Browsing by Author "Rujumba, Joseph"
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Item Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability(Global Health Action, 2018) Zakumumpa, Henry; Kwiringira, Japheth; Rujumba, Joseph; Ssengooba, FreddieBackground: In the context of declining international assistance for ART scale-up in Sub- Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy. Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization. Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review. Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities. Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.Item Challenges encountered in providing integrated HIV, antenatal and postnatal care services: a case study of Katakwi and Mubende districts in Uganda(Reproductive health, 2016) Ahumuza, Sharon E.; Rujumba, Joseph; Nkoyooyo, Abdallah; Byaruhanga, Raymond; Wanyenze, Rhoda K.Integration of sexual and reproductive health (SRH), HIV/AIDS and maternal health (MH) services is a critical strategy to confront the HIV/AIDS epidemic, high maternal mortality and the unmet need for contraception. In 2011 the AIDS Information Centre (AIC) in partnership with the Ministry of Health implemented SRH, HIV/AIDS and MH integration services in the districts of Katakwi and Mubende in Uganda. This paper documents challenges encountered in providing these integrated services in the two districts. This was a cross-sectional qualitative study conducted in Mubende and Katakwi districts in Uganda. Data were collected using 10 focus group discussions with 89 women attending ANC and postnatal care and 21 key informant interviews with district managers and health workers who were involved in the integrated service delivery. Content thematic approach was used for data analysis: The study findings indicate that various challenges were encountered in integrating HIV, ANC and PNC services. Major challenges included inadequate staff, gaps in knowledge of service providers especially with regard to provision of long-term family planning, limited space, shortage of critical supplies such as HIV test kits, drugs and gloves.Item Community-funded integrated care outreach clinics as a capacity building strategy to expand access to health care in remote areas of Uganda(Global Health Action, 2021) Kinney, Rebecca G.; Zakumumpa, Henry; Rujumba, Joseph; Gibbons, Kevin; Heard, Anna; Galárraga, OmarMost Ugandans live in rural, medically underserved communities where geography and poverty lead to reduced access to healthcare. We present a novel low-cost approach for supplemental primary care financing through 1) pooling community wealth to cover overhead costs for outreach clinic activities and 2) issuing microfinance loans to motorcycle taxi entrepreneurs to overcome gaps in access to transportation. The intervention described here, which leverages community participation as a means to extend the reach of government health service delivery, was developed and implemented by Health Access Connect (HAC), a non-governmental organization based in Uganda. HAC began its work in August 2015 in the Lake Victoria region and now serves over 40 sites in Uganda across 5 districts, helping government health-care workers to provide over 1,300 patient services per month (and over 35,000 since the program’s inception) with an average administrative cost of $6.24 per patient service in 2020. In this article, we demonstrate how integrated and appropriately resourced monthly outreach clinics, based on a microfinance-linked model of wealth pooling and government cooperation, can expand the capacity of government-provided healthcare to reach more patients living in remote communities. This scalable, sustainable, and flexible model is responsive to shifting needs of patients and health systems and presents an alternative approach to healthcare financing in low-resource settings. More rigorous evaluation of health outcomes stemming from such community-based models of service delivery is warranted.Item Cost-effectiveness of an interactive voice response system for improving retention in care and adherence to antiretroviral therapy among young adults in Uganda(BMC, 2024-09) Naggirinya, Agnes Bwanika; Nuwamanya, Elly; Nabaggala, Maria Sarah; Musinguzi, Francis; Nanungi, Annet; Waiswa, Peter; Rujumba, Joseph; Meya, David B; Parkes-Ratanshi, RosalindAbstract Background New interventions aimed at increasing access to and adherence to antiretroviral therapy among young people living with the human immunodeficiency virus (YPLHIV) are needed. This study assessed the cost-effectiveness of the call-for-life interaction voice response tool compared to that of the standard of care (SOC) for promoting treatment adherence and retention in care among YPLHIV in Western Uganda. This cost-effectiveness study used data from a randomized controlled trial and a decision-analytic Markov model to estimate the long-term outcomes and costs of the Call for Life-Interactive Voice Response (CFL-IVR) tool and the usual care from the Ugandan public payer perspective. The model was parameterized using primary data and the literature and adopted a 1-year Markov cycle. The main outcomes were mean annual costs, disability-adjusted life-years (DALYs), and the incremental cost-effectiveness ratio (ICER) in form of cost per DALY averted. The CLF-IVR was deemed cost-effective if the ICER was between 1% and 51% of Uganda’s gross domestic product. We conducted deterministic and probabilistic sensitivity analyses to assess the effect of adjusting parameter values on cost-effectiveness estimates. All costs were reported in 2021 US dollars, and a discount rate of 3% was applied to both costs and outcomes. Results The base case analysis showed that, from the Ugandan public payer perspective, the CLF-IVR led to more mean annual costs ($359 vs. $280) and averted more mean annual DALYs (15.78 vs. 11.09) than the SOC, leading to an ICER of $17 per DALY averted. The base-case results did not change significantly in the deterministic and probabilistic sensitivity analyses. The cost-effectiveness estimates were more responsive to uncertainties surrounding ART duration, viral load suppression rates, and discount rates. Conclusion The CLF-IVR may be a cost-effective intervention for promoting treatment adherence and retention in care among YPLHIV in Uganda and other low-income settings. Once implemented, similar interventions may lead to greater returns in encouraging adherence to ART and retention in care among YPLHIV and other vulnerable groups, and eventually favorable clinical outcomes. Trial registration NCT04718974 Registry: clinical Trials.gov https://ichgcp.net/nl/clinical-trials-registry/NCT04718974 (20 Jan 2021).Item Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll(Research Square, 2022) Zakumumpa, Henry; Rujumba, Joseph; Kyomuhendo, Marjorie; Stempler, Ilyse; Amde, WoldekidanHealth worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs with private-sector work backgrounds. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017. Methods We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. Qualitative interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by thematic approach as guided by the analytical framework proposed by Schaefer and Moos regarding individual-level and organizational-context drivers. Results At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to ‘permanent and pensionable’ terms of employment and the opportunity to work in ‘home districts’ where they could serve their ‘kinsmen’ were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid–cadres (such as nurses and midwives), higher-calibre cadres, such as physicians, pharmacists and laboratory technologists, indicated a higher affinity to seek alternative employment in the private sector in the immediate future. Conclusion Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.Item Experiences of Gender Based Violence among Refugee Populations in Uganda: Evidence from Four Refugee Camps(Eastern Africa Social Science Research Review, 2018) Kwiringira, Japheth N.; Mugisha Mutabazi, Marion; Mugumya, Firminus; Kaweesi, Edward; Munube, Deogratias; Rujumba, JosephIn refugee generating situations, flight conditions and actual refugee circumstances, Gender Based Violence take different forms like rape, female genital mutilation, physical, psychological and emotional abuse, defilement and bride kidnapping in the name of ‘early marriage’ and sexual harassment among others. These forms are heightened by the adverse conditions of lack of basic needs, unequal power relations, breakdown of institutions of social control and order, exposure to the dangers of group violence and low capacity of protection agencies both local and international, and the host governments. This study intended to detail refugee experiences of Gender Based Violence among refugees in Uganda as well as the associated factors. We conducted a qualitative study and used content-thematic approach analysis. While there was high GBV awareness; this did not translate into reduced susceptibility. Detection, prevention and response to GBV were curtailed by an intersectionality of unequal power relations, poverty, and a multiplicity of cultures that concealed the nature, extent and reality of GBV. Effective GBV prevention requires an array of interventions and ‘capacities’ especially access to basic needs for individuals and households. Our findings aver that, gender based violence is endemic in peripheral hard to reach, conflict and post-conflict settings than in more stable communities due to underreporting and concealment that are associated with numerous capacity challenges in access and utilisation of the available services. The extreme conditions that refugees go through during displacement, flight and resettlement tend to exacerbate and sustain GBV.Item HIV prevalence among children admitted with severe acute malnutrition and associated factors with mother-to-child HIV transmission at Mulago Hospital, Uganda: A mixed methods study(Public Library of Science, 2024-04) Musiime, Victor; Rujumba, Joseph; Kakooza, Lawrence; Namisanvu, Henriator; Atuhaire, Loice; Naguti, Erusa; Beinomugisha, Judith; Kiggwe, Andrew; Nkinzi, Sharafat; Segawa, Ivan; Matsiko, Nicholas; Babirekere-Iriso, Esther; Musoke, PhilippaDespite global efforts to eliminate mother-to-child-transmission of HIV (MTCT), many children continue to become infected. We determined the prevalence of HIV among children with severe acute malnutrition (SAM) and that of their mothers, at admission to Mwanamugimu Nutrition Unit, Mulago Hospital, Uganda. We also assessed child factors associated with HIV-infection, and explored factors leading to HIV-infection among a subset of the mother-child dyads that tested positive. We conducted a cross-sectional evaluation within the REDMOTHIV (Reduce mortality in HIV) clinical trial that investigated strategies to reduce mortality among HIV-infected and HIV-exposed children admitted with SAM at the Nutrition Unit. From June 2021 to December 2022, we consecutively tested children aged 1 month to 5 years with SAM for HIV, and the mothers who were available, using rapid antibody testing upon admission to the unit. HIV-antibody positive children under 18 months of age had a confirmatory HIV-DNA PCR test done. In-depth interviews (IDIs) were conducted with mothers of HIV positive dyads, to explore the individual, relationship, social and structural factors associated with MTCT, until data saturation. Quantitative data was analyzed using descriptive statistics and logistic regression in STATAv14, while a content thematic approach was used to analyze qualitative data. Of 797 children tested, 463(58.1%) were male and 630(79.1%) were [less than or equal to]18months of age; 76 (9.5%) tested positive. Of 709 mothers, median (IQR) age 26 (22, 30) years, 188(26.5%) were HIV positive. Sixty six of the 188 mother-infant pairs with HIV exposure tested positive for HIV, an MTCT rate of 35.1% (66/188). Child age >18 months was marginally associated with HIV-infection (crude OR = 1.87,95% CI: 1.11-3.12, p-value = 0.02; adjusted OR = 1.72, 95% CI: 0.96, 3.09, p-value = 0.068). The IDIs from 16 mothers revealed associated factors with HIV transmission at multiple levels. Individual level factors: inadequate information regarding prevention of MTCT(PMTCT), limited perception of HIV risk, and fear of antiretroviral drugs (ARVs). Relationship level factors: lack of family support and unfaithfulness (infidelity) among sexual partners. Health facility level factors: negative attitude of health workers and missed opportunities for HIV testing. Community level factors: poverty and health service disruptions due to the COVID-19 pandemic. In this era of universal antiretroviral therapy for PMTCT, a 10% HIV prevalence among severely malnourished children is substantially high. To eliminate vertical HIV transmission, more efforts are needed to address challenges mothers living with HIV face intrinsically and within their families, communities and at health facilities.Item Hypothyroidism among children and adolescents with nephrotic syndrome in Mulago National Referral Hospital, Kampala, Uganda; a cross-sectional study(BioMed Central Ltd, 2024-02) Tumwesige, Maureen; Rujumba, Joseph; Piloya, Thereza; Aujo, Judith CarolineNephrotic syndrome (NS) is the commonest glomerular disease among children. It is characterized by heavy proteinuria and is a risk factor for hypothyroidism in the affected children. Hypothyroidism is of concern because it affects the physical and intellectual development of children and adolescents. This study sought to establish the prevalence and factors associated with hypothyroidism among children and adolescents with NS. A cross-sectional design was used to study 70 children and adolescents aged 1-19 years diagnosed with nephrotic syndrome and being followed up in the kidney clinic in Mulago National Referral Hospital. Questionnaires were used to collect patients' socio-demographics and clinical information. A blood sample was taken for analysis for thyroid stimulating hormone (TSH) and free thyroxine (FT4), renal function tests and serum albumin. Hypothyroidism included both overt and subclinical forms. Overt hypothyroidism was defined as TSH level > 10 mU/L and FT4 < 10pmol/L, or FT4 < 10pmol/l with normal TSH, or TSH < 0.5mU/l. Sub-clinical hypothyroidism was defined as TSH ranging between 5 and10 mU/L with normal age appropriate FT4 levels. Urine samples were collected and taken for a dipstick examination. The data was analyzed using STATA version 14. The Bayesian Logistic regression analysis approach was used to estimate odds ratios (OR) and their associated 95% credible intervals. All predictor variables with p value < 0.05 at frequentist statistical analysis were considered significant. The mean age (standard deviation) of participants was 9 years (3.8). There were more males; 36 of 70 (51.4%). The prevalence of hypothyroidism was 23% (16/70 participants). Of the 16 children with hypothyroidism, 3 (18.7%) had overt hypothyroidism while 13 had subclinical hypothyroidism. Only low serum albumin was found to be strongly associated with hypothyroidism; Bayesian OR 132.57 (CI 9.13-567.10) with a frequentist OR of 37 and a p value of 0.001. The prevalence of hypothyroidism among children and adolescent with nephrotic syndrome attending Mulago Hospital pediatric kidney clinic was 23%. Hypoalbuminemia was found to be associated with hypothyroidism. Therefore, children and adolescents that have severely low levels of serum albumin should be screened for hypothyroidism and linked to endocrinologists for care.Item “If I have money, I cannot allow my baby to breastfeed only …” barriers and facilitators to scale-up of peer counselling for exclusive breastfeeding in Uganda(International Breastfeeding Journal, 2020) Rujumba, Joseph; Ndeezi, Grace; Nankabirwa, Victoria; Kwagala, Mary; Mukochi, Michelle; Diallo, Abdoulaye Hama; Meda, Nicolas; Engebretsen, Ingunn M. S.; Tylleskär, Thorkild; Tumwine, JamesEarly initiation and exclusive breastfeeding for 6 months reduces infant morbidity and mortality and can positively impact on cognitive function. In Uganda, exclusive breastfeeding for 6 months is recommended but many women introduce alternative feeds early. Interventions to scale-up peer support provision for exclusive breastfeeding are limited. We explored the barriers, facilitators and solutions to scaling-up of peer counselling support for exclusive breastfeeding in Uganda.A qualitative study was conducted in Mbale District and Kampala City between April and July 2014. Data were collected through 15 key informant interviews with health workers and managers of organizations involved in child and maternal health as well as seven focus group discussions with peer counsellors who took part in the PROMISE EBF Trial (2006–2008), VHT members, mothers and fathers of children aged 1 year and below. Data were analysed using the content thematic approach.The need for peer support for exclusive breastfeeding, especially for young and first-time mothers, was highlighted by most study participants. While mothers, mothers-in-law, friends and husbands were mentioned as major stakeholders regarding infant feeding, they were perceived to lack adequate information on breastfeeding. Health workers were mentioned as a key source of support, but their constraints of heavy workloads and lack of education materials on breastfeeding were highlighted. High community expectations of peer counsellors, the perceived inadequacy of breast milk, general acceptability of complimentary feeding, household food insecurity, heavy workload for women and unsupportive ‘work-places’ were key barriers to scaling-up of peer counselling support for breastfeeding. The peer counsellors who were part of the PROMISE EBF trial in Mbale, the village health team programme, health facilities, community groups, the media and professional associations emerged as potential facilitators that can aid the scaling-up of peer counselling support for breastfeeding.Peer support for breastfeeding is highly valued in this setting. The health system and health workers are regarded as the main facilitators to scaling-up of peer support for exclusive breastfeeding. Partnerships with village health teams (VHTs), community groups, role models, professional associations and the media are other potential facilitators to this scaling-up.Item Implementation challenges in preeclampsia care: perspectives from health care professionals in urban Uganda(Elsevier Inc, 2024-05) Namagembe, Imelda; Karavadra, Babu; Kazibwe, Lawrence; Rujumba, Joseph; Kiwanuka, Noah; Smith, Brandon; Byamugisha, Josaphat; Moffett, Ashley; Bashford, Tom; Nakimuli, Annettee; Aiken, Catherine E.Sub-Saharan Africa bears the burden of 70% of maternal deaths worldwide, of which ∼10% are attributable to hypertensive disorders of pregnancy, primarily complications of preeclampsia. In other global settings, outcomes of pregnancies affected by preeclampsia are improved with timely and effective medical care. This study aimed to explore the perspectives of local health care professionals on how preeclampsia care is currently delivered in the study setting and what challenges they experience in providing prompt and safe care. We identified specific objectives of exploring stakeholder perceptions of (1) recognizing preeclampsia and (2) timely intervention when preeclampsia is diagnosed. We also explored the wider system factors (eg, cultural, financial, and logistic challenges) that health care professionals perceived as affecting their ability to deliver optimal preeclampsia care. Individual semistructured interviews were conducted with health care professionals and stakeholders. The findings were analyzed using thematic analysis. Thirty-three participants contributed to the study, including doctors and midwives with varying degrees of clinical experience and external stakeholders. The following 5 key themes emerged: delayed patient presentation, recognizing the unwell patient with preeclampsia, the challenges of the existing triage system, stakeholder disconnect, and ways of learning from each other. Health care professionals referenced an important psychosocial perspective associated with preeclampsia in the study setting, which may influence the likelihood of seeking care through traditional healers rather than hospital-based routes. We identify the key barriers to improving maternal and neonatal outcomes of preeclampsia, described at both the institutional level and within the wider setting. The study provides invaluable contextual information that suggests that a systems-based approach to health care quality improvement may be effective in reducing rates of maternal and neonatal morbidity and mortality.Item Interface of culture, insecurity and HIV and AIDS: Lessons from displaced communities in Pader District, Northern Uganda(Conflict and health, 2010) Rujumba, Joseph; Kwiringira, JaphethBackground: Northern Uganda unlike other rural regions has registered high HIV prevalence rates comparable to those of urbanized Kampala and the central region. This could be due to the linkages of culture, insecurity and HIV. We explored community perceptions of HIV and AIDS as a problem and its inter-linkage with culture and insecurity in Pader District. Methods: A cross sectional qualitative study was conducted in four sub-counties of Pader District, Uganda between May and June 2008. Data for the study were collected through 12 focus group discussions (FGDs) held separately; 2 FGDs with men, 6 FGDs with women, and 4 FGDs with the youth (2 for each sex). In addition we conducted 15 key informant interviews with; 3 health workers, 4 community leaders at village and parish levels, 3 persons living with HIV and 5 district officials. Data were analysed using the content thematic approach. This process involved identification of the study themes and sub-themes following multiple reading of interview and discussion transcripts. Relevant quotations per thematic area were identified and have been used in the presentation of study findings. Results: The struggles to meet the basic and survival needs by individuals and households overshadowed HIV as a major community problem. Conflict and risky sexual related cultural practices were perceived by communities as major drivers of HIV and AIDS in the district. Insecurity had led to congestion in the camps leading to moral decadence, rape and defilement, prostitution and poverty which increased vulnerability to HIV infection. The cultural drivers of HIV and AIDS were; widow inheritance, polygamy, early marriages, family expectations, silence about sex and alcoholism. Conclusions: Development partners including civil society organisations, central government, district administration, religious and cultural leaders as well as other stakeholders should mainstream HIV in all community development and livelihood interventions in the post conflict Pader district to curtail the likely escalation of the HIV epidemic. A comprehensive behaviour change communication strategy is urgently needed to address the negative cultural practices. Real progress in the region lies in advocacy and negotiation to realise lasting peace.Item Listening to health workers: lessons from Eastern Uganda for strengthening the programme for the prevention of mother-to-child transmission of HIV(BMC Health Services Research, 2012) Rujumba, Joseph; Tumwine, James K.; Tylleskär, Thorkild; Neema, Stella; Heggenhougen, Harald K.The implementation and utilization of programmes for the prevention of mother-to-child transmission (PMTCT) of HIV in most low income countries has been described as sub-optimal. As planners and service providers, the views of health workers are important in generating priorities to improve the effectiveness of the PMTCT programme in Uganda. We explored the lessons learnt by health workers involved in the provision of PMTCT services in eastern Uganda to better understand what more needs to be done to strengthen the PMTCT programme. Methods: A qualitative study was conducted at Mbale Regional Referral Hospital, The AIDS Support Organisation (TASO) Mbale and at eight neighbouring health centres in eastern Uganda, between January and May 2010. Data were collected through 24 individual interviews with the health workers involved in the PMTCT programme and four key informants (2 district officials and 2 officials from TASO). Data were analyzed using the content thematic approach. Study themes and sub-themes were identified following multiple reading of interview transcripts. Relevant quotations have been used in the presentation of study findings. Results: The key lessons for programme improvement were: ensuring constant availability of critical PMTCT supplies, such as HIV testing kits, antiretroviral drugs (ARVs) for mothers and their babies, regular in-service training of health workers to keep them abreast with the rapidly changing knowledge and guidelines for PMTCT, ensuring that lower level health centres provide maternity services and ARVs for women in the PMTCT programme and provision of adequate facilities for effective follow-up and support for mothers. Conclusions: The voices of health workers in this study revealed that it is imperative for government, civil society organizations and donors that the PMTCT programme addresses the challenges of shortage of critical PMTCT supplies, continuous health worker training and follow-up and support for mothers as urgent needs to strengthen the PMTCT programme.Item Livelihood Risk, Culture, and the HIV Interface: Evidence from Lakeshore Border Communities in Buliisa District, Uganda(Journal of tropical medicine, 2019) Kwiringira, Japheth N.; Ariho, Paulino; Zakumumpa, Henry; Mugisha, James; Rujumba, Joseph; Mugisha, Marion M.Background.While studies have focused on HIV prevalence and incidence among fishing communities, there has been inadequate attention paid to the construction and perception of HIV risk among fisher folk. There has been limited research with respect to communities along Lake Albert on the border between Uganda and the Democratic Republic of Congo (DRC). Methods. We conducted a qualitative study on three landing sites of Butiaba, Bugoigo, and Wanseko on the shores of Lake Albert along the border of Uganda and the Democratic Republic of Congo. Data were collected using 12 Focus Group Discussions and 15 key informant interviews. Analysis was done manually using content and thematic approaches. Results. Lakeshore livelihoods split families betweenmen, women, and children with varying degrees of exposure to HIV infection risk. Sustaining a thriving fish trade was dependent on taking high risks. For instance, profits were high when the lake was stormy. Landing sites were characterized by widespread prostitution, alcohol consumption, drug abuse, and child labour. Such behaviors negatively affected minors and in many ways predisposed them to HIV infection. The lake shore-border heterogeneity resulted in a population with varying HIV knowledge, attitudes, behavior, and competencies to risk perception and adaptation amidst negative masculinities and negative resilience. Conclusion.The susceptibility of lakeshore communities to HIV is attributable to a complex combination of geo-socio, the available (health) services, economic, and cultural factors which converged around the fishing livelihood. This study reveals that HIV risk assessment is an interplay of plural rationalities within the circumstances and constraints that impinge on the daily lives by different actors. A lack of cohesion in amultiethnic setting with large numbers of outsiders and a large transient population made the available HIV interventions less effective.Item PMTCT Option B+ 2012 to 2018 — Taking stock: barriers and strategies to improve adherence to Option B+ in urban and rural Uganda(NISC (Pty) Ltd, 2020) King, Rachel; Namale Matovu, Joyce; Rujumba, Joseph; Wavamunno, Priscilla; Musoke, Philippa; Seeley, Janet,; Amone, Alexander; Gabagaya, Grace; Glenn Fowler, Mary; Homsy, JacoSince 2012, PMTCT Option B+ has been recommended by the World Health Organization to reduce vertical transmission but numerous adherence challenges remain. We conducted a qualitative study at baseline using six focus group discussions and 14 in-depth interviews to explore knowledge, beliefs, attitudes and challenges towards the Option B+ strategy for PMTCT among HIV-infected pregnant and post-partum women and health workers engaged in Uganda’s national Option B+ PMTCT programme. Data were analysed using a thematic approach to capture latent and manifest content with the social ecological model as a theoretic foundation in order to make contextual sense of key stakeholders’ needs for an effective Option B+ intervention. Overall, among all study participants, we found multi-level barriers to adhering to Option B+ cutting across all levels of the social ecological model. In line with the model, our study revealed barriers at personal, relational, organizational and societal levels. Some personal beliefs such as that the baby’s health is more important that the mother’s, organizational (negative attitudes and behaviour of health workers), structural such as poverty, work conflicts, fear and lack of disclosure related to community stigma were all critical obstacles to women adhering to the Option B+ programme. We found that both health workers and participants in the programme have a relatively clear understanding of the benefits of adhering to their treatment; though a more nuanced understanding and thus emphasis in counselling on side effects, is critical to helping patients adhere.Item Pregnant women’s experiences of routine counselling and testing for HIV in Eastern Uganda: a qualitative study(BMC Health Services Research, 2013) Rujumba, Joseph; Neema, Stella; Tumwine, James K.; Tylleskär, Thorkild; Heggenhougen, Harald K.Routine HIV counselling and testing as part of antenatal care has been institutionalized in Uganda as an entry point for pregnant women into the prevention of mother-to-child transmission of HIV (PMTCT) programme. Understanding how women experience this mode of HIV testing is important to generate ideas on how to strengthen the PMTCT programme. We explored pregnant HIV positive and negative women’s experiences of routine counselling and testing in Mbale District, Eastern Uganda and formulated suggestions for improving service delivery. Methods: This was a qualitative study conducted at Mbale Regional Referral Hospital in Eastern Uganda between January and May 2010. Data were collected using in-depth interviews with 30 pregnant women (15 HIV positive and 15 HIV negative) attending an antenatal clinic, six key informant interviews with health workers providing antenatal care and observations. Data were analyzed using a content thematic approach. Results: Prior to attending their current ANC visit, most women knew that the hospital provided HIV counselling and testing services as part of antenatal care (ANC). HIV testing was perceived as compulsory for all women attending ANC at the hospital but beneficial, for mothers, especially those who test HIV positive and their unborn babies. Most HIV positive women were satisfied with the immediate counselling they received from health workers, but identified the need to provide follow up counselling and support after the test, as areas for improvement. However, most HIV negative women mentioned that they were given inadequate attention during post-test counselling. This left them with unanswered questions and, for some, doubts about the negative test results. Conclusions: In this setting, routine HIV counselling and testing services are known and acceptable to mothers. There is need to strengthen post-test and follow up counselling for both HIV positive and negative women in order to maximize opportunities for primary and post exposure HIV prevention. Partnerships and linkages with people living with HIV, especially those in existing support groups such as those at The AIDS Support Organization (TASO), may help to strengthen counselling and support for pregnant women. For effective HIV prevention, women who test HIV negative should be supported to remain negative.Item Prevalence And Factors Associated With Behavioural Problems In Children With Epilepsy Attending Mulago Hospital, Uganda: A Cross-Sectional Study(Seizure, 2021) Josias, Kasereka Songya; Bangirana, Paul; Rujumba, Joseph; Mwesige, Angelina KakoozaTo determine the prevalence of behavioural problems and the associated factors in children with epilepsy (CWE).This was a cross-sectional study conducted at Mulago National Referral Hospital, Kampala, Uganda, from December 2019 to May 2020. A total of 300 CWE aged 6 to 17 years were consecutively enrolled and assessed for behavioural problems using the Strengths and Difficulties Questionnaire. We obtained data on the associated factors by using pretested structured questionnaires, the Rosenberg Self-Esteem Scale, the Kilifi Stigma Scale of Epilepsy, the Morisky medication adherence scale and the Tumaini Child Health Screener for childhood disabilities. Simple logistic regression and multivariate analysis was done to determine the associated factors while adjusting for the presence of neurodevelopmental disorders and childhood disabilities.Behavioural problems were detected in 108/300 CWE (36%) with more internalizing (28%) than externalizing (21%) behaviour scores noted. The odds of behavioural problems increased with the presence of co-morbid neurodevelopmental disorders or childhood disabilities (cOR: 5.42, p-value < 0.001). Factors associated with occurrence of behavioural problems were high stigma perception (aOR: 4.06, p-value < 0.001) and being seizure-free in the last six months (aOR: 3.43, p-value =0.031) while being an adolescent (aOR: 0.33, p=0.001) lessened the risk.Behavioural problems occur in more than a third of CWE. They are more in the internalizing domain than in the externalizing domain. Their odds increase with high perceived stigma and in the first six months of seizure control.Item A Qualitative Exploration of the Referral Process of Children with Common Infections from Private Low-Level Health Facilities in Western Uganda(Children, 2021) Mwanga-Amumpaire, Juliet; Nakayaga Kalyango, Joan; Ndeezi, Grace; Rujumba, Joseph; Owokuhaisa, Judith; Lundborg, Cecilia Stålsby; Alfvén, Tobias; Obua, Celestino; Källander, KarinOver 50% of sick children are treated by private primary-level facilities, but data on patient referral processes from such facilities are limited. We explored the perspectives of healthcare providers and child caretakers on the referral process of children with common childhood infections from private low-level health facilities in Mbarara District. We carried out 43 in-depth interviews with health workers and caretakers of sick children, purposively selected from 30 facilities, until data saturation was achieved. The issues discussed included the process of referral, challenges in referral completion and ways to improve the process. We used thematic analysis, using a combined deductive/inductive approach. The reasons for where and how to refer were shaped by the patients’ clinical characteristics, the caretakers’ ability to pay and health workers’ perceptions. Caretaker non-adherence to referral and inadequate communication between health facilities were the major challenges to the referral process. Suggestions for improving referrals were hinged on procedures to promote caretaker adherence to referral, including reducing waiting time and minimising the expenses incurred by caretakers. We recommend that triage at referral facilities should be improved and that health workers in low-level private health facilities (LLPHFs) should routinely be included in the capacity-building trainings organised by the Ministry of Health (MoH) and in workshops to disseminate health policies and national healthcare guidelines. Further research should be done on the effect of improving communication between LLPHFs and referral health facilities by affordable means, such as telephone, and the impact of community initiatives, such as transport vouchers, on promoting adherence to referral for sick children.Item A qualitative study of the perspectives of health workers and policy makers on external support provided to low-level private health facilities in a Ugandan rural district, in management of childhood infections(Global Health Action, 2021) Mwanga-Amumpaire, Juliet; Kalyango, Joan N.; Källander, Karin; Sundararajan, Radhika; Owokuhaisa, Judith; Rujumba, Joseph; Obua, Celestino; Alfvén, Tobias; Ndeezi, GraceWith the under-five child mortality rate of 46.4 deaths per 1000 live births, Uganda should accelerate measures to reduce child deaths to achieve the Sustainable Development Goal 3. While 60–70% of frontline health services are provided by the private sector, many low-level private health facilities (LLPHF) are unregistered, unregulated, and often miss innovative and quality improvement strategies rolled out by the Ministry of Health. LLPHF need support in order to provide quality health care. Objective: To explore the perspectives of health workers and policy makers on external support given to LLPHF providing health care for children in Mbarara District, Uganda. Methods: We carried out a qualitative study, in which 43 purposively selected health workers and policy makers were interviewed. The issues discussed included their views on the quantity, quality, factors determining support received and preferred modalities of support to LLPHF. We used thematic analysis, employing an inductive approach to code interview transcripts and to identify subthemes and themes. Results: The support currently provided to LLPHF to manage childhood illnesses is inadequate. Health providers emphasised a need for technical capacity building, provision of policies, guidelines and critical supplies as well as adopting a more supportive supervisory approach instead of the current supervision model characterised by policing, fault finding and apportioning blame. Registration of the health facilities and regular submission of reports as well as multi-stakeholder involvement are potential strategies to improve external support. Conclusion: The current support received by LLPHF is inadequate in quantity and quality. Capacity building with emphasis on training, provision of critical guidelines and supplies as well as and supportive supervision are key strategies for delivering appropriate external support to LLPHF.Item Re-conceptualizing sustainable urban sanitation in Uganda: why the roots of ‘Slumification’ must be dealt with(BMC public health, 2021) Kwiringira, Japheth N.; Kabumbuli, Robert; Zakumumpa, Henry; Mugisha, James; Akugizibwe, Mathias; Ariho, Paulino; Rujumba, JosephCountry-wide urbanization in Uganda has continued amidst institutional challenges. Previous interventions in the water and sanitation sector have not addressed the underlying issues of a poorly managed urbanization processes. Poor urbanisation is linked to low productivity, urban poverty, unemployment, limited capacity to plan and offer basic services as well as a failure to enforce urban standards. Methods: This ethnographic study was carried out in three urban centres of Gulu, Mbarara and Kampala. We explored relationships between urban livelihoods and sustainable urban sanitation, using the economic sociology of urban sanitation framework. This framework locates the urbanization narrative within a complex system entailing demand, supply, access, use and sustainability of slum sanitation. We used both inductive and deductive thematic analysis. Results: More than any other city in Uganda, Kampala was plagued with poor sanitation services characterized by a mismatch between demand and the available capacity for service provision. Poor slum sanitation was driven by; the need to escape rural poverty through urban migration, urban governance deficits, corruption and the survival imperative, poor service delivery and lack of capacity, pervasive (urban) informality, lack of standards: ‘to whom it may concern’ attitudes and the normalization of risk as a way of life. Amidst a general lack of affordability, there was a critical lack of public good conscience. Most urbanites were trapped in poverty, whereby economic survival trumped for the need for meeting desirable sanitation standards. Conclusions: Providing sustainable urban livelihoods and meeting sanitation demands is nested within sustainable livelihoods. Previous interventions have labored to fix the sanitation problem in slums without considering the drivers of this problem. Sustainable urban livelihoods are critical in reducing slums, improving slum living and curtailing the onset of slumification. Urban authorities need to make urban centres economically vibrant as an integral strategy for attaining better sanitation standards.Item ‘‘Telling my husband I have HIV is too heavy to come out of my mouth’’: pregnant women’s disclosure experiences and support needs following antenatal HIV testing in eastern Uganda(Journal of the International AIDS Society, 2012) Rujumba, Joseph; Neema, Stella; Byamugisha, Robert; Tylleska¨r, Thorkild; Tumwine, James K.; Heggenhougen, Harald K.Disclosure of HIV serostatus by women to their sexual partners is critical for the success of the prevention of mother-to-child transmission of HIV (PMTCT) programme as an integrated service in antenatal care. We explored pregnant HIV-positive and HIV-negative women’s partner disclosure experiences and support needs in eastern Uganda. Methods: This was a qualitative study conducted at Mbale Regional Referral Hospital in eastern Uganda between January and May 2010. Data collection was through in-depth interviews with 15 HIV-positive and 15 HIV-negative pregnant women attending a follow up antenatal clinic (ANC) at Mbale Hospital, and six key informant interviews with health workers at the clinic. Data management was done using NVivo version 9, and a content thematic approach was used for analysis. Results: All HIV-negative women had disclosed their HIV status to their sexual partners but expressed need for support to convince their partners to also undergo HIV testing.Women reported that their partners often assumed that they were equally HIV-negative and generally perceived HIV testing in the ANC as a preserve for women. Most of the HIV-positive women had not disclosed their HIV status to sexual partners for fear of abandonment, violence and accusation of bringing HIV infection into the family. Most HIV-positive women deferred disclosure and requested health workers’ support in disclosure. Those who disclosed their positive status generally experienced positive responses from their partners. Conclusions: Within the context of routine HIV testing as part of the PMTCT programme, most women who test HIV-positive find disclosure of their status to partners extremely difficult. Their fear of disclosure was influenced by the intersection of gender norms, economic dependency, women’s roles as mothers and young age. Pregnant HIV-negative women and their unborn babies remained at risk of HIV infection owing to the resistance of their partners to go for HIV testing. These findings depict a glaring need to strengthen support for both HIV-positive and HIV-negative women to maximize opportunities for HIV prevention.