Increasing coverage and uptake of voluntary family planning in Uganda's emerging municipalities and secondary cities: An implementation research study protocol.

INTRODUCTION: While urban areas are often perceived to have better access to healthcare services, including modern family planning (FP) services, urban dwellers including those with better socioeconomic status are faced with multidimensional challenges that shape their access to appropriate FP services. In Uganda's urban spaces, there is currently a lack of understanding among service providers, civil society organizations, and individuals/communities regarding the implementation of interventions that promote informed choice and voluntary use of family planning services. This knowledge gap has profound implications for reproductive rights. This study seeks to enhance existing efforts towards increasing coverage and uptake of Voluntary Family Planning (VFP) in Jinja City and Iganga Municipality, central eastern Uganda. Our primary question is, "What interventions can effectively be packaged and delivered to increase the uptake of VFP among different segments of urban residents?" METHODS: We propose to use the Human-Centered Design (HCD) approach to understand the needs and challenges of users and community capabilities in ensuring access to VFP services. Co-creating with stakeholders' engagement and a data-driven-centric approach will steer design and adaptation that respond to the different population segments within the urban space. As such, the study will be implemented in three phases: formative assessment, design and implementation, and implementation monitoring and evaluation. The implementation process will incorporate robust monitoring, learning, and adaptation mechanisms. The primary focus of these mechanisms will be to utilize gathered information effectively to inform the design of the implementation and facilitate continuous learning throughout the process. The study will apply a process monitoring and evaluation approach to address questions related to what package of FP interventions work, for whom, under what circumstances and why. DISCUSSION: Guided by strong learning and implementation flexibility, we hypothesize that our implementation will provide segmentation-specific high-impact interventions in an urban context. REGISTRATION: This implementation research protocol has been registered on the Open Science Framework (OSF) repository Registries (https://osf.io/vqxu9; DOI: 10.17605/OSF.IO/VQXU9).

Many Cooks in the Kitchen: Iterating a Qualitative Analysis Process Across Multiple Countries, Sites, and Teams.

Establishing and proving methodological rigor has long been a challenge for qualitative researchers where quantitative methods prevail, but much published literature on qualitative analysis assumes a relatively small number of researchers working in relative proximity. This is particularly true for research conducted with a grounded theory approach. Different versions of grounded theory are commonly used, but this methodology was originally developed for a single researcher collecting and analyzing data in isolation. Although grounded theory has evolved since its development, little has been done to reconcile this approach with the changing nature and composition of international research teams. Advances in technology and an increased emphasis on transnational collaboration have facilitated a shift wherein qualitative datasets have been getting larger and the teams collecting and analyzing them more diverse and diffuse. New processes and systems are therefore required to respond to these conditions. Data for this article are drawn from the experiences of the Innovations for Choice and Autonomy (ICAN) Research Consortium. ICAN aims to understand how self-injectable contraceptives can be implemented in ways that best meet women's needs in Kenya, Uganda, Malawi, and Nigeria. We found that taking a structured approach to analysis was important for maintaining consistency and making the process more manageable across countries. However, it was equally important to allow for flexibility within this structured approach so that teams could adapt more easily to local conditions, making data collection and accompanying analysis more feasible. Meaningfully including all interested researchers in the analysis process and providing support for learning also increased rigor. However, competing priorities in a complex study made it difficult to adhere to planned timelines. We conclude with recommendations for both funders and study teams to design and conduct global health studies that ensure more equitable contributions to analysis while remaining logistically feasible and methodologically sound.

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries.

BACKGROUND: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

How a co-design process led to more contextually relevant family planning interventions in emerging urban settings in Eastern Uganda.

Voluntary, rights-based family planning upholds women's right to determine freely the number and spacing of their children. However, low-resource settings like Uganda still face a high unmet need for family planning. And, while urban areas are often indicated to have better access to health services, emerging evidence is revealing intra-urban socio-economic differentials in family planning utilization. To address the barriers to contraceptive use in these settings, understanding community-specific challenges and involving them in tailored intervention design is crucial. This paper describes the use of co-design, a human-centred design tool, to develop context-specific interventions that promote voluntary family planning in urban settings in Eastern Uganda. A five-stage co-design approach was used: 1) Empathize: primary data was collected to understand the problem and people involved, 2) Define: findings were shared with 56 participants in a three-day in-person co-design workshop, including community members, family planning service providers and leaders, 3) Ideate: workshop participants generated potential solutions, 4) Prototype: participants prioritized prototypes, and 5) Testing: user feedback was sought about the prototypes. A package of ten interventions was developed. Five interventions targeted demand-side barriers to family planning uptake, four targeted supply-side barriers, and one addressed leadership and governance barriers. Involving a diverse group of co-creators provided varied experiences and expertise to develop the interventions. Participants expressed satisfaction with their involvement in finding solutions to challenges in their communities. However, power imbalances and language barriers were identified by the participants as potential barriers to positive group dynamics and discussion quality. To address them, participants were separated into groups, and medical terminologies were simplified during brainstorming sessions. These changes improved participation and maximized the contributions of all participants. It is therefore important to consider participant characteristics and their potential impact on the process, especially when engaging diverse participant groups, and implement measures to mitigate their effects.

Tale of 22 cities: utilisation patterns and content of maternal care in large African cities.

INTRODUCTION: Globally, the majority of births happen in urban areas. Ensuring that women and their newborns benefit from a complete package of high-quality care during pregnancy, childbirth and the postnatal period present specific challenges in large cities. We examine health service utilisation and content of care along the maternal continuum of care (CoC) in 22 large African cities. METHODS: We analysed data from the most recent Demographic and Health Survey (DHS) since 2013 in any African country with at least one city of ≥1 million inhabitants in 2015. Women with live births from survey clusters in the most populous city per country were identified. We analysed 17 indicators capturing utilisation, sector and level of health facilities and content of three maternal care services: antenatal care (ANC), childbirth care and postnatal care (PNC), and a composite indicator capturing completion of the maternal CoC. We developed a categorisation of cities according to performance on utilisation and content within maternal CoC. RESULTS: The study sample included 25 326 live births reported by 19 217 women. Heterogeneity in the performance in the three services was observed across cities and across the three services within cities. ANC utilisation was high (>85%); facility-based childbirth and PNC ranged widely, 77%-99% and 29%-94%, respectively. Most cities showed inconsistent levels of utilisation and content across the maternal CoC, Cotonou and Accra showed relatively best and Nairobi and Ndjamena worst performance. CONCLUSION: This exploratory analysis showed that many DHS can be analysed on the level of large African cities to provide actionable information about the utilisation and content of the three maternal health services. Our comparative analysis of 22 cities and proposed typology of best and worst-performing cities can provide a starting point for extracting lessons learnt and addressing critical gaps in maternal health in rapidly urbanising contexts.

Knowledge and use of lactational amenorrhoea as a family planning method among adolescent mothers in Uganda: a secondary analysis of Demographic and Health Surveys between 2006 and 2016.

OBJECTIVE: To assess the level of knowledge and use of the lactational amenorrhoea method (LAM) among adolescents in Uganda between 2006 and 2016 using nationally representative data from Demographic and Health Surveys (DHS). DESIGN: Cross-sectional design involving analysis of three DHS (2006, 2011, and 2016) in Uganda. SETTING: The data collection took place in Uganda. The DHS are nationally representative surveys on a wide range of indicators including contraception knowledge and use. PARTICIPANTS: A total of 1948 (2006), 2026 (2011) and 4276 (2016) adolescents (15-19 years) and 1662 (2006), 1666 (2011) and 3782 (2016) young women (20-24 years) were included. PRIMARY OUTCOME MEASURE: Use of LAM among adolescents and young women with a live birth within 6 months before each survey. RESULTS: In 2016, less than 1.0% (95% CI: 0.2% to 3.5%) of eligible adolescents correctly used LAM, and 56.3% (95% CI: 48.8% to 63.6%) were passively benefitting from LAM. The median duration of postpartum amenorrhoea (PPA) among adolescents in 2016 was 6.9 months, declining from 8.3 months in 2006. Compared with adolescents (56.7%), eligible young women had higher knowledge of LAM (64.1%) and higher median PPA duration (8.0 months) in 2016. The percentage of eligible adolescents who met the LAM criteria irrespective of whether they reported LAM use (were protected by LAM) decreased from 76.4% (95% CI: 66.5% to 84.0%) in 2006 to 57.2% (95% CI: 49.5% to 64.6%) in 2016. More than 50.0% (95% CI: 49.2% to 63.8%) of eligible adolescents were aware of LAM in 2016, increasing from 6.0% (95% CI: 2.5% to 13.8) in 2006. CONCLUSION: Despite increasing awareness of LAM, reported and correct use of LAM was low among adolescents who could benefit from this method in Uganda, and declining over time. Support for adolescents to harness the benefits of correct LAM use should be increased. Additional research is needed to better understand the dynamics of LAM use in adolescents, including the transition to use of other modern contraceptive methods.

Levels of depression, anxiety, and psychological distress among Ugandan adults during the first wave of the COVID-19 pandemic: cross-sectional evidence from a mobile phone-based population survey.

Objectives: Policy measures to slow the spread of coronavirus disease 2019 (COVID-19), such as curfews and business closures, may have negative effects on mental health. Populations in low- and middle-income countries (LMICs) may be particularly affected due to high rates of poverty and less comprehensive welfare systems, but the evidence is scarce. We evaluated predictors of depression, anxiety, and psychological distress in Uganda, which implemented one of the world's most stringent lockdowns. Methods: We conducted a mobile phone-based cross-sectional survey from December 2020 through April 2021 among individuals aged 18 years or over in Uganda. We measured depression, anxiety, and psychological distress using the Patient Health Questionnaire (PHQ)-2, the Generalized Anxiety Disorder (GAD)-2, and the PHQ-4. We applied linear regression to assess associations between experiences of COVID-19 (including fear of infection, social isolation, income loss, difficulty accessing medical care, school closings, and interactions with police) and PHQ-4 score, adjusted for sociodemographic characteristics. Results: 29.2% of 4066 total participants reported scores indicating moderate psychological distress, and 12.1% reported scores indicating severe distress. Distress was most common among individuals who were female, had lower levels of education, and lived in households with children. Related to COVID-19, PHQ-4 score was significantly associated with difficulty accessing medical care, worries about COVID-19, worries about interactions with police over lockdown measures, and days spent at home. Conclusions: There is an urgent need to address the significant burden of psychological distress associated with COVID-19 and policy responses in LMICs. Pandemic mitigation strategies must consider mental health consequences.

Knowledge and Information Exposure About Family Planning Among Women of Reproductive Age in Informal Settlements of Kira Municipality, Wakiso District, Uganda.

Introduction: A high unmet need for family planning (FP) prevails in sub-Saharan Africa. Knowledge, awareness creation, and ensuring accessibility are frequently used to increase FP uptake. However, evidence on knowledge or information dissemination about FP among marginalized populations in urban settings in Africa is limited. This study explored the knowledge of FP methods, media exposure, and contact with FP providers among women from an informal settlement in Uganda. Methods: Using a cross-sectional study design, we interviewed 626 women aged 15-49 years living in informal settlements of Kira municipality, selected through multistage sampling. Using a standard questionnaire, data was collected on socioeconomic characteristics, knowledge of FP methods, and access to media FP messages among others. Binomial log-linear regression was used to assess disparities in exposure to media FP messages or provider information. Data were analyzed using STATA version 14, at a 5% level of statistical significance. Results: Nearly all women in the survey were aware of FP methods (99.7%). On average, each woman was aware of 10 FP methods. The most commonly known methods were male condoms (98.2%), injectables (97.4%), and the oral contraceptive pill (95.2%). Use of any contraceptive was found among 42.7% of respondents. Exposure to media was found in 70.6% of the respondents, mostly through television (58.5%) and radio (58.3%). Discussing FP with a provider was significantly associated with media exposure (aPR 1.4, 95% CI: 1.24-1.56). Less than 50% of women who were not using FP had contact with an FP provider. Women in union (aPR 1.6, 95% CI: 1.01-2.68) and those with access to media messages (aPR 2.5, 95% CI: 1.37-4.54) were more likely to have contact with a provider to discuss FP. Conclusion: There is high general awareness about FP methods and media exposure, but method use was low. Further exploration of women's understanding of FP methods and the fit between existing education programs and FP knowledge needs in this urban setting should be conducted. The potential for mobile health solutions in this urban population should be explored. Future studies should focus on the knowledge and understanding of FP among unmarried and nulliparous women and those with no access to media information.

Total Demand, Use and Unmet Need for Modern Contraceptives Among Women Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda. Implications for Urban Health.

Background: Update and utilization of modern contraceptives has public health benefits including reduction of unintended pregnancies, unsafe abortions, and related maternal mortality. However, paucity of evidence on key indicators of family planning in the informal settlements abounds. Data are usually collapsed within the larger urban communities that tend to mask peculiarities of informal settlements. This study determined the proportion of women using modern contraceptives, the unmet need for modern contraceptives and the total demand in informal settlements of an urban municipality. Methods: A cross-sectional study conducted among 626 women in the reproductive age (15-49 years) in the informal settlements of Kira municipality (part of metropolitan Kampala). Multi-stage sampling was applied in the selection of the respondents. Descriptive and log-binomial regression analysis were conducted to determine percentage of women using modern contraceptives, unmet need, and total demand with their associated factors. All analyses were conducted using STATA version 15.0. Results: The total demand for modern contraceptives was 84.9%, modern contraceptive prevalence was 47.4% nearly meeting the national target of 50%, however the unmet need was 37.3%, which much higher than the national target of 10%. Lower total demand for contraceptives was associated with higher women's education status and preference to have another child, while higher total demand was associated with having at least one living child. Higher modern contraceptives use was associated with older age, having at least one living child and high decision-making power, while lower modern contraceptives use was associated with higher education and undetermined fertility preference. Lower unmet need for modern contraceptives was associated with older age (PR 0.68, 95% CI: 0.48-0.97) and high decision-making power (PR 0.64, 95% CI: 0.50-0.81), while higher unmet need was found among those who having at least one living child (PR 1.40, 95% CI: 1.01-1.93) and undetermined fertility preference (PR 1.70, 95% CI: 1.24-2.34). Conclusions: Total demand and contraceptive use were found to be higher in the informal settlements of Kira municipality, however, the unmet need was much higher among this population as compared to the national urban estimates. This indicates a much higher demand for contraceptives and the need to consider the diverse socio-demographic characteristics of urban spaces. Development of Interventions need to critically consider the diverse urban space, associated explanatory variables and a collaborative systems lens to achieve sustained improvements.

Framing Contraceptive Use Motivations Among Adolescents and Young Adults Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda.

Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not). Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda. Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives. Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

Quality and barriers of outpatient diabetes care in rural health facilities in Uganda - a mixed methods study.

BACKGROUND: Despite the increasing burden of diabetes in Uganda, little is known about the quality of type 2 diabetes mellitus (T2DM) care especially in rural areas. Poor quality of care is a serious limitation to the control of diabetes and its complications. This study assessed the quality of care and barriers to service delivery in two rural districts in Eastern Uganda. METHODS: This was a mixed methods cross-sectional study, conducted in six facilities. A randomly selected sample of 377 people with diabetes was interviewed using a pre-tested interviewer administered questionnaire. Key informant interviews were also conducted with diabetes care providers. Data was collected on health outcomes, processes of care and foundations for high quality health systems. The study included three health outcomes, six elements of competent care under processes and 16 elements of tools/resources and workforce under foundations. Descriptive statistics were computed to determine performance under each domain, and thematic content analysis was used for qualitative data. RESULTS: The mean age of participants was 49 years (±11.7 years) with a median duration of diabetes of 4 years (inter-quartile range = 2.7 years). The overall facility readiness score was 73.9%. Inadequacies were found in health worker training in standard diabetes care, availability of medicines, and management systems for services. These were also the key barriers to provision and access to care in addition to lack of affordability. Screening of clients for blood cholesterol and microvascular complications was very low. Regarding outcomes; 56.8% of participants had controlled blood glucose, 49.3% had controlled blood pressure; and 84.0% reported having at least one complication. CONCLUSION: The quality of T2DM care provided in these rural facilities is sub-optimal, especially the process of care. The consequences include sub-optimal blood glucose and blood pressure control. Improving availability of essential medicines and basic technologies and competence of health workers can improve the care process leading to better outcomes.

The availability of six tracer medicines in private medicine outlets in Uganda.

OBJECTIVES: Many low income countries struggle to provide safe and effective medicines due to poor public health care infrastructure, budgetary constraints, and lack of human resource capacity. Private sector pharmacies and drug shops are used by a majority of the population as an alternative to public pharmacies. This study looks at the availability of six essential medicines in private drug outlets across Uganda. METHODS: A standardised medicines availability survey developed by the World Health Organization and Health Action International was adapted for use in this project to collect availability data for six tracer medicines in 126 private medicine outlets across four districts in Uganda from September 2011 to October 2012. RESULTS: Artemisinin-based combination treatments and metformin were the most commonly found medicines in the private medicine outlets surveyed. Ninty-nine percent of all outlets carried artemisinin-based combinations while 93% of pharmacies and 53% of drug shops stocked metformin. Oxytocin was found in one third of outlets surveyed. Fluoxetine was in 70% of pharmacies yet was not found in any drug shops. Rifampicin and lamivudine were found infrequently in outlets across all districts; 10% and 2%, respectively. Not all brands found in surveyed outlets were listed on the Ugandan National Drug Register. In particular, five unlisted brands of rifampicin were found in private medicine outlets. CONCLUSIONS: The regulatory process should be improved through the enforcement of outlet licensing and medicine registration. Additional studies to elucidate the reasons behind the use of private medicine outlets over the public sector would assist the government in implementing interventions to increase use of public sector medicine outlets.