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

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

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

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

Development of a multi-level family planning intervention for couples in rural Uganda: key findings & adaptations made from community engaged research methods.

BACKGROUND: Uganda has among the highest fertility rates in the world and multi-level barriers contribute to the low contraceptive use. OBJECTIVE: The objective of this study was to develop a culturally and socially relevant, community-based intervention to increase contraceptive use among couples in rural Uganda through community-engaged research methods. This study reports on the community-engaged research that informed the intervention's content and structure and the final content of the intervention; the evaluation of the pilot intervention will be reported upon completion. METHODS: An intervention steering committee of community stakeholders reviewed the initially proposed intervention content and approach. Four (4) gender-segregated focus groups were conducted with twenty-six (26) men and women who had an unmet need for family planning. Fifteen key-informant interviews were conducted with community leaders and family planning stakeholders. Finally, the 4-session intervention was pilot tested with a cohort of couples (N = 7) similar in demographics to the target sample of the future pilot intervention trial. Qualitative data were analyzed thematically. RESULTS: Findings included the identification of community beliefs to reshape in order to increase family planning acceptance, as well as strategies to engage men, acceptable approaches for community leader involvement in the intervention to endorse family planning, and methods for managing gender dynamics and minimizing risk of unintended negative consequences of participation. The findings were used to inform the ideal structure and format of the intervention, including the distribution of contraceptives directly during group sessions, and identified the need to strengthen health worker capacity to provide Long-Acting Reversable Contraceptives (LARCs) as part of the intervention. CONCLUSIONS: These findings were used to refine an intervention before a larger scale pilot test of its feasibility, acceptability, and potential efficacy. They can inform other multi-level family planning interventions in similar settings and the methods can be adopted by others to increase the feasibility, acceptability, and cultural relevance of interventions.

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

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

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

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

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

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

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

Prevalence and correlates of depressive symptoms, and points of intervention, in rural central Uganda: results from a cross-sectional population-based survey of women and men.

OBJECTIVES: The present study aimed to identify the prevalence and correlates of depressive symptoms and potential intervention points among women and men from a population-based sample in rural central Uganda. DESIGN: A cross-sectional study. SETTING: Four districts in rural Uganda. PARTICIPANTS: Women and men aged 15-59 residing in four districts in rural Uganda accepting home-based HIV testing who completed a baseline survey at the time of testing. PRIMARY OUTCOME MEASURES: Depressive symptoms measured by the 10-item Center for Epidemiological Studies Depression Scale using a cut-off score of 13 for significant depressive symptoms. RESULTS: Among a sample of 9609 women and 6059 men, 1415 (14.7%) women and 727 (12.0%) men met criteria for significant depressive symptoms. Having ever received mental health services was associated with lower odds of significant depressive symptoms (women: adjusted OR (adjOR)=0.32, 95% CI=0.22 to 0.47; men: adjOR=0.36, 95% CI=0.18 to 0.62). Having received outpatient (women: adjOR=3.64, 95% CI=3.14 to 4.22; men: adjOR=3.37, 95% CI=2.78 to 4.07) or inpatient (women: adjOR=5.44, 95% CI=4.24 to 6.97; men: adjOR=3.42, 95% CI=2.21 to 5.28) care in the prior 6 months was associated with greater odds of significant depressive symptoms. For women only, known HIV positive status (adjOR=1.37, 95% CI=1.05 to 1.77), and for men only, alcohol misuse (adjOR=1.38, 95% CI=1.12 to 1.70), were associated with increased odds of significant depressive symptoms. CONCLUSION: Our findings suggest that depression screening within outpatient and inpatient settings may help to identify people in need of mental health services. Routine screening in outpatient or inpatient clinics along with the implementation of evidence-based interventions could ultimately help close the mental health gap for depression in this and similar settings.

Perceived HIV stigma and HIV testing among men and women in rural Uganda: a population-based study.

BACKGROUND: Stigma is a formidable social structural barrier to HIV testing, and yet the effect of stigma on HIV testing is rarely examined at the community level. We aimed to examine the geospatial relationships of perceived HIV stigma and HIV testing among men and women living in rural Uganda. METHODS: Women and men (aged ≥18 years or emancipated minor) residing in rural areas of Uganda who self-identified as HIV negative completed interviews that included measures of HIV testing history and how participants perceived HIV stigma. We used geospatial cluster analyses to identify areas of higher perceived stigma and lower perceived stigma and the geographical dispersion of these areas. We used Poisson regression models stratified by gender to test individual-level and community-level perceived stigma in relation to frequency of HIV testing in the previous 2 years. FINDINGS: Between Nov 25, 2015, and May 26, 2017, we interviewed 9740 participants (4359 [45%] men and 5381 [55%] women]), among whom 940 (9%) had never been tested for HIV, and among those who had been tested, 1131 (12%) had not been tested in the previous 2 years. Men (3134 [72%] of 4359) were less likely to have been tested in the past 2 years than women (4535 [84%] of 5381) were (p<0·001). We used Poisson regression models, reporting B coefficients, to test study hypotheses regarding the effects of individual-level and community-level stigma on HIV testing frequency counts. Multilevel modelling showed that women showed significant individual-level (B=-0·173, p<0·001) and community-level (B=-0·223, p<0·001) associations between lower stigma predicting higher rates of HIV testing. For men, lower individual-level perceived stigma was also associated with higher testing frequency (B=-0·030, p=0·018), whereas higher community-level perceived stigma was associated with higher testing frequency (B=0·077, p=0·008). INTERPRETATION: Our results suggest that perceived HIV stigma at the community level exerts a differential influence on testing for women and men. HIV testing campaigns that are targeted to men and women in rural Uganda will require gender tailoring to fit local contexts. FUNDING: US National Institute of Mental Health.

Efficacy of an enhanced linkage to HIV care intervention at improving linkage to HIV care and achieving viral suppression following home-based HIV testing in rural Uganda: study protocol for the Ekkubo/PATH cluster randomized controlled trial.

BACKGROUND: Though home-based human immunodeficiency virus (HIV) counseling and testing (HBHCT) is implemented in many sub-Saharan African countries as part of their HIV programs, linkage to HIV care remains a challenge. The purpose of this study is to test an intervention to enhance linkage to HIV care and improve HIV viral suppression among individuals testing HIV positive during HBHCT in rural Uganda. METHODS: The PATH (Providing Access To HIV Care)/Ekkubo Study is a cluster-randomized controlled trial which compares the efficacy of an enhanced linkage to HIV care intervention vs. standard-of-care (paper-based referrals) at achieving individual and population-level HIV viral suppression, and intermediate outcomes of linkage to care, receipt of opportunistic infection prophylaxis, and antiretroviral therapy initiation following HBHCT. Approximately 600 men and women aged 18-59 who test HIV positive during district-wide HBHCT in rural Uganda will be enrolled in this study. Villages (clusters) are pair matched by population size and then randomly assigned to the intervention or standard-of-care arm. Study teams visit households and participants complete a baseline questionnaire, receive HIV counseling and testing, and have blood drawn for HIV viral load and CD4 testing. At baseline, standard-of-care arm participants receive referrals to HIV care including a paper-based referral and then receive their CD4 results via home visit 2 weeks later. Intervention arm participants receive an intervention counseling session at baseline, up to three follow-up counseling sessions at home, and a booster session at the HIV clinic if they present for care. These sessions each last approximately 30 min and consist of counseling to help clients: identify and reduce barriers to HIV care engagement, disclose their HIV status, identify a treatment supporter, and overcome HIV-related stigma through links to social support resources in the community. Participants in both arms complete interviewer-administered questionnaires at six and 12 months follow-up, HIV viral load and CD4 testing at 12 months follow-up, and allow access to their medical records. DISCUSSION: The findings of this study can inform the integration of a potentially cost-effective approach to improving rates of linkage to care and HIV viral suppression in HBHCT. If effective, this intervention can improve treatment outcomes, reduce mortality, and through its effect on individual and population-level HIV viral load, and decrease HIV incidence. TRIAL REGISTRATION: NCT02545673.

How Do We Get Partners to Test for HIV?: Predictors of Uptake of Partner HIV Testing Following Individual Outpatient Provider Initiated HIV Testing in Rural Uganda.

In a sample of outpatients (152 females, 152 males) receiving individual provider-initiated HIV testing and counselling (PITC) we aimed to identify factors associated with subsequent uptake of partner HIV testing. Purposively sampled outpatients receiving PITC at a Ugandan hospital completed a questionnaire immediately prior to testing for HIV, and then at 3 and 6 months post-test. By 6-month follow-up 96% of participants reported disclosing their HIV test results to their partner and 96.4% reported asking their partner to test. 38.8% of women and 78.9% of men reported that their partner tested and they knew their results. Recent (men AOR 5.84, 95.0% CI 1.90-17.99; women AOR 6.19, 95.0% CI 2.74-13.59) or any previous testing by the partner (women AOR 4.01, 95% CI 1.06-15.10) predicted uptake of partner testing by the 6-month follow-up. Among women, perceiving greater social support from their partner, which perhaps reflects better relationship quality, was predictive of their male partner testing for HIV (AOR 2.37, 95% CI 1.22-4.58). Notably intimate partner violence showed no negative association with partner testing. Our findings demonstrate that women are at a disadvantage compared to men in their ability to influence their partner to test for HIV, and that improving social support in intimate relationships should be a focus of HIV partner testing interventions. However, more research on interventions to improve partner testing is needed, particularly in identifying effective ways to support women in engaging their partners to test.

Depression, alcohol use, and intimate partner violence among outpatients in rural Uganda: vulnerabilities for HIV, STIs and high risk sexual behavior.

BACKGROUND: Intimate partner violence (IPV), alcohol use, and depression are key vulnerabilities for HIV in Uganda, and taken together may have a synergistic effect on risk. Our objective was to investigate the associations between depression, IPV, and alcohol use and HIV-risk indicators among a sample of outpatients in rural Uganda, and the effect of co-occurrence of these factors on HIV-risk indicators. METHODS: In a structured interview we collected data on high-risk sexual behavior, depression symptoms, emotional and physical IPV, and alcohol use, as well as a blood sample for HIV and syphilis tests and a urine sample for chlamydia and gonorrhea tests from 325 male and female outpatients receiving provider-initiated HIV testing and counseling (PITC) at a public hospital outpatient clinic in rural Uganda. We used logistic regression and generalized linear modeling to test independent associations between depression, IPV, and alcohol use and HIV-risk indicators, as well as the effect of co-occurrence on HIV-risk indicators. RESULTS: Twelve percent of men and 15% of women had two or more of the following conditions: depression, IPV, and alcohol use; another 29% of men and 33% of women had 1 condition. Each condition was independently associated with HIV risk behavior for men and women, and for women, depression was associated with testing positive for HIV or a sexually transmitted infection (STI). Men with one condition (AOR 2.32, 95% CI 1.95-2.77) and two or more conditions (AOR 12.77, 95% CI 7.97-20.47) reported more high risk sex acts compared to those with no potential co-occurring conditions. For men, experiencing two or more conditions increased risky sex more than one alone (χ 2 24.68, p < 0.001). Women experiencing one condition (AOR 3.33, 95% CI 137-8.08) and two co-occurring conditions (AOR 5.87, 95% CI 1.99-17.35) were more likely to test positive for HIV or an STI and women with two co-occurring conditions were also at increased risk for risky sex (AOR 2.18, 95% CI 1.64-2.91). We also found preliminary evidence suggesting synergistic effects between depression and emotional IPV and between alcohol use and depression. CONCLUSIONS: This study demonstrates the co-occurrence of depression, IPV, and alcohol use in men and women in an outpatient setting in rural Uganda. The co-occurrence of these factors was associated with greater HIV risk, highlighting the need for a more holistic approach to HIV prevention and care research and programming.

"That would be good but most men are afraid of coming to the clinic": Men and women's perspectives on strategies to increase male involvement in women's reproductive health services in rural Uganda.

In Uganda, increasing male involvement in reproductive health services may improve women's access to care. The purpose of this study was to explore factors influencing male support for women's reproductive health services and to elicit suggestions for strategies to increase male involvement. In 2008-2009, focus groups ( N = 76) were conducted with men and women in a rural hospital in Uganda. A content analysis approach was used for data analysis. Our findings point to the need for multi-level approaches that educate and mobilize men, while improving quality of care at the facility level to increase male involvement in reproductive health services.

Concordance Between Laboratory Diagnosed Sexually Transmitted Infections and Self-Reported Measures of Risky Sex by Partner Type Among Rural Ugandan Outpatients.

Numerous HIV risk reduction interventions which show effects on sexual risk behaviors fail to find effects on STIs. We examined the concordance between laboratory diagnosed STIs and sexual risk behavior among Ugandan outpatients (n = 328). We screened for STIs and assessed sexual behavior at baseline and 6 month follow-up. Less risk was associated with an STI at baseline. At follow-up more unprotected sex with casual partners was associated with incident Syphilis, more unprotected sex with primary and secondary regular partners was associated with incident Chlamydia or Gonorrhea. Our results suggest ways to improve concordance between behavioral measures and STIs.

The Effect of Motivational Interviewing-Based Counseling During Outpatient Provider Initiated HIV Testing on High-Risk Sexual Behavior in Rural Uganda.

Provider-initiated HIV testing and counseling (PITC) has rapidly expanded in many countries including Uganda. However, because it provides HIV prevention information without individualized risk assessment and risk reduction counseling it may create missed opportunities for effective HIV prevention counseling. Our objective was to assess the effect of a brief motivational interviewing-based intervention during outpatient PITC in rural Uganda compared to Uganda's standard-of-care PITC at reducing HIV transmission-relevant sexual risk behavior. We enrolled 333 (160 control, 173 intervention) participants in a historical control trial to test the intervention vs. standard-of-care. Participants received PITC and standard-of-care or the intervention counseling and we assessed sexual risk behavior at baseline and 3 and 6 months follow-up. The intervention condition showed 1.5-2.4 times greater decreases in high risk sexual behavior over time compared to standard-of-care (p = 0.015 and p = 0.004). These data suggest that motivational interviewing based counseling during PITC may be a promising intervention to reduce high-risk sexual behavior and potentially reduce risk of HIV infection.

Determinants of family planning service uptake and use of contraceptives among postpartum women in rural Uganda.

OBJECTIVE: Uganda has one of the highest unmet needs for family planning globally, which is associated with negative health outcomes for women and population-level public health implications. The present cross-sectional study identified factors influencing family planning service uptake and contraceptive use among postpartum women in rural Uganda. METHODS: Participants were 258 women who attended antenatal care at a rural Ugandan hospital. We used logistic regression models in SPSS to identify determinants of family planning service uptake and contraceptive use postpartum. RESULTS: Statistically significant predictors of uptake of family planning services included: education (AOR = 3.03, 95 % CI 1.57-5.83), prior use of contraceptives (AOR = 7.15, 95 % CI 1.58-32.37), partner communication about contraceptives (AOR = 1.80, 95 % CI 1.36-2.37), and perceived need of contraceptives (AOR = 2.57, 95 % CI 1.09-6.08). Statistically significant predictors of contraceptive use since delivery included: education (AOR = 2.04, 95 % CI 1.05-3.95), prior use of contraceptives (AOR = 10.79, 95 % CI 1.40-83.06), and partner communication about contraceptives (AOR = 1.81, 95 % CI 1.34-2.44). CONCLUSIONS: Education, partner communication, and perceived need of family planning are key determinants of postpartum family planning service uptake and contraceptive use, and should be considered in antenatal and postnatal family planning counseling.

Barriers to and acceptability of provider-initiated HIV testing and counselling and adopting HIV-prevention behaviours in rural Uganda: a qualitative study.

In Uganda, a nationwide scale-up of provider-initiated HIV testing and counselling presents an opportunity to deliver HIV-prevention services to large numbers of people. In a rural Ugandan hospital, focus group discussions and key informant interviews were conducted with outpatients receiving provider-initiated HIV testing and counselling and staff to explore the HIV-prevention information, motivation and behavioural skills strengths and weaknesses, and community-level and structural barriers to provider-initiated HIV testing and counselling acceptability and HIV prevention among this population. Strengths and weakness occurred at all levels, and results suggest brief client-centred interventions during provider-initiated HIV testing and counselling may be an effective approach to increase prevention behaviours in outpatient settings.

An empirical test of the Theory of Planned Behaviour applied to contraceptive use in rural Uganda.

There is a high unmet need for contraceptives in developing countries such as Uganda, with high population growth, where efforts are needed to promote family planning and contraceptive use. Despite this high need, little research has investigated applications of health-behaviour-change theories to contraceptive use among this population. This study tested the Theory of Planned Behaviour's ability to predict contraceptive-use-related behaviours among post-partum women in rural Uganda. Results gave modest support to the theory's application and suggest an urgent need for improved theory-based interventions to promote contraceptive use in the populations of developing countries.

Initial outcomes of provider-initiated routine HIV testing and counseling during outpatient care at a rural Ugandan hospital: risky sexual behavior, partner HIV testing, disclosure, and HIV care seeking.

Provider-initiated routine HIV testing is being scaled up throughout the world, however, little is known about the outcomes of routine HIV testing on subsequent behavior. This study examined the initial outcomes of provider-initiated routine HIV testing at a rural Ugandan hospital regarding partner HIV testing, sexual risk behavior, disclosure, and HIV care seeking. In a prospective cohort study, 245 outpatients receiving routine HIV testing completed baseline and 3-month follow-up interviews. After receiving routine HIV testing the percentage of participants engaging in risky sex decreased from 70.1% to 50.3% among HIV-negative and from 75.0% to 53.5% among HIV-positive participants, the percentage knowing their partner(s)' HIV status increased from 18.7% to 34.3% of HIV-negative and from 14.3% to 35.7% of HIV-positive participants. Among those reporting risky sex at baseline, HIV-positive participants were more likely to eliminate risky sex in general and specifically to become abstinent at follow-up than were HIV-negative participants. Similarly, unmarried participants who were risky at baseline were more likely to become safe in general, become abstinent, and start 100% condom use than were married/cohabitating participants. Rates of disclosure were high. Over 85% of those who tested HIV positive enrolled in care. Routine HIV testing in this setting may promote earlier HIV diagnosis and access to care but leads to only modest reductions in risky sexual behavior. To fully realize the potential HIV prevention benefits of routine HIV testing an emphasis on tailored risk-reduction counseling may be necessary.