and Mbarara/Ntungamo respectively. 1.7% of the children in Eastern Uganda tested positive for haemoglobin ss relative to 3% in Bundibugyo, giving gene frequencies of 0.105 and 0.097 for the recessive gene respectively. No ss was detected in Mbarara/Ntungamo. CONCLUSIONS: A shift in the prevalence of the SCT and ss in Uganda is notable and may be explained by several biological and social factors. This study offers some evidence for the possible outcome of intermarriages in reducing the incidence of the SCT.

Determinants of infant growth in Eastern Uganda: a community-based cross-sectional study.

BACKGROUND: Child under-nutrition is a leading factor underlying child mortality and morbidity in Sub-Saharan Africa. Several studies from Uganda have reported impaired growth, but there have been few if any community-based infant anthropometric studies from Eastern Uganda. The aim of this study was to describe current infant growth patterns using WHO Child Growth Standards and to determine the extent to which these patterns are associated with infant feeding practices, equity dimensions, morbidity and use of primary health care for the infants. METHODS: A cross-sectional survey of infant feeding practices, socio-economic characteristics and anthropometric measurements was conducted in Mbale District, Eastern Uganda in 2003; 723 mother-infant (0-11 months) pairs were analysed. Infant anthropometric status was assessed using z-scores for weight-for-length (WLZ), length-for-age (LAZ) and weight-for-age (WAZ). Dependent dichotomous variables were constructed using WLZ < -2 (wasting) and LAZ < -2 (stunting) as cut-off values. A conceptual hierarchical framework was used as the basis for controlling for the explanatory factors in multivariate analysis. Household wealth was assessed using principal components analysis. RESULTS: The prevalences of wasting and stunting were 4.2% and 16.7%, respectively. Diarrhoea during the previous 14 days was associated with wasting in the crude analysis, but no factors were significantly associated with wasting in the adjusted analysis. The adjusted analysis for stunting showed associations with age and gender. Stunting was more prevalent among boys than girls, 58.7% versus 41.3%. Having brothers and/or sisters was a protective factor against stunting (OR 0.4, 95% CI 0.2-0.8), but replacement or mixed feeding was not (OR 2.7, 95% CI 1.0-7.1). Lowest household wealth was the most prominent factor associated with stunting with a more than three-fold increase in odds ratio (OR 3.5, 95% CI 1.6-7.8). This pattern was also seen when the mean LAZ was investigated across household wealth categories: the adjusted mean difference between the top and the bottom wealth categories was 0.58 z-scores, p < 0.001. Those who had received pre-lacteal feeds had lower adjusted mean WLZ than those who had not: difference 0.20 z-scores, p = 0.023. CONCLUSION: Sub-optimal infant feeding practices after birth, poor household wealth, age, gender and family size were associated with growth among Ugandan infants.

Infant and young child feeding in western Uganda: knowledge, practices and socio-economic correlates.

In a cross-sectional household survey conducted in the rural district of Hoima, western Uganda, 720 child/mother pairs were recruited using a two-stage cluster design. Infant and young child feeding knowledge and practices were assessed in relation to recommendations and household socio-economic factors. Age specific feeding patterns were described using frequencies, proportions and life-tables. Logistic regressions were done with feeding practice as dependent and socio-economic factors as independent variables. Breastfeeding was universal (99%) with a median duration of 21 months. Pre-lacteal use was high (43%), with educated mothers more prone to the practice. Using a 24-hour recall: the median duration of exclusive breastfeeding was 3.5 months; 10% of infants were bottle-fed; 92% of the 0-5 month-old infants breastfed 6 or more times; 21% of 2-3 month-olds received complementary food instead of breast milk only and 19% of 6-8 month-olds were only breastfed instead of receiving complementary food. Of children 12 months and above, 42% were complemented twice or less and 49% complemented 3 or 4 times. Only 36% of breastfeeding children between 6-23 months received dairy milk. Over 50% of mothers did not know that adding oil to complementary food could improve it. The least poor were more likely, than the poorest, to use dairy milk (OR 3.9, CI 1.6-9.6); and educated mothers were more likely to prepare special complementary foods than the un-educated (OR 2.7, CI 1.1-6.2). Emphasis should be on promotion of exclusive breastfeeding, timeliness of complementary feeding and socio-economic empowerment.

Mothers' education but not fathers' education, household assets or land ownership is the best predictor of child health inequalities in rural Uganda.

BACKGROUND: Health and nutrition inequality is a result of a complex web of factors that include socio-economic inequalities. Various socio-economic indicators exist however some do not accurately predict inequalities in children. Others are not intervention feasible. OBJECTIVE: To examine the association of four socio-economic indicators namely: mothers' education, fathers' education, household asset index, and land ownership with growth stunting, which is used as a proxy for health and nutrition inequalities among infants and young children. METHODS: This was a cross-sectional survey conducted in the rural district of Hoima, Uganda. Two-stage cluster sampling design was used to obtain 720 child/mother pairs. Information on indicators of household socio-economic status and child anthropometry was gathered by administering a structured questionnaire to mothers in their home settings. Regression modelling was used to determine the association of socio-economic indicators with stunting. RESULTS: One hundred seventy two (25%) of the studied children were stunted, of which 105 (61%) were boys (p < 0.001). Bivariate analysis indicated a higher prevalence of stunting among children of: non-educated mothers compared to mothers educated above primary school (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.4-4.4); non-educated fathers compared to fathers educated above secondary school (OR 1.7, 95% CI 0.8-3.5); households belonging in the "poorest" quintile for the asset index compared to the "least poor" quintile (OR 2.1, 95% CI 1.2-3.7); Land ownership exhibited no differentials with stunting. Simultaneously adjusting all socio-economic indicators in conditional regression analysis left mothers' education as the only independent predictor of stunting with children of non-educated mothers significantly more likely to be stunted compared to those of mothers educated above primary school (OR 2.1, 95% CI 1.1-3.9). More boys than girls were significantly stunted in poorer than wealthier socio-economic strata. CONCLUSIONS: Of four socio-economic indicators, mothers' education is the best predictor for health and nutrition inequalities among infants and young children in rural Uganda. This suggests a need for appropriate formal education of the girl child aimed at promoting child health and nutrition. The finding that boys are adversely affected by poverty more than their female counterparts corroborates evidence from previous studies.