Risk factors associated with the intensity of COVID-19 outbreaks in Canadian community settings: a retrospective analysis of outbreak-level surveillance data.

BACKGROUND: The severity of COVID-19 outbreaks is disproportionate across settings (e.g., long-term care facilities (LTCF), schools) across Canada. Few studies have examined factors associated with outbreak severity to inform prevention and response. Our study objective was to assess how outbreak severity, as measured using outbreak intensity and defined as number of outbreak-associated cases divided by outbreak duration, differed by setting and factors known to influence SARS-CoV-2 transmission. METHODS: We described outbreak intensity trends in 2021 using data from the Canadian COVID-19 Outbreak Surveillance System from seven provinces/territories, representing 93% of the Canadian population. A negative binomial fixed-effects model was used to assess for associations between the outcome, outbreak intensity, and characteristics of outbreaks: setting type, median age of cases, number at risk, and vaccination coverage of at least 1 dose. Also included were variables previously reported to influence SARS-CoV-2 transmission: stringency of non-pharmaceutical interventions (NPI) and the predominant SARS-CoV-2 variant detected by surveillance. RESULTS: The longest outbreaks occurred in LTCF (mean = 25.4 days) and correctional facilities (mean = 20.6 days) which also reported the largest outbreaks (mean = 29.6 cases per outbreak). Model results indicated that outbreak intensity was highest in correctional facilities. Relative to correctional facilities (referent), the second highest adjusted intensity ratio was in childcare centres (intensity ratio = 0.58 [95% CI: 0.51-0.66]), followed by LTCF (0.56 [95% CI: 0.51-0.66]). Schools had the lowest adjusted intensity ratio (0.46 [95% CI: 0.40-0.53]) despite having the highest proportion of outbreaks (37.5%). An increase in outbreak intensity was associated with increases in median age, the number at risk, and stringency of NPI. Greater vaccination coverage with at least 1 dose was associated with reduced outbreak intensity. CONCLUSION: Descriptive and multivariable model results indicated that in Canada during 2021, outbreak intensity was greatest in closed congregate living facilities: correctional facilities and LTCF. Findings from this study support the importance of vaccination in reducing outbreak intensity when vaccines are effective against infection with circulating variants, which is especially important for closed congregate living facilities where NPIs are more challenging to implement.

Antenatal Care Research in East Africa During the Millennium Development Goals Initiative: A Scoping Review.

INTRODUCTION: The global burden of maternal mortality remains high and inequitably distributed between countries. Antenatal care (ANC) was identified as critical component in achieving the Millennium Development Goal of improving maternal health. This scoping review aimed to summarize trends and critically explore research about ANC attendance for East African women conducted during the Millennium Development Goals initiative, with a specific focus on barriers to ANC access. METHODS: Using a scoping review methodology, aggregator databases were searched for relevant articles. Articles were screened by independent reviewers using a priori inclusion criteria. Eligible articles were retained for data charting and analysis. RESULTS: Following screening, 211 articles were analyzed. The number of relevant articles increased over time; utilized primarily quantitative methods; and involved authors with affiliations from various African countries. Many interrelated physical, social, and cultural factors influenced women's seeking, reaching, and receiving of quality ANC. The extent of studies identified suggest that ANC is a priority research area, yet key gaps in the literature exist. Limited qualitative research, and few articles examining ANC experiences of women from vulnerable groups (e.g. adolescents, women with a disability, and Indigenous women) were identified. DISCUSSION: These context-specific findings are important considering the Sustainable Development Goals aim to nearly triple the maternal mortality reductions by 2030. In order to achieve this goal, interventions should focus on improving the quality of ANC care and patient-provider interactions. Furthermore, additional qualitative research examining vulnerable populations of women and exploring the inclusion of men in ANC would help inform interventions intended to improve ANC attendance in East Africa.

Factors influencing antenatal care attendance for Bakiga and Indigenous Batwa women in Kanungu District, Southwestern Uganda.

INTRODUCTION: The number of maternal deaths remains high in sub-Saharan Africa. Effective antenatal care (ANC) reduces maternal morbidity and mortality; therefore, provision of improved antenatal care services has been prioritised across sub-Saharan Africa. Yet, research is limited on the ANC experiences of Indigenous women in sub-Saharan Africa. This study characterised ANC attendance patterns at a hospital, and characterised factors influencing attendance among Bakiga and Indigenous Batwa women in Kanungu District, Uganda. METHODS: A community-based, mixed-methods approach was used. Quantitative data were collected from a local hospital (records for 2299 ANC visits) and analysed by using descriptive statistics and multivariable regression analysis. Qualitative data from eight key informant interviews (n=9 healthcare providers) and 16 focus group discussions (n=120 Batwa and Bakiga women) were analysed by thematic analysis. RESULTS: Most ANC patients attended between one and three ANC visits per pregnancy (n=1259; 92.57%), and few attended the recommended four or more visits (n=101; 7.43%). Distance from a woman's home to the hospital was significantly associated with lower ANC attendance (p<0.05, 95% confidence interval 0.01-0.96), after adjusting for maternal age and number of previous pregnancies. The qualitative data revealed that many factors influenced ANC attendance for both Batwa and Bakiga: long distances from the home to a health centre, high direct and indirect costs of ANC, lack of power in household decision-making, and poor interactions with healthcare providers. While the types of barriers were similar among Batwa and Bakiga, some were more pronounced for Indigenous Batwa women. CONCLUSION: This study partnered with and collected in-depth data with Indigenous Peoples who remain underrepresented in the literature. The findings indicated that Indigenous Batwa continue to face unique and more pronounced barriers to accessing ANC in Kanungu District, Uganda. Ensuring access to ANC for these populations requires an in-depth understanding of their experiences within the local healthcare context. To reduce health inequities that Indigenous Peoples experience, policy-makers and healthcare workers need to adequately understand, effectively address, and appropriately prioritise factors influencing ANC attendance.

Acute gastrointestinal illness in an African Indigenous population: the lived experience of Uganda's Batwa.

INTRODUCTION: Indigenous populations in low-income regions are often the most acutely affected by social gradients that impact health, including high burdens of infectious disease. Using a mixed methods approach, this study characterized the lived experience of acute gastrointestinal illness (AGI) in an Indigenous Batwa population in south-western Uganda. METHODS: Quantitative data analyses were conducted on data from three cross-sectional census surveys of Batwa conducted in January 2013 (n=583), January 2014 (n=569) and April 2014 (n=540). Using a 14-day recall period, cases of AGI were defined as three or more loose stools or any vomiting in a 24-hour period. These analyses were supplemented by qualitative data from key informant interviews (n=11 interviews) and Batwa focus group discussions (n=61 participants). RESULTS: From the surveys, episodes of diarrhea and episodes of vomiting lasted on average 3.6 (95%CI 2.3-4.3) and 3.0 (95%CI 2.1-3.9) days, and individuals experienced an average of 4.3 (95%CI 3.9-4.8) and 2.6 (95%CI 2.1-3.1) loose stools and vomiting episodes in 24 hours. Focus group participants and key informants indicated that episodes of AGI for Batwa were not limited to symptom-based consequences for the individual, but also had economic, social and nutritional impacts. CONCLUSION: Despite efforts to increase health literacy in disease transmission dynamics, risks and prevention measures, the perceived barriers and a lack of benefits still largely underscored adopting positive AGI prevention behaviors. This study moved beyond surveillance and provided information on the broader community-level burden of AGI and highlighted the current challenges and opportunities for improved uptake of AGI prevention measures for the Batwa.

Seasonal variation of food security among the Batwa of Kanungu, Uganda.

OBJECTIVE: Climate change is projected to increase the burden of food insecurity (FI) globally, particularly among populations that depend on subsistence agriculture. The impacts of climate change will have disproportionate effects on populations with higher existing vulnerability. Indigenous people consistently experience higher levels of FI than their non-Indigenous counterparts and are more likely to be dependent upon land-based resources. The present study aimed to understand the sensitivity of the food system of an Indigenous African population, the Batwa of Kanungu District, Uganda, to seasonal variation. DESIGN: A concurrent, mixed methods (quantitative and qualitative) design was used. Six cross-sectional retrospective surveys, conducted between January 2013 and April 2014, provided quantitative data to examine the seasonal variation of self-reported household FI. This was complemented by qualitative data from focus group discussions and semi-structured interviews collected between June and August 2014. SETTING: Ten rural Indigenous communities in Kanungu District, Uganda. SUBJECTS: FI data were collected from 130 Indigenous Batwa Pygmy households. Qualitative methods involved Batwa community members, local key informants, health workers and governmental representatives. RESULTS: The dry season was associated with increased FI among the Batwa in the quantitative surveys and in the qualitative interviews. During the dry season, the majority of Batwa households reported greater difficulty in acquiring sufficient quantities and quality of food. However, the qualitative data indicated that the effect of seasonal variation on FI was modified by employment, wealth and community location. CONCLUSIONS: These findings highlight the role social factors play in mediating seasonal impacts on FI and support calls to treat climate associations with health outcomes as non-stationary and mediated by social sensitivity.

Responding to and managing multijurisdictional outbreaks of COVID-19 in Canadian industrial worksite/work camp settings.

SETTING: Early in the COVID-19 pandemic, the Public Health Agency of Canada (PHAC) and provincial/territorial (P/T) public health identified the need for a coordinated response to complex multijurisdictional COVID-19 outbreaks. The first large multijurisdictional industrial worksite COVID-19 outbreak highlighted the risk of transmission within these congregate work settings, the risk of transmission to the broader community(ies), and the need to develop setting-specific outbreak response frameworks. INTERVENTION: PHAC assembled a team to provide national outbreak support for multijurisdictional COVID-19 outbreaks in May 2020. The COVID-19 Outbreak Response Unit (ORU) worked with P/T partners to develop guiding principles for outbreak response and outbreak investigation processes, guidance documents, and investigation tools (e.g., minimum data elements and questionnaires). OUTCOMES: The ORU, P/T partners, and onsite industrial worksite health and safety staff leveraged outbreak investigation guidelines, industrial worksite outbreak process documents (including minimum data elements), and enhanced case questionnaires to respond to multiple COVID-19 outbreak investigations in industrial worksites. Clear roles/responsibilities and processes, along with standardized data, allowed for more efficient outbreak investigations and earlier implementation of mitigation measures. IMPLICATIONS: Multijurisdictional COVID-19 outbreaks highlighted the importance of public health collaboration with industry partners onsite. The assembly of a national outbreak response team was important to facilitate information sharing and provide technical support. Lessons learned and recommendations on outbreak preparation, detection, management, and communication are included to enhance a response framework applicable to future emerging or re-emerging pathogens with epidemic and/or pandemic potential.

RéSUMé: CONTEXTE: Au début de la pandémie de COVID-19, l'Agence de la santé publique du Canada (ASPC) et les autorités provinciales/territoriales de santé publique ont reconnu la nécessité d'une réponse coordonnée en cas d'éclosions complexes multi-juridictionnelles de COVID-19. La première grande éclosion multi-juridictionnelle de COVID-19 dans un chantier industriel a mis en évidence le risque de transmission dans ces milieux de travail collectifs, le risque de transmission à l'ensemble de la (des) communauté(s) et la nécessité d'élaborer des cadres d'intervention en cas d'éclosion spécifiques aux types de milieux. INTERVENTION: L'ASPC a formé une équipe chargée de soutenir la réponse nationale contre les éclosions multi-juridictionnelles de COVID-19 en mai 2020. L'Unité d'intervention en cas d'éclosion (UIE) de COVID-19 a collaboré avec des partenaires provinciaux et territoriaux pour élaborer des principes de référence pour la lutte contre les éclosions de COVID-19 et des processus d'enquête sur les éclosions, des documents d'orientation et des outils d'enquête (p.ex. des éléments de données minimales et des questionnaires). RéSULTATS: L'UIE, les provinces et territoires et le personnel chargé de la santé et sécurité du travail sur le site se sont appuyés sur des principes de référence aux enquêtes sur les éclosions, les documents de processus d'enquête sur les éclosions dans les sites industriels, y compris les éléments de données minimales et le questionnaire détaillé sur les cas, pour répondre à multiples enquêtes d'éclosions de COVID-19 dans les sites industriels. Des rôles/responsabilités et des processus clairs, ainsi que des données standardisées, ont permis de mener des enquêtes plus efficaces sur les éclosions et de mettre en œuvre plus rapidement des mesures d'atténuation. IMPLICATIONS: Les éclosions multi-juridictionnelles de COVID-19 ont mis en évidence l'importance de la collaboration entre les autorités de santé publique et les partenaires industriels sur site. La constitution d'une équipe nationale d'intervention en cas d'éclosion a été importante pour faciliter le partage des informations et fournir un soutien technique. Les connaissances acquises et les recommandations sur la préparation, la détection, la gestion et la communication des éclosions sont incluses afin d'améliorer le cadre de réponse aux futurs agents pathogènes émergents ou ré-émergents ayant un potentiel épidémique et/ou pandémique.

Place, displacement, and health-seeking behaviour among the Ugandan Batwa: A qualitative study.

For many Indigenous Peoples, relationships to the land are inherent in identity and culture, and to all facets of health and wellbeing, physically, emotionally, psychologically, and spiritually. The Batwa are Indigenous Peoples of rural, southwest Uganda who have experienced tremendous social and economic upheaval, due to relatively recent forced displacement and land dispossession. This loss of physical connection to their ancestral lands has significantly impacted Batwa health, and also affected available healthcare options for Batwa. This exploratory study (1) identified and characterized factors that influence Batwa health-seeking behaviour, using acute gastrointestinal illness, a critical public health issue, as a focal point for analysis; and (2) explored possible intersections between the Batwa's connection to place-and displacement-and their health-seeking behaviour for acute gastrointestinal illness. Twenty focus group discussions, stratified by gender, were conducted in ten Batwa settlements in Kanungu District, Uganda and eleven semi-structured interviews were conducted with primary healthcare workers, community health coordinators, clinical officers, and development program coordinators. Qualitative data were thematically analyzed using a constant comparative method. Batwa identified several significant motivators to engage with Indigenous and/or biomedical forms of healthcare, including transition to life outside the forest and their reflections on health in the forest; 'intellectual access' to care and generational knowledge-sharing on the use of Indigenous medicines; and Batwa identity and way of life. These nuanced explanations for health-seeking behaviour underscore the significance of place-and displacement-to Batwa health and wellbeing, and its relationship to their health-seeking behaviour for acute gastrointestinal illness. As such, the results of this study can be used to inform healthcare practice and policy and support the development of a culturally- and contextually-appropriate healthcare system, as well as to reduce the burden of acute gastrointestinal illness among Batwa.

Canadian COVID-19 Outbreak Surveillance System: implementation of national surveillance during a global pandemic.

SETTING: Early in the SARS-CoV-2 pandemic, the need to develop systematic outbreak surveillance at the national level to monitor trends in SARS-CoV-2 outbreaks was identified as a priority for the Public Health Agency of Canada (PHAC). The Canadian COVID-19 Outbreak Surveillance System (CCOSS) was established to monitor the frequency and severity of SARS-CoV-2 outbreaks across various community settings. INTERVENTION: PHAC engaged with provincial/territorial partners in May 2020 to develop goals and key data elements for CCOSS. In January 2021, provincial/territorial partners began submitting cumulative outbreak line lists on a weekly basis. OUTCOMES: Eight provincial and territorial partners, representing 93% of the population, submit outbreak data on the number of cases and severity indicators (hospitalizations and deaths) for 24 outbreak settings to CCOSS. Outbreak data can be integrated with national case data to supply information on case demographics, clinical outcomes, vaccination status, and variant lineages. Data aggregated to the national level are used to conduct analyses and report on outbreak trends. Evidence from CCOSS analyses has been useful in supporting provincial/territorial outbreak investigations, informing policy recommendations, and monitoring the impact of public health measures (vaccination, closures) in specific outbreak settings. IMPLICATIONS: The development of a SARS-CoV-2 outbreak surveillance system complemented case-based surveillance and furthered the understanding of epidemiological trends. Further efforts are required to better understand SARS-CoV-2 outbreaks for Indigenous populations and other priority populations, as well as create linkages between genomic and epidemiological data. As SARS-CoV-2 outbreak surveillance enhanced case surveillance, outbreak surveillance should be a priority for emerging public health threats.

RéSUMé: CONTEXTE: Au début de la pandémie de SRAS-CoV-2, l'Agence de la santé publique du Canada (ASPC) a déterminé comme priorité la nécessité de développer un système de surveillance systématique des éclosions à l'échelle nationale afin de suivre les tendances des éclosions de SRAS-CoV-2. Le système canadien de surveillance des éclosions de COVID-19 (SCSEC) a été établi pour surveiller la fréquence et la gravité des éclosions de SRAS-CoV-2 dans différents milieux communautaires. INTERVENTION: L'ASPC s'est engagée avec les partenaires provinciaux et territoriaux en mai 2020 pour élaborer des objectifs et des éléments de données clés pour le SCSEC. En janvier 2021, les partenaires provinciaux et territoriaux ont commencé à transmettre des listes d'éclosions cumulatives hebdomadaires. RéSULTATS: Huit partenaires provinciaux et territoriaux, représentant 93 % de la population, transmettent au SCSEC des données sur les éclosions sur le nombre de cas et les indicateurs de gravité (les hospitalisations et les décès) pour 24 types de milieux. Les données sur les éclosions peuvent être intégrées avec les données nationales sur les cas pour obtenir des informations sur la démographie des cas, les résultats cliniques, le statut vaccinal et les lignées de variants. Les données agrégées à l'échelle nationale sont utilisées pour effectuer des analyses et faire rapport des tendances sur les éclosions. Les résultats des analyses du SCSEC ont été utiles pour soutenir les enquêtes provinciales/territoriales sur les éclosions, informer les recommandations politiques et surveiller l'impact des mesures de santé publique (la vaccination, les fermetures) dans des milieux d'éclosions spécifiques. IMPLICATIONS: Le développement d'un système de surveillance des éclosions de SRAS-CoV-2 a permis de complémenter la surveillance des cas et d'approfondir notre compréhension des tendances épidémiologiques. Des efforts supplémentaires sont nécessaires pour mieux comprendre les éclosions de SRAS-CoV-2 chez les populations autochtones et d'autres populations minoritaires, ainsi que pour créer des liens entre les données génomiques et les données épidémiologiques. Comme la surveillance des éclosions de SRAS-CoV-2 a enrichi la surveillance des cas, la surveillance des éclosions devrait être une priorité pour les menaces émergentes pour la santé publique.

Community-based COVID-19 outbreak of the B.1.1.7 (Alpha) variant of concern in Newfoundland, February to March 2021.

Background: From March 2020 to January 2021, Newfoundland and Labrador experienced 408 coronavirus disease 2019 (COVID-19) cases (incidence 78 per 100,000). In February and March 2021, a community outbreak of the B.1.1.7 (Alpha) variant occurred in the Eastern Regional Health Authority. This article describes the epidemiology of this variant of concern outbreak, identifies settings that likely contributed to spread and informs recommendations for public health measures (PHMs). Methods: Provincial surveillance data were linked with case interview data and a school class roster. Descriptive epidemiological methods were used to characterize the outbreak. Secondary attack rates (SAR) were calculated for households and classrooms. Results: This outbreak involved 577 laboratory-confirmed and 38 probable cases. Whole genome sequencing determined cases were B.1.1.7. The median age was 31 years and the highest proportion of cases were in the 15 to 19-year age group (29%); 293 (51%) were female and 140 (24%) were asymptomatic upon identification. Early cases were linked to a high school, sports activities, a restaurant and social gatherings. As the outbreak progressed, cases were associated with household transmission, a daycare, healthcare settings and a workplace. The unadjusted SAR estimate among laboratory-confirmed cases was 24.4% for households and 19.3% for classroom exposures. When adjusted for other potential exposures, SAR estimates were 19.9% for households and 11.3% for classrooms. Conclusion: This outbreak demonstrated how B.1.1.7 spread rapidly through a community with previously low COVID-19 transmission and few preventative PHMs in place. Implementation and compliance with school and community-based PHMs is critical for preventing transmission during outbreaks.

COVID-19 outbreak trends in Canada, 2021.

Background: In January 2021, the Public Health Agency of Canada launched an outbreak surveillance system, the Canadian COVID-19 Outbreak Surveillance System (CCOSS), with the goal of monitoring incidence and severity of coronavirus disease 2019 (COVID-19) outbreaks across various community settings and complementing case surveillance. Methods: Seven provinces were included in this report; these provinces submitted weekly cumulative COVID-19 outbreak line lists to CCOSS in 2021. Data includes administrative variables (e.g. date outbreak declared, date outbreak declared over, outbreak identifier), 24 outbreak settings, and number of confirmed cases and outcomes (hospitalization, death). Descriptive analyses for COVID-19 outbreaks across Canada from January 3, 2021, to January 1, 2022, were performed examining trends over time, severity, and outbreak size. Results: Incidence of outbreaks followed similar trends to case incidence. Outbreaks were most common in school and childcare settings (39%) and industrial/agricultural settings (21%). Outbreak size ranged from 2 to 639 cases per outbreak; the median size was four cases per outbreak. Correctional facilities had the largest median outbreak size with 18 cases per outbreak, followed by long-term care facilities with 10 cases per outbreak. During periods of high case incidence, outbreaks may be under-ascertained due to limited public health capacity, or reporting may be biased towards high-risk settings prioritized for testing. Outbreaks reported to CCOSS were dominated by jurisdictions with the largest populations. Conclusion: The trends illustrate that COVID-19 outbreaks in 2021 were reported most frequently in community settings such as schools; however, the largest outbreaks occurred in congregate living settings. The information gathered from outbreak surveillance complemented case incidence trends and furthered understanding of COVID-19 in Canada.

Demographic patterns of exposure and transmission for a rural Canadian community outbreak of COVID-19, 2020.

Background: A coronavirus disease 2019 (COVID-19) community outbreak was declared October 5-December 3, 2020, in the Restigouche region of New Brunswick, Canada. This article describes the epidemiological characteristics of the outbreak and assesses factors associated with its transmission in rural communities, informing public health measures and programming. Methods: A provincial line list was developed from case and contact interviews. Descriptive epidemiological methods were used to characterize the outbreak. Incidence rates among contacts, and by gender for the regional population were estimated. Results: There were 83 laboratory-confirmed cases of COVID-19 identified during the observation period. The case ages ranged from 10-89 years of age (median age group was 40-59 years of age) and 51.2% of the cases were male. Symptom onset dates ranged from September 27-October 27, 2020, with 83% of cases being symptomatic. A cluster of early cases at a social event led to multiple workplace outbreaks, though the majority of cases were linked to household transmission. Complex and overlapping social networks resulted in multiple exposure events and that obscured transmission pathways. The incidence rate among men was higher than women, men were significantly more likely to have transmission exposure at their workplace than women, and men were the most common index cases within a household. No transmission in school settings among children was documented despite multiple exposures. Conclusion: This investigation highlighted the gendered nature and complexity of a COVID-19 outbreak in a rural Canadian community. Targeted action at workplaces and strategic messaging towards men are likely required to increase awareness and adherence to public health measures to reduce transmission in these settings.

Are Indigenous research principles incorporated into maternal health research? A scoping review of the global literature.

BACKGROUND: Indigenous women world-wide are diverse and heterogenous, yet many have similar experiences of colonization, land dispossession, and discrimination. These experiences along with inequitable access to, and quality of, maternal healthcare increase adverse maternal health outcomes. To improve health outcomes for Indigenous women, studies must be conducted with Indigenous involvement and reflect Indigenous research principles. Objectives/Aim: The aim of this review was to explore the range, extent, and nature of Indigenous maternal health research and to assess the reporting of Indigenous research principles in the global Indigenous maternal health literature. METHODS: Following a systematic scoping review protocol, four scholarly electronic databases were searched. Articles were included if they reported empirical research published between 2000 and 2019 and had a focus on Indigenous maternal health. Descriptive data were extracted from relevant articles and descriptive analysis was conducted. Included articles were also assessed for reporting of Indigenous research principles, including Indigenous involvement, context of colonization, Indigenous conceptualizations of health, community benefits, knowledge dissemination to participants or communities, and policy or intervention recommendations. RESULTS: Four-hundred and forty-one articles met the inclusion criteria. While studies were conducted in all continents except Antarctica, less than 3% of articles described research in low-income countries. The most researched topics were access to and quality of maternity care (25%), pregnancy outcome and/or complications (18%), and smoking, alcohol and/or drug use during pregnancy (14%). The most common study design was cross-sectional (49%), and the majority of articles used quantitative methods only (68%). Less than 2% of articles described or reported all Indigenous research principles, and 71% of articles did not report on Indigenous People's involvement. CONCLUSIONS: By summarizing the trends in published literature on Indigenous maternal health, we highlight the need for increased geographic representation of Indigenous women, expansion of research to include important but under-researched topics, and meaningful involvement of Indigenous Peoples.

'We don't use the same ways to treat the illness:' A qualitative study of heterogeneity in health-seeking behaviour for acute gastrointestinal illness among the Ugandan Batwa.

The Batwa (Twa), an Indigenous People of southwest Uganda, were evicted from their ancestral forest lands in 1991 due to establishment of the Bwindi Impenetrable Forest. This land dispossession forced Batwa to transition from a semi-nomadic, hunting-gathering livelihood to an agricultural livelihood; eliminated access to Indigenous food, medicines, and shelter; and shifted their healthcare options. Therefore, this exploratory study investigated why Batwa choose Indigenous or biomedical treatment, or no treatment, when experiencing acute gastrointestinal illness. Ten gender-stratified focus groups were conducted in five Batwa settlements in Kanungu District, Uganda (n = 63 participants), alongside eleven semi-structured interviews (2014). Qualitative data were analysed thematically, using a constant comparative method. Batwa emphasised that health-seeking behaviour for acute gastrointestinal illness was diverse: some Batwa used only Indigenous or biomedical healthcare, while others preferred a combination, or no healthcare. Physical and economic access to care, and also perceived efficacy and quality of care, influenced their healthcare decisions. This study provides insight into the Kanungu District Batwa's perceptions of biomedical and Indigenous healthcare, and barriers they experience to accessing either. This study is intended to inform public health interventions to reduce their burden of acute gastrointestinal illness and ensure adequate healthcare, biomedical or Indigenous, for Batwa.

Socio-economic and environmental factors affecting breastfeeding and complementary feeding practices among Batwa and Bakiga communities in south-western Uganda.

Improving breastfeeding and complementary feeding practices is needed to support good health, enhance child growth, and reduce child mortality. Limited evidence is available on child feeding among Indigenous communities and in the context of environmental changes. We investigate past and present breastfeeding and complementary feeding practices within Indigenous Batwa and neighbouring Bakiga populations in south-western Uganda. Specifically, we describe the demographic and socio-economic characteristics of breastfeeding mothers and their children, and individual experiences of breastfeeding and complementary feeding practices. We investigate the factors that have an impact on breastfeeding and complementary feeding at community and societal levels, and we analysed how environments, including weather variability, affect breastfeeding and complementary feeding practices. We applied a mixed-method design to the study, and we used a community-based research approach. We conducted 94 individual interviews (n = 47 Batwa mothers/caregivers & n = 47 Bakiga mothers/caregivers) and 12 focus group discussions (n = 6 among Batwa & n = 6 among Bakiga communities) from July to October 2019. Ninety-nine per cent of mothers reported that their youngest child was currently breastfed. All mothers noted that the child experienced at least one episode of illness that had an impact on breastfeeding. From the focus groups, we identified four key factors affecting breastfeeding and nutrition practices: marginalisation and poverty; environmental change; lack of information; and poor support. Our findings contribute to the field of global public health and nutrition among Indigenous communities, with a focus on women and children. We present recommendations to improve child feeding practices among the Batwa and Bakiga in south-western Uganda. Specifically, we highlight the need to engage with local and national authorities to improve breastfeeding and complementary feeding practices, and work on food security, distribution of lands, and the food environment. Also, we recommend addressing the drivers and consequences of alcoholism, and strengthening family planning programs.

Socio-demographic associations with pregnancy loss among Bakiga and Indigenous Batwa women in Southwestern Uganda.

OBJECTIVE: To assess the extent of pregnancy loss (i.e., miscarriage and/or stillbirth) and examine its association with socio-demographic characteristics among Bakiga and Indigenous Batwa women in Kanungu District, southwest Uganda. METHODS: As part of a larger community-based, participatory project, a retrospective survey of maternal health histories was conducted in ten Batwa and ten Bakiga communities (n = 555 participants) collecting data on self-reported pregnancy loss (i.e., miscarriage and stillbirth) and socio-demographic characteristics. Socio-demographic associations with pregnancy loss (i.e., total miscarriages and stillbirths) were examined using multivariable Poisson and negative binomial regression. RESULTS: Batwa women experienced pregnancy loss more commonly than Bakiga women did (149.8/1000 vs. 96.3/1000 pregnancies). In the final adjusted model for Batwa women, being in the middle (RR 1.92; CI: 1.21-3.07) and highest (RR 1.79; CI: 1.14-2.82) wealth tertiles (compared to lowest wealth tertile) and living in Community X (RR 4.33; CI 2.27-8.28) (compared to all other communities) were associated with increased pregnancy loss. For Bakiga women, the proportion of pregnancy loss was higher for those who reported drinking alcohol during pregnancy (RR: 1.54; CI: 1.04-2.13) and being food insecure (RR 1.39; CI: 1.02-1.91). CONCLUSION: The proportion of, and the socio-demographic associations with, pregnancy loss differed for Bakiga and Indigenous Batwa women. These differences underscore the importance of collecting Indigenous health data to understand not only the extent of, but also the varied contextual circumstances that are associated with pregnancy loss. This nuanced and stratified information is critical for planning meaningful health programming to reduce pregnancy loss for Indigenous women.

Seasonality, climate change, and food security during pregnancy among indigenous and non-indigenous women in rural Uganda: Implications for maternal-infant health.

BACKGROUND: Climate change is expected to decrease food security globally. Many Indigenous communities have heightened sensitivity to climate change and food insecurity for multifactorial reasons including close relationships with the local environment and socioeconomic inequities which increase exposures and challenge adaptation to climate change. Pregnant women have additional sensitivity to food insecurity, as antenatal undernutrition is linked with poor maternal-infant health. This study examined pathways through which climate change influenced food security during pregnancy among Indigenous and non-Indigenous women in rural Uganda. Specific objectives were to characterize: 1) sensitivities to climate-associated declines in food security for pregnant Indigenous women; 2) women's perceptions of climate impacts on food security during pregnancy; and 3) changes in food security and maternal-infant health over time, as observed by women. METHODS: Using a community-based research approach, we conducted eight focus group discussions-four in Indigenous Batwa communities and four in non-Indigenous communities-in Kanungu District, Uganda, on the subject of climate and food security during pregnancy. Thirty-six women with ≥1 pregnancy participated. Data were analysed using a constant comparative method and thematic analysis. RESULTS: Women indicated that food insecurity was common during pregnancy and had a bidirectional relationship with antenatal health issues. Food security was thought to be decreasing due to weather changes including extended droughts and unpredictable seasons harming agriculture. Women linked food insecurity with declines in maternal-infant health over time, despite improved antenatal healthcare. While all communities described food security struggles, the challenges Indigenous women identified and described were more severe. CONCLUSIONS: Programs promoting women's adaptive capacity to climate change are required to improve food security for pregnant women and maternal-infant health. These interventions are particularly needed in Indigenous communities, which often face underlying health inequities. However, resiliency among mothers was strong and, with supports, they can reduce food security challenges in a changing climate.

A Community-Based Approach to Integrating Socio, Cultural and Environmental Contexts in the Development of a Food Database for Indigenous and Rural Populations: The Case of the Batwa and Bakiga in South-Western Uganda.

Comprehensive food lists and databases are a critical input for programs aiming to alleviate undernutrition. However, standard methods for developing them may produce databases that are irrelevant for marginalised groups where nutritional needs are highest. Our study provides a method for identifying critical contextual information required to build relevant food lists for Indigenous populations. For our study, we used mixed-methods study design with a community-based approach. Between July and October 2019, we interviewed 74 participants among Batwa and Bakiga communities in south-western Uganda. We conducted focus groups discussions (FGDs), individual dietary surveys and markets and shops assessment. Locally validated information on foods consumed among Indigenous populations can provide results that differ from foods listed in the national food composition tables; in fact, the construction of food lists is influenced by multiple factors such as food culture and meaning of food, environmental changes, dietary transition, and social context. Without using a community-based approach to understanding socio-environmental contexts, we would have missed 33 commonly consumed recipes and foods, and we would not have known the variety of ingredients' quantity in each recipe, and traditional foraged foods. The food culture, food systems and nutrition of Indigenous and vulnerable communities are unique, and need to be considered when developing food lists.

Assessing the determinants of antenatal care adherence for Indigenous and non-Indigenous women in southwestern Uganda.

BACKGROUND: With an increasing number of women attending antenatal care for the recommended number of contacts, focus now must be placed on the quality and utility of care; without understanding adherence, the true contribution of antenatal care to improved maternal health outcomes is difficult to determine. OBJECTIVE: This research explored the practicality of antenatal care recommendations for women and the factors which facilitate or hinder adherence and shape the overall utility of care. DESIGN: Qualitative data were collected using a community-centred approach by means of focus group discussions with women and key informant interviews with healthcare providers throughout May and June of 2017. Data were analysed via thematic analysis guided by an essentialist/realist paradigm. SETTING: Kanungu District, Uganda; a district in southwestern Uganda. PARTICIPANTS: A convenience sample of 38 Indigenous Batwa and non-Indigenous Bakiga women from four matched communities and three healthcare providers. FINDINGS: A number of barriers to antenatal care adherence were identified which included a lack of monetary and material resources, a lack of a shared understanding and perceived value of care, and gender and position-based power dynamics, all of which were compounded by previous experiences with antenatal care. The factors identified which influenced adherence were highly complex and non-linear, affected by individual, community, health centre, and health system-level factors. Promotion of spousal involvement in antenatal care had different effects based on pre-existing individual levels of spousal support, either improving or hindering adherence. A lack of resources created a double burden for women through which maternal health was jeopardized by the inability to adhere to antenatal care recommendations and the poor quality patient-provider relationships which resulted and deterred future antenatal care attendance. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The capacity to avail oneself of antenatal care varied significantly for women based on their socio-economic status, levels of autonomy, and spousal support. Strategies to improve antenatal care need to focus on health equity to ensure care has a high degree of utility for all women. The interconnectedness of care and those who deliver care necessitates healthcare providers to develop strong patient-provider relationships through their attitudes, behaviours, and the delivery of equitable care. In light of a historical emphasis on attendance, this research highlights the significance of improving the quality and utility of antenatal care, inclusive of Indigenous perspectives, to deliver high-value care.

Is the effect of precipitation on acute gastrointestinal illness in southwestern Uganda different between Indigenous and non-Indigenous communities?

Acute gastrointestinal illness (AGI) is a global public health priority that often disproportionately effects Indigenous populations. While previous research examines the association between meteorological conditions and AGI, little is known about how socio-cultural factors may modify this relationship. This present study seeks to address this research gap by comparing AGI prevalence and determinants between an Indigenous and non-Indigenous population in Uganda. We estimate the 14-day self-reported prevalence of AGI among adults in an Indigenous Batwa population and their non-Indigenous neighbours using cross-sectional panel data collected over four periods spanning typically rainy and dry seasons (January 2013 to April 2014). The independent associations between Indigenous status, precipitation, and AGI are examined with multivariable multi-level logistic regression models, controlling for relative wealth status and clustering at the community level. Estimated prevalence of AGI among the Indigenous Batwa was greater than among the non-Indigenous Bakiga. Our models indicate that both Indigenous identity and decreased levels of precipitation in the weeks preceding the survey period were significantly associated with increased AGI, after adjusting for confounders. Multivariable models stratified by Indigenous identity suggest that Indigenous identity may not modify the association between precipitation and AGI in this context. Our results suggest that short-term changes in precipitation affect both Indigenous and non-Indigenous populations similarly, though from different baseline AGI prevalences, maintaining rather than exacerbating this socially patterned health disparity. In the context of climate change, these results may challenge the assumption that changing weather patterns will necessarily exacerbate existing socially patterned health disparities.

An analysis of the nutrition status of neighboring Indigenous and non-Indigenous populations in Kanungu District, southwestern Uganda: Close proximity, distant health realities.

OBJECTIVES: Malnutrition is a persistent health concern throughout the world. Globally, Indigenous peoples experience poorer health outcomes compared to their non-Indigenous neighbours. Despite this, malnutrition among Indigenous populations is poorly understood. This analysis estimated the prevalence, and modeled possible determinants of, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) for Indigenous Batwa and non-Indigenous Bakiga of Kanungu District in Southwestern Uganda. We then characterize possible mechanisms driving differences in malnutrition. METHODS: Retrospective cross-sectional surveys were administered to 10 Batwa communities and 10 matched Bakiga Local Councils during April of 2014 (n = 1167). Individuals were classified as MAM and SAM based on middle upper-arm circumference (MUAC) for their age-sex strata. Mixed-effects regression models quantified the variation in malnutrition occurrence, considering individual, household, and community-ethnicity level effects. Models controlled for age, sex, number of dependents, education, and relative wealth. RESULTS: Malnutrition is high among Batwa children and adults, with nearly half of Batwa adults (45.34%, 95% CI 34.82 to 55.86 for males; 45.86%, 95% CI 37.39 to 54.33 for females) and nearly a quarter of Batwa children (20.31%, 95% CI 13.07 to 26.93 for males; 25.81%, 95% CI 17.56 to 32.84 for females) meeting MAM criteria. SAM prevalence is lower than MAM prevalence, with SAM highest among adult Batwa males (11.60%, 95% CI 4.83 to 18.37) and adult Batwa females (3.00%, 95% CI 0.10 to 5.90). SAM prevalence among children was higher for Batwa males (7.03%, 95% CI 1.36 to 12.70) compared to Bakiga males (0.57%, 95% CI 0 to 1.69). Models that incorporated community ethnicity explained the greatest variance (>60%) in MUAC values. CONCLUSION: This research demonstrates a malnutrition inequality between the Indigenous Batwa and non-Indigenous Bakiga of Kanungu District, Uganda, with model results suggesting further investigation into the role of ethnicity as an upstream social determinant of health.