Decision-making pathways for contraceptive use among refugee and host populations in Adjumani district, Uganda; an exploratory study.

INTRODUCTION: Contraceptive use is known to have a positive impact on maternal and child health outcomes; however, its use is still low in low-income countries, especially among people in humanitarian situations. This study explored decision-making processes towards the use of contraceptives by people in humanitarian situations to inform program design and uptake. METHODS: A qualitative exploratory study was conducted among women of reproductive age (15-49 years) and men (15-60 years) living in three refugee settlements of Pagirinya, Nyumanzi, and Mirieyi and the surrounding host communities in Adjumani district, Uganda. Data were collected using 49 in-depth interviews (IDIs), 11 Key Informant Interviews (KIIs,) and 20 Focus Group Discussions (FGDs). Inductive thematic analysis was done with the aid of Atlas ti. Version 14. RESULTS: We found that the decision-making processes entailed linear and nonlinear internalized cognitive and contextual processes involving four dynamic pathways. In the linear pathway, participants reported starting with 1) idea inception, 2) followed by cognitive processing, 3) consultation, and 4) decision-making for contraceptive use. The complex linear pathway happened when participants did not go through consultation but went straight to decision-making. However, participants who followed the non-linear pathway repeatedly went back to cognitive processing. Some women after consultation, or those already using and those not using contraceptives, decided to go back to cognitive processing to reconsider their current positions. This study found that some women who were not using contraceptives ended up using, while some who were using contraception ended up dropping out. CONCLUSIONS: This study showed dynamic decision-making processes involving both internal and external environments as triggers to decision-making for contraceptive use. Interventions to increase contraceptive use should target both users and significant others who influence the decision to use particularly among refugees. TRIAL REGISTRATION: This study was registered by Makerere University School of Public Health Higher Degrees Research and Ethic Committee (HDREC) #188 and approved by Uganda National Council of Science and Technology on 15th/7/2021, Registration number-SS809ES.

Factors associated with family planning use among refugee and host populations in Adjumani district, West Nile, Uganda: a comparative study.

INTRODUCTION: Uganda currently hosts an estimated 1.5 million refugees. The refugees have challenges in accessing family planning (FP) services in the host country. The study aimed to investigate factors associated with FP use among host and refugee populations in Adjumani district, Uganda. METHODS: A comparative cross-sectional study was conducted in May 2021 in three refugee settlements and their host communities in Adjumani district. A total of 1,310 respondents, (664 refugees and 646 host) were randomly selected using multistage cluster sampling and interviewed. Quantitative data were collected using structured questionnaires and analyzed using STATA V.15. Descriptive and Multivariate analysis performed. RESULTS: We found that modern Contraceptive Prevalence Rate (mCPR) was 30.2% (32.2% for host and 28.2% for refugees). Multivariate analysis showed that women who live singly (AOR = 2.25, 95%, CI: 1.56 -3.84), completed primary education [AOR = 1.65, 95% CI: 1.27-2.16], acquired skills [AOR = 2.28, 95% CI: 2.11-2.47], have the desire for another child [AOR = 3.73, 95% CI: 1.45- 9.60], have stayed in the study area between 3-5 years [AOR = 2.24, 95% CI: 1.46-3.42] were statistically significantly associated with FP use among both refugee and host populations. The key barrier to FP use by host was harassment of women and separation/divorce for not consulting the family members. Whereas amongst the refugees, they do not want to use FP methods. CONCLUSION: Our findings revealed low FP use amongst both populations in Adjumani district. The main factors associated with FP use amongst refugee populations included marital status, level of education, type of occupation, and duration of stay in the study area whereas amongst the host is the marital status. Main reasons for not using FP methods included fear of side effects by hosts and not wanting to use FP by refugees. There is need to sensitize both communities about the benefits of FP at community level.

Prevalence and factors associated with hepatitis b vaccination uptake and completion among communities targeted for mass vaccination in gulu: a cross-sectional study.

BACKGROUND: Hepatitis B virus (HBV) is associated with several acute and long-term complications and vaccination is the cornerstone of prevention. A recent outbreak in Gulu, Uganda, one of the districts covered by a mass vaccination campaign, suggests low uptake of HBV vaccination. This study aims to determine the uptake and completion of HBV vaccination and associated factors among residents of Gulu, Uganda. METHODS: A mixed methods cross-sectional study was conducted in Gulu, Northern Uganda, among 434 adult residents. A pretested questionnaire was used to collect data on socio-demographics, perceptions, and knowledge of HBV vaccination. Modified Poisson regression analysis was used in STATA 14 software to obtain prevalence ratios for the association between the independent and dependent variables. For qualitative data, 9 key informant interviews were conducted and thematic analysis was done using Quirkos software. RESULTS: Out of the 434 respondents, 41.9% had received at least one dose of the hepatitis B vaccine, 32.5% had received at least 2 doses, and only 20% had completed all 3 doses, with an overall completion rate of 47.8% for participants who had been initiated on the vaccine. Gender, residence, risk perception of Hepatitis B infection, perceived safety of the vaccine, and awareness of mass vaccination were associated with uptake of Hepatitis B vaccination. Residence, knowledge, and perception of being at risk of acquiring Hepatitis B were associated with completion. Qualitative results revealed that the levels of uptake and completion could have been affected by access to vaccination sites; inadequate knowledge about the disease; myths about the vaccine and inadequate community engagement. CONCLUSION: Low Hepatitis B vaccine uptake and completion rates were observed in Gulu. To enhance vaccination coverage, future initiatives should prioritize awareness, education, and dispelling of vaccination myths. Additionally, increased government investment in training health workers can serve as a valuable strategy to improve information dissemination and awareness among the population.

Attitudes and perceptions towards developing a health educational video to enhance optimal uptake of malaria preventive therapy among pregnant women in Uganda: a qualitative study involving pregnant women, health workers, and Ministry of health officials.

BACKGROUND: Malaria in pregnancy remains a major global public health problem. Intermittent prophylaxis treatment of malaria in pregnancy with Sulphadoxine-pyrimethamine and co-trimoxazole is efficacious for prevention of malaria in pregnancy HIV negative and positive women, respectively. However, uptake of the recommended doses of therapies has remained suboptimal in Uganda, majorly due to inadequate knowledge among pregnant women. Therefore, this study aimed to explore attitudes and perceptions towards developing an educational video for malaria preventive therapy. METHODS: We conducted an exploratory study with qualitative methods among pregnant women attending antenatal care at Kisenyi Health Center IV (KHCIV), health workers from KHCIV, and officials from the Ministry of Health. The study was conducted at KHCIV from October 2022 to March 2023. Focus group discussions (FGD) were conducted among purposively selected pregnant women and key informant interviews (KII) among health workers and Ministry of Health officials. Data were analyzed using inductive and deductive thematic methods in atlas ti.8. RESULTS: A total of five FGDs comprising of 7-10 pregnant women were conducted; and KIIs were conducted among four mid-wives, two obstetricians, and two Ministry of Health officials. Generally, all respondents mentioned a need for interventions to improve malaria preventive knowledge among pregnant women; were positive about developing an educative video for malaria preventive therapy in pregnancy; and suggested a short, concise, and edutaining video focusing both the benefits of taking and risks of not taking malaria preventive therapy. They proposed that women may be encouraged to view the video as soon as they conceive and throughout the pregnancy. It also was suggested that the video may be viewed on television sets in maternal and reproductive health clinics and homes, and on smart phones. CONCLUSION: Pregnant women, health workers, and Ministry of Health officials were positive about the development of a short edutaining video on malaria preventive therapy that focuses on both benefits of taking and risks of not taking the malaria preventive therapy in pregnancy. This information guided the video development and therefore, in the development of health educative videos, client and stakeholder inputs may always be solicited.

A qualitative study of influences on the uptake of contraceptive services among people of reproductive age in Uganda.

BACKGROUND: Uganda has registered an increased investment in family planning (FP) programs, which has contributed to improvement in knowledge of modern contraceptive methods being nearly universal. However, this has not matched the uptake of modern methods or the reduction in the unmet need for FP. This may be explained by the different influences which include health workers, family, and friends. Due to the limited uptake of contraceptive methods, a program on improving awareness, access to, and uptake of modern contraceptives is being implemented in selected regions in Uganda. We, therefore, conducted a formative study to determine the influences on contraceptive uptake at the onset of this program. METHODS: Using a qualitative study design, we conducted thirty-two focus group discussions and twenty-one in-depth interviews involving men and women of reproductive age. We also carried out twenty-one key informant interviews with people involved in FP service delivery. Data was collected in four districts where implementation of the program was to take place. Audio recorders were used to collect data and tools were translated into local languages. A codebook was developed, and transcripts were coded in vivo using the computer software Atlas-ti version 7 before analysis. Ethical clearance was obtained from institutional review boards and informed consent was sought from all participants. RESULTS: From the study, most married people mentioned health workers as their main influence while adolescents reported their peers and friends. Religious leaders and mothers-in-law were reported to mainly discourage people from taking up modern contraceptive methods. The cultural value attached to having many children influenced the contraceptive use decision among people in rural settings. Other influences included a person's experience and housing. CONCLUSIONS: Health workers, religious leaders, and mothers determine the uptake of contraceptive services. The study recommends the consideration of the role of these influences in the design of FP program interventions as well as more involvement of health workers in sensitization of communities about contraceptive methods.

Child pedestrian crossing behaviour and associated risk factors in school zones: a video-based observational study in Kampala, Uganda.

BACKGROUND: Pedestrian crashes, often occurring while road crossing and associated with crossing behaviour, make up 34.8% of road casualties in Uganda. This study determined crossing behaviour and associated factors among child pedestrians around primary schools in Kampala, Uganda. METHODS: We conducted a cross-sectional study in 2022 among 2100 primary school children. Data on their crossing behaviour were collected using video recordings from cameras staged at the crossing points of 21 schools. We estimated prevalence ratios (PR) with their corresponding 95% CIs using a modified Poisson regression model for the association between unsafe behaviour and the predictors. RESULTS: The prevalence for each of 5 unsafe child pedestrian behaviour was 206 (25.8%) for crossing outside the crosswalk, 415 (19.8%) for failing to wait at the kerb, 238 (11.3%) for failing to look for vehicles, 361 (17.2%) for running and 235 (13%) for crossing between vehicles. There was a higher likelihood of crossing outside the crosswalk when an obstacle was present (adjusted PR (aPR) 1.8; 95% CI 1.40 to 2.27) and when children crossed alone (aPR 1.5; 95% CI 1.13 to 2.06). Children who crossed without a traffic warden (aPR 2; 95% CI 1.40 to 2.37) had a significantly higher prevalence of failing to wait at a kerb. CONCLUSION: These findings reveal the interaction between child pedestrians, vehicles and the environment at crossings. Some factors associated with unsafe child pedestrian behaviour were the presence of an obstacle, crossing alone and the absence of a traffic warden. These findings can help researchers and practitioners understand child pedestrian crossing behaviour, highlighting the need to prioritise targeted safety measures.

Perceptions and factors associated with the uptake of the community client-led antiretroviral therapy delivery model (CCLAD) at a large urban clinic in Uganda: a mixed methods study.

INTRODUCTION: Community Client-Led ART Delivery (CCLAD) is a community HIV care model. In this model, a group of persons living with HIV (PLHIV) in a specific location, take turns going to the HIV clinic to pick up Antiretroviral Treatment refills for members. The uptake of this model, however, remains low despite its improvements in patient retention. In this study, we explored PLHIV's perceptions of this model and identified the factors associated with its low uptake. METHODS: This was a mixed methods study based on a retrospective review of records of PLHIV and in-depth interviews. We reviewed the medical records of people receiving ART to determine their current model of ART delivery and conducted in-depth interviews with 30 participants who were eligible to be enrolled in the CCLAD model at the Mulago ISS clinic. We performed logistic regression to identify factors associated with the uptake of the CCLAD model and inductive thematic analysis to explore PLHIV's perceptions of the CCLAD model. RESULTS: A total of 776 PLHIV were sampled for the study, 545 (70.2%) of whom were female. The mean age (standard deviation) was 42 (± 9.3) years. Overall, 55 (7.1%) received ART using the CCLAD model. Compared to other ART-delivery models, CCLAD was associated with being on ART for at least eight years (AOR 3.72; 95% CI: 1.35-10.25) and having no prior missed clinic appointments (AOR 10.68; 95% CI: 3.31-34.55). Mixed perceptions were expressed about the CCLAD model. Participants interviewed appreciated CCLAD for its convenience and the opportunities it offered members to talk and support each other. Others however, expressed concerns about the process of group formation, and feeling detached from the health facility with consequences of lack of confidentiality. CONCLUSION: The current uptake of the CCLAD model is lower than the national recommended percentage of 15%. Its uptake was associated with those who had been in care for a longer period and who did not miss appointments. Despite CCLAD being perceived as convenient and as promoting support among members, several challenges were expressed. These included complexities of group formation, fear of stigma and feelings of detachment from health facilities among others. So, while CCLAD presents a promising alternative ART delivery model, more attention needs to be paid to the processes of group formation and improved patient monitoring to address the feelings of detachment from the facility and facility staff.

Socio-economic and education related inequities in use of modern contraceptive in seven sub-regions in Uganda.

BACKGROUND: Advocacy for equity in health service utilization and access, including Family Planning (FP) continues to be a cornerstone in increasing universal health coverage. Inequities in Family planning are highlighted by the differences in reproductive health outcomes or in the distribution of resources among different population groups. In this study we examine inequities in use of modern contraceptives with respect to Socio-economic and Education dimensions in seven sub-regions in Uganda. METHODS: The data were obtained from a baseline cross-sectional study in seven statistical regions where a program entitled "Reducing High Fertility Rates and Improving Sexual Reproductive Health Outcomes in Uganda, (RISE)" is implemented in Uganda. There was a total of 3,607 respondents, half of whom were women of reproductive age (15-49 years) and the other half men (18-54 years). Equity in family planning utilization was assessed by geography, wealth/economic and social-demographics. The use of modern family planning was measured as; using or not using modern FP. Concentration indices were used to measure the degree of Inequality in the use of modern contraceptives. Prevalence Ratios to compare use of modern FP were computed using modified Poisson regression run in STATA V15. RESULTS: Three-quarters (75.6%) of the participants in rural areas were married compared to only 63% in the urban. Overall use of modern contraceptives was 34.2% [CI:30.9, 37.6], without significant variation by rural/urban settings. Women in the higher socio-economic status (SES) were more advantaged in use of modern contraceptives compared to lower SES women. The overall Erreygers Concentration Index, as a measure of inequity, was 0.172, p<0.001. Overall, inequity in use of modern contraceptives by education was highest in favor of women with higher education (ECI=0.146, p=0.0001), and the concentration of use of modern contraceptives in women with higher education was significant in the rural but not urban areas CONCLUSION: Inequities in the use of modern contraceptives still exist in favor of women with more education or higher socio-economic status, mainly in the rural settings. Focused programmatic interventions in rural settings should be delivered if universal Family Planning uptake is to be improved.

Barriers to HIV care in Uganda and implications for universal test-and-treat: a qualitative study.

Achieving universal HIV test-and-treat will require targeted interventions for those with worse outcomes, including advanced HIV. We conducted qualitative, semi-structured interviews with healthcare workers (HCWs) and people living with HIV (PLWH) at 5 HIV clinics in Kampala, Uganda, to understand barriers to care. PLWH enrolled started/restarted on HIV treatment ≤3 months prior. PLWH were grouped as 1) "ART-experienced" or those restarted therapy after ≥12 months off, 2) ART naïve CD4 count <100 cells/uL "late presenters" or 3) ART naïve CD4 count >350 cells/uL "early presenters". In-depth interviews were conducted in Luganda, translated, and transcribed verbatim. Between May and August 2017, 58 PLWH and 20 HCWs were interviewed. High stigma and low social support emerged as themes among all as barriers to care. Alcohol abuse was a barrier for men. Fear of domestic violence and abandonment were barriers for women, limiting disclosure of their HIV status to their male partners. Clinic factors such as rapport with staff, distance, efficiency, and privacy impacted care. Future interventions to decrease delayed ART initiation should target stigma and social support. Assisted disclosure, contact tracing, and alcohol abuse treatment should be implemented. Strengthening client support, reducing wait times, and increasing privacy assurances would improve care-seeking behaviors.

Developing strategies to address barriers for tuberculosis case finding and retention in care among refugees in slums in Kampala, Uganda: a qualitative study using the COM-B model.

BACKGROUND: Globally, displaced populations face an increased burden of tuberculosis (TB). Uganda is currently hosting unprecedented big numbers of refugees from the East African region. Recent evidence shows increased spread of multi-drug resistant TB (MDR-TB) across East Africa as a result of migrants from Somalia- a high MDR-TB prevalent country, calling for urgent identification and management of cases for the countries in the region. One of the strategies recommended is optimization of diagnosis, treatment and prevention of TB in refugees. This study aimed at exploring the barriers to and facilitators for TB case finding and retention in care among urban slum refugees and suggestions on how to improve. This was to guide the development of interventions to improve TB case finding and retention in care among the said population. METHODS: A cross-sectional study utilizing qualitative methods was conducted among refugees in an urban slum in Kampala City, Uganda. Key informant interviews with health care workers and community leaders and in-depths interviews with refugee TB patients and care takers of TB patients were conducted (30 interviews in total). Interview questions were based on constructs from the COMB-B model (Capability, Opportunity and Motivation Model of Behaviour change). Manual content analysis was performed and identified targeted intervention strategies guided by the related Behavior Change Wheel implementation framework. RESULTS: Key barriers included; physical capability (availability of and easily accessible private facilities in the community with no capacity to diagnose and treat TB), psychological capability (lack of knowledge about TB among refugees), social opportunity (wide spread TB stigma and language barrier), physical opportunity (poor living conditions, mobility of refugees), reflective motivation (lack of facilitation for health workers), automatic motivation (discrimination and rejection of TB patients). Facilitators were; physical capability (availability of free TB services in the public health facilities), social opportunity (availability of translators). We identified education, incentivization, training, enablement, and restructuring of the service environment as relevant intervention functions with potential to address barriers to and enhance facilitators of TB case finding and retention among refugees in urban slums. CONCLUSION: The key barriers to TB control among refugees living urban slums in Kampala- Uganda, included; poor access to health services, limited knowledge about TB, TB stigma, language barrier and lack of facilitation of community health workers. Identified intervention strategies included; education, training, enablement, environmental restructuring and persuasion. The findings could serve as a guide for the design and implementation of interventions for improving the same.

Evaluating women's acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians: a mixed methods study.

BACKGROUND: Studies evaluating task sharing in postabortion care have mainly focused on women in first trimester and many lack a qualitative component. We aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients' lived treatment experiences in Uganda. METHODS: Our mixed methods study combined 1140 structured interview data from a randomized controlled equivalence trial and in-depth interviews (n = 28) among women managed with misoprostol for second trimester incomplete abortion at 14 public health facilities in Uganda. Acceptability, our main outcome, was measured at the 14-day follow-up visit using a structured questionnaire as a composite variable of: 1) treatment experience (as expected/ better than expected/ worse than expected), and 2) satisfaction - if patient would recommend the treatment to a friend or choose the method again. We used generalized mixed effects models to obtain the risk difference in acceptable post abortion care between midwife and physician groups. We used inductive content analysis for qualitative data. RESULTS: From 14th August 2018 to 16th November 2021, we assessed 7190 women for eligibility and randomized 1191 (593 to midwife and 598 to physician). We successfully followed up 1140 women and 1071 (94%) found the treatment acceptable. The adjusted risk difference was 1.2% (95% CI, - 1.2 to 3.6%) between the two groups, and within our predefined equivalence range of - 5 to + 5%. Treatment success and feeling calm and safe after treatment enhanced acceptability while experience of side effects and worrying bleeding patterns reduced satisfaction. CONCLUSIONS: Misoprostol treatment of uncomplicated second trimester incomplete abortion was equally and highly acceptable to women when care was provided by midwives compared with physicians. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient's access to postabortion care services. TRIAL REGISTRATION: ClinicalTrials.gov NCT03622073.

Approximately 9.6% of abortion-related deaths occur in Sub-Saharan Africa. These deaths can be prevented if unintended pregnancies are avoided, women can access safe abortions within the expectations of the country's laws, and post abortion care (PAC) services are provided equitably. Previous research shows that women with abortion complications in the first trimester of pregnancy can be treated with misoprostol by either midwives or physicians. This sharing of tasks between the midwives and physicians is safe, effective, and acceptable. However, there is a gap in evidence on task sharing in the second trimester. To check practicability of task sharing in second trimester, we aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients' lived treatment experiences. Our study therefore combined quantitative and qualitative approaches. Women's acceptability of misoprostol treatment for incomplete second trimester abortion was found to be equally acceptable when provided by midwives compared with physicians. Treatment success, feeling calm and safe after treatment increased acceptability, while experience of side effects and worrying bleeding patterns reduced satisfaction. Counselling of women may address some of these problems since it provides reassurance and reduces anxiety. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient's access to PAC services.

Awareness of pubertal body changes among primary school children aged 10-14 years in Eastern Uganda; challenges and opportunities.

BACKGROUND: Globally, programs that educate young people about pubertal body changes are vital. In some communities, teaching sexual education in schools has been the subject of debate. This is probably why access to sexual and reproductive health information and resources is still a challenge to children aged 10-14 years. METHODS: We conducted a qualitative study design among school children aged 10-14 years. Data were collected from 19 focus group discussions (FGDs) in 16 primary schools purposively selected from Eastern Uganda. Data were transcribed, coded and thematically analysed. RESULTS: We established that girls in rural schools were aware of their body changes than those from urban schools. Boys in urban schools were knowledgeable of pubertal body changes than those from rural schools. We further found that girls experienced pubertal-related challenges amongst themselves and boys including lack of shavers, pain while shaving, rape, bad boy-girl relationships, unwanted early pregnancies, limited funds to buy pads, menstrual pain, etc. Boys too indicated that they experienced similar challenges and these included lack of shavers, pain during and after shaving, changes in height, raping of girls, bad boy-girl relationships, peer pressure, HIV and other STIs, limited infrastructure, voice changes, bad body odour etc. Girls and boys endeavoured to overcome pubertal-related challenges by utilising advise from teachers, parents and friends. CONCLUSION: Boys and girls who were knowledgeable about puberty body changes possessed opportunities that enable them to cope with pubertal-related challenges.

Alike, every child is entitled to pubertal-related information irrespective of being-in-school or out-of-school. Children's understanding of their pubertal body changes is vital in as far as "positive" sexual health is concerned in their adulthood. In this study, we aimed at determining awareness of pubertal body changes, pubertal-related challenges faced by primary school children and opportunities for them to navigate through challenges during puberty. Data was collected from 19 FGDs conducted among boys and girls aged between 10 and 14 years from urban and rural schools in Jinja, Uganda. Our study found that girls in rural schools were aware of their body changes than those from urban schools probably due to the fact that girls in rural schools interact with many close relatives compared to those from urban schools. Pubertal-related challenges experienced by both girls and boys included lack of shavers, pain while shaving, rape, "bad" boy­girl relationships, unwanted early pregnancies, limited financial support, menstrual pain, peer pressure, sexually transmitted diseases, changes in voices, bad body odour etc. Unlike in girls, we found that boys in urban schools were knowledgeable of pubertal body changes than those from rural schools. Over all, our participants navigated through pubertal-related challenges by utilising advise from mainly their teachers, parents and friends. However, boys and girls who were aware of puberty body changes easily navigated through pubertal-related challenges. This therefore means that efforts to create awareness of pubertal-related challenges among young people especially those aged 10­14 years may yield positive results in one's sexual health during adulthood.

'Endure and excuse': a mixed-methods study to understand disclosure of intimate partner violence among women living with HIV in Uganda.

Intimate partner violence and HIV remain significant health challenges among women living with HIV. Intimate partner violence has been linked to negative health outcomes and poorer HIV care engagement. This study examined intimate partner violence among Ugandan women living with HIV, their experiences disclosing such violence and how culturally normative factors affected disclosure-related outcomes. In a mixed-methods study conducted in Uganda in 2018, 168 women participated in interviewer-administered surveys; a sub-set who reported experiencing intimate partner violence participated in in-depth interviews (IDIs). Intimate partner violence was prevalent among women in the sample (68.0%); almost half experienced emotional violence (45.2%), while a smaller proportion had experienced physical (32.1%) and/or sexual violence (19.6%). Most women living with HIV (61.8%) had disclosed their experience of intimate partner violence to someone. Women who experienced intimate partner violence had higher odds of disclosure if they feared their partner and perpetrated violence against their partner. Thematic analysis of IDIs revealed enduring violence and blaming alcohol for men's perpetration of violence. Traditional cultural and gender norms, especially concerning motherhood and partnership, influenced women's experiences of intimate partner violence and disclosure. Multi-sectoral responses to challenge and reform cultural norms that perpetuate violence are needed, including mobilising key stakeholders (e.g. family, community, policy-makers) to serve as catalysts for change and encourage resource- and safety-seeking for women living with HIV to escape violence.

"Mine did not breastfeed", mothers' experiences in breastfeeding children aged 0 to 24 months with oral clefts in Uganda.

BACKGROUND: Appropriate breastfeeding is vital for infant and young child nutrition. Annually, oral clefts affect 0.73 per 1000 children in Uganda. Despite this low incidence, children with a cleft face breastfeeding difficulty which affect their nutrition status. In addition, knowledge on maternal experiences with breastfeeding and support is limited. We explored maternal perceptions, experiences with breastfeeding and support received for their children 0 to 24 months with a cleft attending Comprehensive Rehabilitative Services of Uganda (CoRSU) Hospital. METHODS: This cross-sectional study combined quantitative and qualitative methods. We consecutively recruited 32 mothers of children with a cleft aged 0 to 24 months attending CoRSU hospital between April and May 2018. A structured questionnaire collected data on breastfeeding practices and device use (n = 32). To gain a broad understanding of mothers' perceptions and experiences with breastfeeding and support received, we conducted two Focus Group Discussions (in each, n = 5), and 15 In Depth Interviews. Descriptive statistics were analyzed using SPSS software. Qualitative data were analyzed thematically. RESULTS: Of the 32 children with a cleft, 23(72%) had ever breastfed, 14(44%) were currently breastfeeding, and among those under 6 months, 7(35%) exclusively breastfed. Of 25 mothers interviewed in IDIs and FGDs, 17(68%; IDIs = 8/15, FGD1 = 5/5 and FGD2 = 4/5) reported the child's failure to latch and suckle as barriers to breastfeeding. All ten mothers who used the soft squeezable bottle reported improved feeding. Nineteen (76%) mothers experienced anxiety and 14(56%), social stigma. Family members, communities and hospitals supported mothers with feeding guidance, money, child's feeds and psycho-social counselling. Appropriate feeding and psycho-social support were only available at a specialized hospital which delayed access. CONCLUSIONS: Breastfeeding practices were sub-optimal. Mothers experienced breastfeeding difficulties, anxiety and social stigma. Although delayed, feeding, social and psycho-social support helped mothers cope. Routine health care for mothers and their children with a cleft should include timely support.

Predictors of job satisfaction and intention to stay in the job among health-care providers in Uganda and Zambia.

BACKGROUND: A shortage of competent health-care providers is a major contributor to poor quality health care in sub-Saharan Africa. To increase the retention of skilled health-care providers, we need to understand which factors make them feel satisfied with their work and want to stay in their job. This study investigates the relative contribution of provider, facility and contextual factors to job satisfaction and intention to stay on the job among health-care providers who performed obstetric care in Uganda and Zambia. METHODS: This study was a secondary analysis of data from a maternal and newborn health program implementation evaluation in Uganda and Zambia. Using a Likert scale, providers rated their job satisfaction and intention to stay in their job. Predictors included gender, cadre, satisfaction with various facility resources and country. We used the Shapley and Owen decomposition of R2 method to estimate the variance explained by individual factors and groups of factors, adjusting for covariates at the facility and provider levels. RESULTS: Of the 1134 providers included in the study, 68.3% were female, 32.4% were nurses and 77.1% worked in the public sector. Slightly more than half (52.3%) of providers were strongly satisfied with their job and 42.8% strongly agreed that they would continue to work at their facility for some time. A group of variables related to facility management explained most of the variance in both job satisfaction (37.6%) and intention to stay (43.1%). Among these, the most important individual variables were satisfaction with pay (20.57%) for job satisfaction and opinions being respected in the workplace (17.52%) for intention to stay. Doctors reported lower intention to stay than nurses. Provider demographics and facility level and ownership (public/private) were not associated with either outcome. There were also differences in job satisfaction and intention to stay between Ugandan and Zambian health-care providers. CONCLUSION: Our study suggests that managers play a crucial role in retaining a sufficient number of satisfied health-care providers providing obstetric care in two sub-Saharan African countries, Uganda and Zambia. Prioritizing and investing in health management systems and health managers are essential foundations for high-quality health systems.

Determinants of healthcare providers' confidence in their clinical skills to deliver quality obstetric and newborn care in Uganda and Zambia.

BACKGROUND: Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals' knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia. METHODS: This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics. RESULTS: Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers' mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence. CONCLUSIONS: Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.

Trends and determinants of adolescent childbirth in Uganda- analysis of rural and urban women using six demographic and health surveys, 1988-2016.

INTRODUCTION: Uganda has high adolescent pregnancy. The details of adolescent childbirth and urban/rural patterns are scarce. We investigated the levels, time trends and determinants of adolescent childbirth in Uganda separately for urban and rural women. METHODS: We estimated the percentage of women 20-24 years at each of the six Uganda Demographic and Health Surveys (1988/89, 1995, 2000/01, 2006, 2011 and 2016) who reported a live childbirth before age 20 years ("adolescent childbirth"), and examined change over time using t-test. A modified multivariable Poisson regression was used to examine determinants of having adolescent childbirth on the 2016 survey. RESULTS: Among these women, 67.5, 66.4, 70.1, 62.3, 57.3 and 54.1% reported an adolescent childbirth in 1988/89, 1995, 2000/01, 2006, 2011 and 2016 surveys, respectively. Between 1988/89 to 2000/01, there was no evidence of change (+ 2.6% point (pp), p = 0.170), unlike between the 2000/01 and 2016 surveys when a significant decline occurred (- 16.0 pp., p < 0.001). First childbirth < 18 years of age declined by - 13.5 pp. (p < 0.001) between 2000/01 and 2016. There was no change over time in the percentage of adolescents 18-19.9 years of age having first childbirth. Among rural residents, childbirth < 18 years declined from 43.8% in 1988/89 to 32.7% in 2016 (- 11.1 pp., p < 0.001), in urban it declined from 28.3 to 18.2% (- 10.1 pp., p = 0.006). There was an increase over time in the percentage of women, both rural and urban, who wanted to delay their first pregnancy. Independent determinants of reporting an adolescent childbirth in both urban and rural residents were: no education/incomplete primary and younger age at first sex. Additional determinants for rural women were residence in Eastern region, Muslim religion, and poor household wealth index. CONCLUSION: In the 30-year period examined, adolescent childbirth in Uganda declined from highs of 7 in 10 to approximately 5 in 10 women, with more wanting to delay the pregnancy. The decline started after the 2000/01 survey and affected predominantly younger adolescent childbirth < 18 years among both rural and urban residence women. Efforts need to be intensified to sustain the decline in adolescent pregnancies. Targeted and specific strategies for urban and rural areas might be required.

Prevalence and factors associated with utilization of rehabilitation services among people with physical disabilities in Kampala, Uganda. A descriptive cross sectional study.

BACKGROUND: Worldwide, fifteen percent (15%) of the world's population or one (1) billion people live with some form of disability. In Uganda, 12.4% of the Uganda's population lives with some form of disability and Kawempe division accounts for (22.6%) of all persons with disabilities living in Kampala district. Rehabilitation services are provided within Kawempe division at Mulago hospital physiotherapy department and Katalemwa rehabilitation center in Kampala district, Uganda at a free and a subsidized cost to help to improve the function, independence, and quality of life of persons with physical disabilities. However, many people with physical disabilities do not utilize the services and the reasons are not clear. METHODS: The study design was a descriptive cross-sectional study employing quantitative methods of data collection. A total of 318 participants were included in the study. Simple random sampling was used to select the study participants. Ethical issues were maintained at all levels during data collection and dissemination of results. RESULTS: The study revealed a prevalence of 26.4% of the utilization rehabilitation services among people with physical disabilities in Kawempe division, Kampala, Uganda. Factors that were significantly associated with utilization of rehabilitation services among people with physical disabilities at multivariable logistic regression analysis included; age (AOR: 0.30; 95% CI: 0.12-0.74), socioeconomic status (AOR: 2.13; 95% CI: 1.03-4.41), education level (AOR: 4.3; 95% CI: 1.34-13.91) and awareness of the participants about the rehabilitation services (AOR: 5.1; 95% CI: 2.74-9.54) at p value ≤0.05. CONCLUSION: The study revealed a prevalence of 26.4% of the utilization rehabilitation services among people with physical disabilities in Kawempe division, Uganda. Factors that were significantly associated with utilization of rehabilitation services included; age, socioeconomic status, education level and awareness of the participants about the services. Therefore, the government and other relevant stake holders should increase sensitization and awareness of rehabilitation services, their benefits and facilities providing such services to people with physical disabilities, healthcare professionals and the general public.

Postgraduate training for trauma prevention, injury surveillance and research, Uganda.

PROBLEM: The burden of trauma and injuries in Uganda is substantial and growing. Two important gaps that need addressing are the shortage of trained people and a lack of national data on noncommunicable diseases and their risk factors in Uganda. APPROACH: We developed and implemented a new track within an existing master of public health programme, aimed at developing graduate-level capacity and promoting research on key national priorities for trauma and injuries. We also offered training opportunities to a wider audience and set up a high-level national injury forum to foster national dialogue on addressing the burden of trauma, injuries and disability. LOCAL SETTING: The Chronic Consequences of Trauma, Injuries and Disability in Uganda programme was implemented in 2012 at Makerere University School of Public Health in Kampala, Uganda, in conjunction with Johns Hopkins Bloomberg School of Public Health in Baltimore, United States of America. RELEVANT CHANGES: Over the years 2012 to 2017 we supported four cohorts of master's students, with a total of 14 students (9 females and 5 males; mean age 30 years). Over 1300 individuals participated in workshops and seminars of the short-term training component of the programme. The forum hosted three research symposia and two national injury forums. LESSONS LEARNT: Institutional support and collaborative engagement is important for developing and implementing successful capacity development programmes. Integration of training components within existing academic structures is key to sustainability. Appropriate mentorship for highly motivated and talented students is valuable for guiding students through the programme.

Postnatal Care Experiences and Barriers to Care Utilization for Home- and Facility-Delivered Newborns in Uganda and Zambia.

Objectives The objective of this study was to examine experiences with, and barriers to, accessing postnatal care services, in the context of a maternal health initiative. Methods As part of a larger evaluation of an initiative to promote facility deliveries in 8 rural districts in Uganda and Zambia, 48 focus groups were held with recently-delivered women with previous home and facility deliveries (6 per district). Data on postnatal care experiences were translated, coded and analyzed using thematic content analysis techniques. Results were categorized into: positive postnatal care experiences, barriers to postnatal care utilization, and negative postnatal care experiences. Results Women who accessed care largely reported positive experiences, with Zambian women generally reporting more positive interactions than Ugandan women. The main reasons given for low postnatal care utilization were low awareness about the need, fear of mistreatment by clinic staff, cost and distance. In half of the focus groups, women described personal experience or knowledge of denial or threatened denial of postnatal care due to the birth location. Although outright denial of care was not common, women frequently described various types of actual or presumed discrimination because of having a home birth. Conclusions for Practice While many women reported positive experiences with postnatal care utilization, cases of delay or denial of postnatal care exist. As programs incentivize facility deliveries, the lack of focus on postnatal support may place home-delivered newborns in "double jeopardy" due to poor quality intra-partum care and reduced access to postnatal care.