'What kind of life is this?' Diabetes related notions of wellbeing among adults in eastern Uganda and implications for mitigating future chronic disease risk.

BACKGROUND: Effective prevention and care for type 2 diabetes requires that people link healthy behaviours to chronic disease-related wellbeing. This study explored how people perceive current and future wellbeing, so as to inform lifestyle education. METHODS: Eight focus group discussions and 12 in-depth interviews were conducted in Iganga and Mayuge districts in rural Eastern Uganda among people aged 35-60 years in three risk categories (1) People with diabetes, (2) people at higher risk of diabetes (with hypertension or overweight) and (3) community members without diabetes. RESULTS: People define wellbeing in three notions: 1) Physical health, 2) Socio-economic status and 3) Aspirational fulfilment. Most people hold the narrower view of wellbeing that focuses on absence of pain. Most overweight participants did not feel their condition as affecting their wellbeing. However, for several people with hypertension, the pains they describe indicate probable serious heart disease. Some people with diabetes expressed deep worry and loss of hope, saying that 'thoughts are more bothersome than the illness'. Wellbeing among people with diabetes was described in two perspectives: Those who view diabetes as a 'static' condition think that they cannot attain wellbeing while those who view it as a 'dynamic' condition think that with consistent treatment and healthy lifestyles, they can be well. While many participants perceive future wellbeing as important, people without diabetes are less concerned about it than those with diabetes. Inadequate knowledge about diabetes, drug stock-outs in health facilities, unaffordable healthier food, and contradictory information were cited as barriers to future wellbeing in people with diabetes. CONCLUSIONS: To make type 2 diabetes prevention relevant to healthy people, health education messages should link current lifestyles to future wellbeing. Diabetes patients need counselling support, akin to that in HIV care, to address deep worry and loss of hope.

Sexual behaviour among persons living with HIV/AIDS in Kampala, Uganda.

OBJECTIVE: To identify sexual behaviour and reproductive health needs of people living with HIV/AIDS (PLWHAs). DESIGN: A cross sectional study. SETTING: Joint Clinical Research Centre, Kampala Uganda. PARTICIPANTS: Three hundred and eighty PLWHAs, 50% of whom had initiated anti-retro viral therapy (ART). MAIN OUTCOME MEASURES: PLWHAs answered questions regarding sexual behaviour, number and type of sexual partners, symptoms of sexually transmitted infections, having been pregnant or causing a pregnancy, social demographic characteristics, consumption of alcohol, having biological children, desire for more children and use of condoms. RESULTS: In the past 12 months 227 (60%) of the PLWHAs were sexually active. Of the sexually active 42 (19%) never used a condom, and 92 (40%) used condoms inconsistently, thus 134 (35%) of PLWHAs engaged in high risk sex. Two hundred and sixty five (70%) said that PLWHAs can have healthy children and 115 (30%) desired more children with 21 (10%) of the women in the reproductive age group reporting a pregnancy and 22 (17%) of the men reporting having caused a pregnancy. Only three (7%) of the pregnancies were unplanned. Desire for more children was a strong independent predictor of engaging in high risk sex (Adjusted Odds Ratio 2.44, 95% CI 1.35-4.42). CONCLUSIONS: This study demonstrates that abstinence and use of condoms on their own may not be enough for HIV prevention among PLWHAs who desire children. Additional methods such as use of ART to reduce HIV infectiousness and sperm washing are needed.

Strategies for sustainability and equity of prepayment health schemes in Uganda.

BACKGROUND: Despite the long existence of community health insurance schemes (CHI) in Uganda, their numbers and coverage levels have remained small with limited accessibility by the poor. OBJECTIVES: To examine issues of equity and sustainability in CHI schemes, which are prerequisites to health sector financing. METHODS: We carried out a descriptive cross-sectional study employing qualitative techniques. Eight focus group discussions (FGDs) with CHI scheme members and seven FGDs with non-members were held. Twelve Key informant interviews (KIs) were held with scheme managers, officials from Ministry of Health and one health financing organisation. We reviewed relevant documents and records of schemes. RESULTS: Respondents' perceptions of unfairness in schemes were: non-members were treated better in hospital than members; some members pay premiums continuously without falling sick and schemes refused to cover illnesses like diabetes and hypertension. Fairness was related with the very little payment for the services received, members paying less than non-members but both getting the same treatment and no patient discrimination based on gender, age or social status. Schemes are not sustainable because they operate on small budgets, have low enrolment and lack government support. Effect of abolition of user fees on scheme enrolment was minimal. CONCLUSION: Government should ensure that quality of health care does not deteriorate in the context of increased utilisation after user fees removal, schemes need substantial support to build their sustainability and there is need for technical and policy considerations about whether or not CHI has a role to play in Ugandan health system.

Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence.

Inequalities in the burden of disease and access to health care is a prominent concern in Uganda and other sub-Saharan African countries. This is a systematic review of socio-economic differences in morbidity and access to health care in Uganda. It includes published studies from electronic databases and official reports from surveys done by government, bilateral and multilateral agencies and universities. The outcome measures studied were: the distribution of HIV/AIDS; maternal and child morbidity; and access to and utilisation of health services for people belonging to different socio-economic and vulnerability groups. Forty-eight of 678 identified studies met our inclusion criteria. Results indicate that the poor and vulnerable experience a greater burden of disease but have lower access to health services than the less poor. Barriers to access arise from both the service providers and the consumers. Distance to service points, perceived quality of care and availability of drugs are key determinants of utilisation. Other barriers are perceived lack of skilled staff in public facilities, late referrals, health worker attitude, costs of care and lack of knowledge. Longitudinal and controlled studies are needed to see if strategies to improve access to services reach the poor.