Barriers and facilitators of retention in care after cervical cancer screening: patients' and healthcare providers' perspectives.

BACKGROUND: Cervical cancer continues to threaten women's health, especially in low-resource settings. Regular follow-up after screening and treatment is an effective strategy for monitoring treatment outcomes. Consequently, understanding the factors contributing to patient non-attendance of scheduled follow-up visits is vital to providing high-quality care, reducing morbidity and mortality, and unnecessary healthcare costs in low-resource settings. METHODS: A descriptive qualitative study was done among healthcare providers and patients who attended the cervical cancer screening clinic at Mbarara Regional Referral Hospital in southwestern Uganda. In-depth interviews were conducted using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim, and thematically analysed in line with the social-ecological model to identify barriers and facilitators. RESULTS: We conducted 23 in-depth interviews with 5 healthcare providers and 18 patients. Health system barriers included long waiting time at the facility, long turnaround time for laboratory results, congestion and lack of privacy affecting counselling, and healthcare provider training gaps. The most important interpersonal barrier among married women was lacking support from male partners. Individual-level barriers were lack of money for transport, fear of painful procedures, emotional distress, and illiteracy. Inadequate and inaccurate information was a cross-cutting barrier across the individual, interpersonal, and community levels of the socio-ecological model. The facilitators were social support, positive self-perception, and patient counselling. CONCLUSIONS: Our study revealed barriers to retention in care after cervical cancer screening, including lack of partner support, financial and educational constraints, and inadequate information. It also found facilitators that included social support, positive self-perception, and effective counselling.

Burden of care and coping strategies among informal caregivers of people with behavioral and psychological symptoms of dementia in rural south-western Uganda.

BACKGROUND: Caregiving is a draining role that inflicts a significant level of burden upon caregivers for older people with Behavioral and Psychological Symptoms of Dementia (BPSD). Caregiver burden is associated with poor health outcomes for both the people with BPSD and their caregivers. This study explored the burden of care and coping strategies used by informal caregivers of older people with BPSD in rural Southwestern Uganda. METHODS: This was a qualitative study among informal caregivers of older people with BPSD in Rubanda and Rukiga districts. We conducted in-depth interviews with a purposive sample of 27 caregivers using an interview guide. The interviews were conducted in the local language, audio recorded, transcribed, translated into English, and thematically analyzed. RESULTS: There were two major themes: caregiver burden and coping strategies. Caregiver burden was described as financial, physical, psychological and social. Caregivers mainly used emotion-focused coping strategies (religious coping, acceptance and emotional support seeking). Problem-focused coping strategies (planning) and dysfunctional coping strategies (self-distraction) were used to a lesser extent. CONCLUSION: Informal caregivers of people with BPSD adopted both emotional and problem-focused coping strategies to cope with the burden of care for people with BPSD. Such coping strategies seemed to lighten the burden of caring, in the long motivating the caregivers to continue with the caring role.

Contextual and psychological factors influencing open defecation free status: an exploratory qualitative study in rural South Western Uganda.

INTRODUCTION: Achieving the Open defecation free (ODF) status remains a major challenge in Uganda, yet it contributes significantly to child health improvement. Literature on social, cultural and behavioral aspects that influence the ODF status in rural Uganda is limited. The study therefore, explored perceived factors influencing the ODF status in rural South Western Uganda. METHODS: An exploratory study employing qualitative techniques and based on deductive analysis between month December 2020 and January 2021 was conducted. Seven Focus Group Discussions (FGDs and three Key Informant Interviews (KIs) were conducted in Kabale District, southwestern Uganda. Focus Group Discussion participants were mothers and fathers having children of 2 years and below while KIIs included local community leaders and health extension workers. Data was analyzed using a categorization matrix derived from the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model which is comprised of contextual and psychological factors. Text was further categorized into high and low statements for attainment of ODF status. RESULTS: The contextual factors influencing the Open Defecation Free status behavior included; farming activities far from home, financial constraints, rainy seasons, collapsible soft soils, and alcohol use. Psychological factors influencing ODF status included; perceived health risk for typhoid disease, low perceived severity for lack of ODF components, negative attitude of less value attached to ODF components, and a feeling of time wastage practicing ODF status behavior. The perception that the community has the ability to attain the ODF status was high. Although, the capability to maintain ODF was low when it comes to replacement of ODF component if stolen or destroyed. CONCLUSION: Open Defecation Free status is influenced by contextual and psychological factors. Therefore, it's crucial for sanitation promotors to always identify such context specific factors in order to design sanitation and hygiene promotion interventions to address the ODF free status related challenges.

Assessing changes in knowledge, attitudes, and intentions to use family planning after watching documentary and drama health education films: a qualitative study.

BACKGROUND: There is a paucity of literature on the effectiveness of drama or documentary films in changing knowledge, beliefs, attitudes, and behavior of people towards family planning. This study aimed to compare and assess the acceptability of health promotion films based on documentary or drama, and their effect on knowledge, attitudes, and intention to use family planning. METHODS: We developed short documentary and drama films about contraceptive implants, using the person-based approach. Their acceptability was assessed in focus group discussions with younger women below 23 years, women over 23 years, men of reproductive age, and health workers in four different areas of Uganda (Bwindi/Kanungu, Walukuba/Jinja, Kampala, and Mbarara). Transcripts of the focus group discussions were analyzed using thematic analysis, to generate themes and examine the key issues. We assessed changes in knowledge, attitudes, and intentions to use family planning after watching the films. RESULTS: Sixteen focus groups with 150 participants were carried out. Participants said that the documentary improved their knowledge and addressed their fears about side effects, myths, and implant insertion. The drama improved their attitudes towards the implant and encouraged them to discuss family planning with their partner. The final versions of the documentary and the drama films were equally liked. CONCLUSIONS: Viewing a short documentary on the contraceptive implant led to positive changes in knowledge, while a short drama improved attitudes and intentions to discuss the implant with their partner. The drama and documentary have complementary features, and most participants wanted to see both.

Thousands of women and children in Uganda die every year due to problems related to pregnancy and childbirth. About 20% of these deaths are avoidable by better use of contraception. Many women are reluctant to begin contraception because of fears and myths about side-effects, and because they need the agreement of their husbands. The aim of this research was to study whether health education films could address these fears, and to compare a short documentary with a short drama film. We produced two health education films (a documentary and a drama) in two local languages with the involvement of local people. Films aimed to (1) dispel some myths on contraception, (2) encourage men to attend at least one antenatal clinic with their wives, and (3) discuss with a health worker whether they would like a method of family planning after the delivery. We showed these films to focus groups of local women, men and health workers in four contrasting areas of Uganda. The people taking part in the focus groups discussed their reactions to the films, whether they had learned anything from them, whether their attitudes towards family planning had changed as a result, and whether they intended to discuss this with their partner. Viewing a short documentary on the contraceptive implant improved knowledge, and short drama films improved attitudes and intentions to discuss the implant with their partner. The documentary and drama had different advantages, and most participants wanted to see both.

Community perceptions about dementia in southwestern Uganda.

BACKGROUND: With the increasing number of people surviving into older age in Africa, dementia is becoming a public health concern. Understanding the social dynamics of dementia in resource-limited settings is critical for developing effective interventions. We explored community perceptions about people with dementia in southwestern Uganda. METHODS: Fifty-nine individuals (aged 19-85 years, 56% female) participated in seven focus group discussions. In addition, 22 individual in-depth interviews were conducted among individuals (aged 22-84 years, 36% female). Both interviews and focus group discussions were audio recorded, transcribed verbatim, and evaluated using a quantitative content analysis approach. RESULTS: Five themes were generated during content analysis: i) Labeling of the illness, ii) Presentation of the person with dementia, iii) Causation, iv) Impact of the disease on people with dementia and their caregivers and v) Views on how to address unmet needs in dementia care. Dementia was commonly referred to as "okuhuga"or "okwebwayebwa" (also, oruhuzyo/ empugye / akahuriko) which translates as "mental disorientation". The participants reported that most people with dementia presented with forgetfulness, defecating and urinating on themselves, wandering away from home, going out naked, and picking up garbage. Some participants perceived memory problems as a normal part of the aging process, while others attributed the cause of dementia to syphilis, cancer, allergy, old age, satanic powers, witchcraft, poor nutrition, or life stress. Participants reported multiple sources of stress for caregivers of people with dementia, including financial, social, and emotional burdens. Finally, participants suggested that community and governmental organizations should be involved in meeting the needs of people with dementia and their caregivers. CONCLUSIONS: Community members in southwestern Uganda largely identified dementia as a problem that comes with older age, and can identify key features of dementia presentation. Participants identified significant stressors affecting people with dementia and their caregivers, and reported that families and caregivers would benefit from education on the management of symptoms of dementia, and assistance in overcoming associated financial, social, and emotional burdens related to caretaking.

Barriers and Facilitators to Screening for Kidney Disease Among Older Adults with Hypertension and Diabetes in Mbarara Southwestern Uganda: Healthcare Providers' Perspective.

Background: Screening for kidney disease (KD) among high-risk patients (patients with hypertension or diabetes) allows early diagnosis, intervention and delayed progression of the disease. In low- and middle-income countries (LMIC), KD screening is still sub-optimal. This study explored the healthcare providers' perceived barriers and facilitators to KD screening among older adults with hypertension and diabetes in Mbarara southwestern Uganda. Methods: This was a descriptive qualitative study among healthcare providers caring for older adults with diabetes mellitus and hypertension at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda. In-depth interviews were conducted using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed to develop themes of barriers and facilitators. Results: We conducted 30 in-depth interviews among healthcare providers. Barriers to screening for kidney disease included patient related factors according to healthcare providers (financial hardships, poor health seeking behavior, limited knowledge and awareness), healthcare factors (work overload, ineffective patient healthcare provider communication) and system/policy related factors (lack of laboratory supplies, lack of guidelines and poor medical record keeping and documentation). With respect to facilitators, we found formation of peer support groups, effective team, and continuous medical education (CME). Conclusion: Healthcare providers encounter substantial but modifiable barriers in screening older adults for KD. The identification of barriers and facilitators in timely KD detection gives us an outlook of the problem in Uganda and leads for proposals of action. Interventions that address these barriers and promote facilitators may improve the healthcare provider's effectiveness and capacity to care including screening for patients at risk of KD.

Behavioral and Psychological Symptoms of Dementia: Prevalence, Symptom Severity, and Caregiver Distress in South-Western Uganda-A Quantitative Cross-Sectional Study.

The purpose of the study was to investigate behavioral and psychological symptoms (BPSD) prevalence, severity, and distress experienced by caregivers of people living with dementia (PLWD). A cross-sectional, population-based study was conducted in a rural area in southwestern Uganda. A Neuropsychiatric Inventory Questionnaire (NPI-Q) was used to determine the presence of BPSD as perceived by caregivers of PLWD. We carried out both descriptive and inferential data analysis. A total of 175 caregivers of PLWD were enrolled in this study. Among PLWD, 99% had presented BPSD in the past month. Hallucinations (75%) and dysphoria/depression (81%) were the two BPSD that occurred most frequently. Most participants (70%) stated that PLWD experienced hallucinations of significant severity. Aberrant motor activity was reported by 60% of the participants as the type of BPSD that caused severe distress. There was a high positive correlation (0.82) between the total severity score and total distress scores. Interventions aimed at addressing dysphoria and hallucinations may be essential for the reduction of caregiver distress. These findings point to the need for promoting early screening for BPSDs and the provision of support to caregivers.

Planning for Hospital Discharge for Older Adults in Uganda: A Qualitative Study Among Healthcare Providers Using the COM-B Framework.

Background: Proper discharge planning enhances continuity of patient care, reduces readmissions, and ensures safe and timely transition from health facility to home-based care. The current study aimed at exploring the healthcare providers' perspectives of discharge planning among older adults, with respect to barriers and facilitators within the Ugandan health system. Methods: We conducted a qualitative exploratory study that used one-on-one interviews (Additional file 1) to describe individual perspectives of healthcare providers in their routine clinical care setting. The study included medical doctors (including consultants and physicians), nurses and physiotherapists directly involved in providing care to older adults. We conducted 25 in-depth interviews among healthcare providers for older adults with non-communicable diseases. The audio-recorded interviews were transcribed verbatim. Data were manually organized using a framework matrix guided by the COM-B domains (capability, opportunity and motivation) as the broad themes and sub-themes (physical and psychological capability, social and physical opportunity, reflective and automatic motivation) that influence behavior change (discharge planning). Results: Discharge planning was facilitated by availability of discharge forms, continuous medical education and working experience. The barriers to discharge planning were understaffing, workload/insufficient time, lack of discharge planning guidelines, lack of multidisciplinary approach and congested inpatient wards. Both barriers and facilitators were at various levels of healthcare service delivery such as patient, caregiver, healthcare provider, health facility and policy levels. Conclusion: Barriers to discharge planning spread across all levels of healthcare service delivery, but they can be addressed by enhancing the facilitators. This calls for a multi-level action to ensure adequate and quality patient care during and after hospitalization.

Barriers and facilitators to cognitive impairment screening among older adults with diabetes mellitus and hypertension by primary healthcare providers in rural Uganda.

Background: The burden of non-communicable diseases and cognitive impairment exhibit a linear rise in sub-Saharan Africa due to the increase in life expectancy. Non-communicable diseases like diabetes mellitus and hypertension increase the risk for cognitive impairment. To improve our understanding of the underpinnings of the cognitive impairment screening, this study explored the barriers and facilitators of routine cognitive impairment screening in a primary healthcare setting guided by the Capacity, Opportunity, Motivation Behavioral change (COM-B) model. Methods: This was a descriptive qualitative study with primary healthcare providers who provide care to older adults with diabetes mellitus and hypertension at three primary healthcare centers in Mbarara district southwestern Uganda. In-depth interviews were conducted using a semi structured interview guide. Interviews were audio-recorded, transcribed verbatim, and analyzed using the framework approach along the COM-B components. Each COM-B component factors were categorized as barriers and facilitators. Results: We conducted 20 in-depth interviews with clinical officers, enrolled nurses, and a psychiatric nurse. The questions were guided by the Capacity, Opportunity and Motivation Behavioral change (COM-B) framework to identify barriers and facilitators to cognitive impairment screening. The factors that negatively affected the screening were considered as barriers, while the positive as facilitators. Capacity related barriers to cognitive impairment screening included chronic understaffing, primary healthcare provider non-involvement, lack of training/skills, lack of knowledge and awareness in screening, absence of caretakers, lack of patient awareness of cognitive problems; while facilitators were staff recruitment, primary healthcare provider involvement, and specialized training. Opportunity related barriers to screening included patient overload, infrastructure shortage, and time constraints. Motivation related barriers included lack of screening guidance and policy, while the facilitators were availability of mentorship programs for primary healthcare providers. Conclusions: Integrating cognitive impairment screening in primary health care requires engagement of relevant stakeholders with the focus on addressing implementation challenges through capacity development. Timely cognitive impairment screening at the first point of care initiates a cascade of interventions for timely enrollment into care, thus arresting the progress of cognitive impairment that leads to dementia.

A Qualitative Exploration of the Referral Process of Children with Common Infections from Private Low-Level Health Facilities in Western Uganda.

Over 50% of sick children are treated by private primary-level facilities, but data on patient referral processes from such facilities are limited. We explored the perspectives of healthcare providers and child caretakers on the referral process of children with common childhood infections from private low-level health facilities in Mbarara District. We carried out 43 in-depth interviews with health workers and caretakers of sick children, purposively selected from 30 facilities, until data saturation was achieved. The issues discussed included the process of referral, challenges in referral completion and ways to improve the process. We used thematic analysis, using a combined deductive/inductive approach. The reasons for where and how to refer were shaped by the patients' clinical characteristics, the caretakers' ability to pay and health workers' perceptions. Caretaker non-adherence to referral and inadequate communication between health facilities were the major challenges to the referral process. Suggestions for improving referrals were hinged on procedures to promote caretaker adherence to referral, including reducing waiting time and minimising the expenses incurred by caretakers. We recommend that triage at referral facilities should be improved and that health workers in low-level private health facilities (LLPHFs) should routinely be included in the capacity-building trainings organised by the Ministry of Health (MoH) and in workshops to disseminate health policies and national healthcare guidelines. Further research should be done on the effect of improving communication between LLPHFs and referral health facilities by affordable means, such as telephone, and the impact of community initiatives, such as transport vouchers, on promoting adherence to referral for sick children.

A qualitative study of the perspectives of health workers and policy makers on external support provided to low-level private health facilities in a Ugandan rural district, in management of childhood infections.

BACKGROUND: With the under-five child mortality rate of 46.4 deaths per 1000 live births, Uganda should accelerate measures to reduce child deaths to achieve the Sustainable Development Goal 3. While 60-70% of frontline health services are provided by the private sector, many low-level private health facilities (LLPHF) are unregistered, unregulated, and often miss innovative and quality improvement strategies rolled out by the Ministry of Health. LLPHF need support in order to provide quality health care. OBJECTIVE: To explore the perspectives of health workers and policy makers on external support given to LLPHF providing health care for children in Mbarara District, Uganda. METHODS: We carried out a qualitative study, in which 43 purposively selected health workers and policy makers were interviewed. The issues discussed included their views on the quantity, quality, factors determining support received and preferred modalities of support to LLPHF. We used thematic analysis, employing an inductive approach to code interview transcripts and to identify subthemes and themes. RESULTS: The support currently provided to LLPHF to manage childhood illnesses is inadequate. Health providers emphasised a need for technical capacity building, provision of policies, guidelines and critical supplies as well as adopting a more supportive supervisory approach instead of the current supervision model characterised by policing, fault finding and apportioning blame. Registration of the health facilities and regular submission of reports as well as multi-stakeholder involvement are potential strategies to improve external support. CONCLUSION: The current support received by LLPHF is inadequate in quantity and quality. Capacity building with emphasis on training, provision of critical guidelines and supplies as well as and supportive supervision are key strategies for delivering appropriate external support to LLPHF.

Couples' decision-making on post-partum family planning and antenatal counselling in Uganda: A qualitative study.

BACKGROUND: Although health workers have been trained to provide post-partum family planning (PPFP), uptake remains low in Uganda. An important reason is that women want the agreement of their partner, who is often absent at the time of delivery. In order to address this, we aimed to understand the views of couples and explore barriers and facilitators to implementation of antenatal couples' counselling on PPFP in Uganda. METHODS: We conducted individual interviews with a purposive sample of 12 postpartum and 3 antenatal couples; and 34 focus groups with a total of 323 participants (68 adolescent women, 83 women aged 20-49, 79 men, 93 health workers) in four contrasting communities (urban and rural) in South-West and Central Uganda. These were recorded, transcribed, translated, and analysed thematically. RESULTS: Although most participants felt that it is important for partners to discuss family planning, half of the couples were unaware of each other's views on contraception. Most had similar views on motivation to use family planning but not on preferred contraceptive methods. Most liked the idea of antenatal couples' counselling on PPFP. The main barrier was the reluctance of men to attend antenatal clinics (ANC) in health facilities. Respondents felt that Village Health Teams (VHTs) could provide initial counselling on PPFP in couples' homes (with telephone support from health workers, if needed) and encourage men to attend ANC. Suggested facilitators for men to attend ANC included health workers being more welcoming, holding ANC clinics at weekends and "outreach" clinics (in rural villages far from health facilities). CONCLUSION: Antenatal couples' counselling has the potential to facilitate agreement PPFP, but some men are reluctant to attend antenatal clinics. Counselling at home by VHTs as well as simple changes to the organisation of antenatal clinics, could make it possible to deliver antenatal couples' counselling on PPFP.

Prevalence of Pulmonary Tuberculosis among Prison Inmates at Mbarara Central Prison, South Western Uganda.

AIMS: This study was conducted to determine the prevalence of tuberculosis among prison inmates at Mbarara Central prison. DESIGN: A cross sectional study was carried out at Mbarara Central Prison in Mbarara district, Kiswahili cell in Mbarara municipality among female and male prison in mates between June 2012 to August 2012. A questionnaire was administered to each prison inmate who consented in writing and two sputum specimens were collected and examined by Ziehl-Neelsen technique. RESULTS: At the time of the study, the prison had 900 inmates (both males and females). A total of 648 in mates were screened and 248 inmates enrolled in the study. Of the 248 inmates, 5 inmates were new cases of TB while 29 inmates were already on TB treatment. The median age of participants was 28 years (23.5-33 IQR) and 96.4% were males with majority (22.6%) coming from Mbarara as a home district. The participants had stayed in prison for a median duration of 2 years (1-3 IQR) and 23.7% had ever been in prison before. The median number of inmates per cell was 140 (138-149 IQR) and inmates (female and male) had a body mass index of 21.4 (19.9-22.6 IQR) and 20.2 (19.2-26.7 IQR) respectively. Of the inmates evaluated, 68.8% reported cough for 2 or more weeks. Other symptoms reported were weight loss (in 40.7%) and night sweats (in 35.8%). Of the 248 inmates evaluated, 95 inmates were tested for HIV and 4.1% were HIV serology positive. CONCLUSION: The prevalence of TB in Mbarara Central prison South Western Uganda is low but calls for continued surveillance through regular TB screening.