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  • 1. Ajeani, Judith
    et al.
    Ayiasi, Richard Mangwi
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Namazzi, Gertrude
    Kananura, Rornald Muhumuza
    Kiwanuka, Suzanne Namusoke
    Beyeza-Kashesya, Jolly
    A cascade model of mentorship for frontline health workers in rural health facilities in Eastern Uganda: processes, achievements and lessons2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1345497Article in journal (Refereed)
    Abstract [en]

    Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers.

    Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model.

    Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors.

    Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better.

    Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.

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  • 2.
    AlShurman, Bara’ Abdallah
    et al.
    School of Public Health Sciences, Faculty of Health, University of Waterloo, ON, Waterloo, Canada.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Public Health Sciences, Faculty of Health, University of Waterloo, ON, Waterloo, Canada; School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Nanyonjo, Agnes
    Lincoln International Institute for Rural Health, University of Lincoln, Brayford Way, Brayford, Pool, Lincoln, United Kingdom.
    Butt, Zahid Ahmad
    School of Public Health Sciences, Faculty of Health, University of Waterloo, ON, Waterloo, Canada.
    Waite, Nancy M.
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Vernon-Wilson, Elizabeth
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Wong, Ginny
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Understanding the COVID-19 vaccine policy terrain in Ontario Canada: a policy analysis of the actors, content, processes, and context2023In: Vaccines, E-ISSN 2076-393X, Vol. 11, no 4, article id 782Article in journal (Refereed)
    Abstract [en]

    (1) Background: Canada had a unique approach to COVID-19 vaccine policy making. The objective of this study was to understand the evolution of COVID-19 vaccination policies in Ontario, Canada, using the policy triangle framework.

    (2) Methods: We searched government websites and social media to identify COVID-19 vaccination policies in Ontario, Canada, which were posted between 1 October 2020, and 1 December 2021. We used the policy triangle framework to explore the policy actors, content, processes, and context.

    (3) Results: We reviewed 117 Canadian COVID-19 vaccine policy documents. Our review found that federal actors provided guidance, provincial actors made actionable policy, and community actors adapted policy to local contexts. The policy processes aimed to approve and distribute vaccines while continuously updating policies. The policy content focused on group prioritization and vaccine scarcity issues such as the delayed second dose and the mixed vaccine schedules. Finally, the policies were made in the context of changing vaccine science, global and national vaccine scarcity, and a growing awareness of the inequitable impacts of pandemics on specific communities.

    (4) Conclusions: We found that the triad of vaccine scarcity, evolving efficacy and safety data, and social inequities all contributed to the creation of vaccine policies that were difficult to efficiently communicate to the public. A lesson learned is that the need for dynamic policies must be balanced with the complexity of effective communication and on-the-ground delivery of care.

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  • 3. Apolot, Rebecca R.
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Nyachwo, Evelyne B.
    Waldman, Linda
    Morgan, Rosemary
    Aanyu, Christine
    Mutebi, Aloysius
    Kiwanuka, Suzanne N.
    Ekirapa, Elizabeth
    Maternal health challenges experienced by adolescents; could community score cards address them?: A case study of Kibuku District- Uganda2020In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, no 1, article id 191Article in journal (Refereed)
    Abstract [en]

    Introduction: Approximately 34.8% of the Ugandan population is adolescents. The national teenage pregnancy rate is 25% and in Kibuku district, 17.6% of adolescents aged 12-19 years have begun child bearing. Adolescents mothers are vulnerable to many maternal health challenges including; stigma, unfriendly services and early marriages. The community score card (CSC) is a social accountability tool that can be used to point out challenges faced by the community in service delivery and utilization and ultimately address them. In this paper we aimed to document the challenges faced by adolescents during pregnancy, delivery and postnatal period and the extent to which the community score card could address these challenges.

    Methods: This qualitative study utilized in-depth interviews conducted in August 2018 among 15 purposively selected adolescent women who had given birth 2 years prior to the study and had attended CSC meetings. The study was conducted in six sub counties of Kibuku district where the CSC intervention was implemented. Research assistants transcribed the audio-recorded interviews verbatim, and data was analyzed manually using the framework analysis approach.

    Findings: This study found five major maternal health challenges faced by adolescents during pregnancy namely; psychosocial challenges, physical abuse, denial of basic human rights, unfriendly adolescent services, lack of legal and cultural protection, and lack of birth preparedness. The CSC addressed general maternal and new born health issues of the community as a whole rather than specific adolescent health related maternal health challenges.

    Conclusion: The maternal health challenges faced by adolescents in Kibuku have a cultural, legal, social and health service dimension. There is therefore need to look at a multi-faceted approach to holistically address them. CSCs that are targeted at the entire community are unlikely to address specific needs of vulnerable groups such as adolescents. To address the maternal health challenges of adolescents, there is need to have separate meetings with adolescents, targeted mobilization for adolescents to attend meetings and deliberate inclusion of their maternal health challenges into the CSC.

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  • 4.
    Bangoura, Charlotte
    et al.
    Maferinyah National Centre for Training and Research in Rural Health (CNFRSR), Forécariah, Guinea.
    Dioubaté, Nafissatou
    Maferinyah National Centre for Training and Research in Rural Health (CNFRSR), Forécariah, Guinea.
    Manet, Hawa
    Maferinyah National Centre for Training and Research in Rural Health (CNFRSR), Forécariah, Guinea.
    Camara, Bienvenu Salim
    Maferinyah National Centre for Training and Research in Rural Health (CNFRSR), Forécariah, Guinea.
    Kouyaté, Mariama
    Africa Centre of Excellence for Prevention and Control of Transmissible Diseases (CEA-PCMT), University Gamal Abdel Nasser, Conakry, Guinea..
    Douno, Moussa
    Maferinyah National Centre for Training and Research in Rural Health (CNFRSR), Forécariah, Guinea.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, Waterloo University, Waterloo, ON, Canada; epartment of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    El Ayadi, Alison M.
    Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States.
    Delamou, Alexandre
    Maferinyah National Centre for Training and Research in Rural Health (CNFRSR), Forécariah, Guinea.
    Experiences, Preferences, and Needs of Adolescents and Urban Youth in Contraceptive Use in Conakry, 2019, Guinea2021In: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 2, article id 655920Article in journal (Refereed)
    Abstract [en]

    Introduction: The use of contraceptive methods is very low in Guinea, particularly among adolescents and young people. The purpose of this study is to analyze the experiences and expectations of adolescents and young people regarding the use of contraceptive methods in 2019 in Conakry, Guinea.

    Methods: We conducted a 6-month qualitative and descriptive study. Data were collected through individual in-depth interviews and focus group discussions with adolescents and young people, health providers and health policy makers. Two approaches of deductive and inductive analysis were used to synthesize the main insights from the data.

    Findings: Twenty-six participants were included in this study. Adolescents and young people have personal, family and community experiences that positively or negatively influence their contraceptive needs and preferences. Positive experiences include the relative cost of injectable forms, perceived absence of side effects of implants, proven efficacy and duration of action of the modern method used (implants and injectable form). Negative experiences included cost of implants remain high (15 Euros), perceived side effects including weight gain, pill compliance, method indiscretion, and low sensation of sexual pleasure for the condom. The preferences of the young participants were dominated by Implants and injectable forms that better meet their contraceptive needs. In terms of needs, the expectations expressed revolved around needs related to the health system, including sex education, reduction in the cost of some contraceptives (implants), availability of contraceptive methods, and equity in the provision of family planning services to adolescents and young people.

    Conclusion: Exploring the contraceptive experiences, needs and preferences of adolescents and young people reveals decision-making dilemmas. Adolescents and young people expressed their experiences in terms of the cost of preferred contraceptives (implants), side effects, proven efficacy, and duration of action. However, their decisions are still influenced by availability, equity in service delivery, and the involvement of parents and religious leaders in sex education. Decision-makers should then place particular emphasis on improving health service delivery, adolescent sexual and reproductive health, availability of preferred contraceptive methods at affordable cost, and a program on sexuality education with the involvement of parents and religious leaders and the promotion of condom use.

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  • 5. Bennett, Sara
    et al.
    Mahmood, Shehrin Shaila
    Edward, Anbrasi
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda2017In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, article id 108Article in journal (Refereed)
    Abstract [en]

    Background: Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.

    Methods: We draw upon three IR studies conducted by Future Health Systems (FHS) in Afghanistan, Bangladesh and Uganda. We reviewed project documents from the period 2011-2016 to identify information related, to the dimensions of scaling up. Further, for each country, we developed rich descriptions of how the research teams approached scaling up, and how IR contributed to scale-up. The rich descriptions were checked by FHS research teams. We identified common patterns and. differences across the three cases.

    Results: The three cases planned quite different innovations/interventions and had very different types of scale-up strategies. In all three cases, the research teams had extensive prior experience within the study communities, and. little explicit attention was paid, to contextual factors. All three cases involved complex interactions between the research teams and other stakeholders, among stakeholders, and between stakeholders and the intervention. The IR planned by the research teams focussed primarily on feasibility and effectiveness, but in practice, the research teams also had critical insights into other factors such as sustainability, acceptability, cost-effectiveness and appropriateness. Stakeholder analyses and other project management tools further complemented IR.

    Conclusions: IR can provide significant insights into how best to scale-up a particular intervention. To take advantage of insights from IR, scale-up strategies require flexibility and IR must also be sufficiently flexible to respond to new emerging questions. While commonly used conceptual frameworks for scale-up clearly delineate actors, such as implementers, target communities and the support team, in our experience, IR blurred the links between these groups.

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  • 6.
    Birabwa, Catherine
    et al.
    Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Chemonges, Dennis
    Department of Programs, Population Services International Uganda, Kampala, Uganda; Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda; School of Pharmacy, Waterloo University, Waterloo, ON, Canada.
    Baroudi, Mazen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Namatovu, Fredinah
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Akuze, Joseph
    Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
    Makumbi, Fredrick
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Ssekamatte, Tonny
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Atuyambe, Lynn
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Hernandez, Alison
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Sewe, Maquins Odhiambo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Knowledge and information exposure about family planning among women of reproductive age in informal settlements of Kira municipality, Wakiso district, Uganda2021In: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 2, article id 650538Article in journal (Refereed)
    Abstract [en]

    Introduction: A high unmet need for family planning (FP) prevails in sub-Saharan Africa. Knowledge, awareness creation, and ensuring accessibility are frequently used to increase FP uptake. However, evidence on knowledge or information dissemination about FP among marginalized populations in urban settings in Africa is limited. This study explored the knowledge of FP methods, media exposure, and contact with FP providers among women from an informal settlement in Uganda.

    Methods: Using a cross-sectional study design, we interviewed 626 women aged 15–49 years living in informal settlements of Kira municipality, selected through multistage sampling. Using a standard questionnaire, data was collected on socioeconomic characteristics, knowledge of FP methods, and access to media FP messages among others. Binomial log-linear regression was used to assess disparities in exposure to media FP messages or provider information. Data were analyzed using STATA version 14, at a 5% level of statistical significance.

    Results: Nearly all women in the survey were aware of FP methods (99.7%). On average, each woman was aware of 10 FP methods. The most commonly known methods were male condoms (98.2%), injectables (97.4%), and the oral contraceptive pill (95.2%). Use of any contraceptive was found among 42.7% of respondents. Exposure to media was found in 70.6% of the respondents, mostly through television (58.5%) and radio (58.3%). Discussing FP with a provider was significantly associated with media exposure (aPR 1.4, 95% CI: 1.24–1.56). Less than 50% of women who were not using FP had contact with an FP provider. Women in union (aPR 1.6, 95% CI: 1.01–2.68) and those with access to media messages (aPR 2.5, 95% CI: 1.37–4.54) were more likely to have contact with a provider to discuss FP.

    Conclusion: There is high general awareness about FP methods and media exposure, but method use was low. Further exploration of women's understanding of FP methods and the fit between existing education programs and FP knowledge needs in this urban setting should be conducted. The potential for mobile health solutions in this urban population should be explored. Future studies should focus on the knowledge and understanding of FP among unmarried and nulliparous women and those with no access to media information.

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  • 7. Daniels, Karen
    et al.
    Loewenson, Rene
    George, Asha
    Howard, Natasha
    Koleva, Gergana
    Lewin, Simon
    Marchal, Bruno
    Nambiar, Devaki
    Paina, Ligia
    Sacks, Emma
    Sheikh, Kabir
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Makerere University School of Public Health, Makerere, Uganda.
    Theobald, Sally
    Topp, Stephanie M.
    Zwi, Anthony B.
    Fair publication of qualitative research in health systems: a call by health policy and systems researchers2016In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 15, article id 98Article in journal (Other academic)
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  • 8. Ekirapa-Kiracho, Elizabeth
    et al.
    Kananura, Rornald Muhumuza
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Namazzi, Gertrude
    Mutebi, Aloysius
    George, Asha
    Paina, Ligia
    Waiswa, Peter
    Bumba, Ahmed
    Mulekwa, Godfrey
    Nakiganda-Busiku, Dinah
    Lyagoba, Moses
    Naiga, Harriet
    Putan, Mary
    Kulwenza, Agatha
    Ajeani, Judith
    Kakaire-Kirunda, Ayub
    Makumbi, Fred
    Atuyambe, Lynn
    Okui, Olico
    Kiwanuka, Suzanne Namusoke
    Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1363506Article in journal (Refereed)
    Abstract [en]

    Background: The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services.

    Objectives: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices.

    Methods: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The data was analysed using difference in differences (DiD) analysis and logistic regression.

    Results: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.171.74] and saving for maternal health (aOR 2.11, 95% CI 1.39-3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care.

    Conclusions: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.

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  • 9. Ekirapa-Kiracho, Elizabeth
    et al.
    Namazzi, Gertrude
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda.
    Mutebi, Aloysius
    Waiswa, Peter
    Oo, Htet
    Peters, David H.
    George, Asha S.
    Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda2016In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 16, article id 638Article in journal (Refereed)
    Abstract [en]

    Background: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. Methods: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Results: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women's access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. Conclusions: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.

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  • 10. Ekirapa-Kiracho, Elizabeth
    et al.
    Paina, Ligia
    Kananura, Rornald Muhumuza
    Mutebi, Aloysius
    Jane, Pacuto
    Tumuhairwe, Juliet
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health, Department of Health Policy Planning and Management, Kampala, Uganda.
    Kiwanuka, Suzanne N.
    'Nurture the sprouting bud; do not uproot it'. Using saving groups to save for maternal and newborn health: lessons from rural Eastern Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1347311Article in journal (Refereed)
    Abstract [en]

    Background: Saving groups are increasingly being used to save in many developing countries. However, there is limited literature about how they can be exploited to improve maternal and newborn health.

    Objectives: This paper describes saving practices, factors that encourage and constrain saving with saving groups, and lessons learnt while supporting communities to save through saving groups.

    Methods: This qualitative study was done in three districts in Eastern Uganda. Saving groups were identified and provided with support to enhance members' access to maternal and newborn health. Fifteen focus group discussions (FGDs) and 18 key informant interviews (KIIs) were conducted to elicit members' views about saving practices. Document review was undertaken to identify key lessons for supporting saving groups. Qualitative data are presented thematically.

    Results: Awareness of the importance of saving, safe custody of money saved, flexible saving arrangements and easy access to loans for personal needs including transport during obstetric emergencies increased willingness to save with saving groups. Saving groups therefore provided a safety net for the poor during emergencies. Poor management of saving groups and detrimental economic practices like gambling constrained saving. Efficient running of saving groups requires that they have a clear management structure, which is legally registered with relevant authorities and that it is governed by a constitution.

    Conclusions: Saving groups were considered a useful form of saving that enabled easy acess to cash for birth preparedness and transportation during emergencies. They are like 'a sprouting bud that needs to be nurtured rather than uprooted', as they appear to have the potential to act as a safety net for poor communities that have no health insurance. Local governments should therefore strengthen the management capacity of saving groups so as to ensure their efficient running through partnerships with non-governmental organizations that can provide support to such groups.

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  • 11. Ekirapa-Kiracho, Elizabeth
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Bua, John
    Kananura, Rornald Muhumuza
    Waiswa, Peter
    Makumbi, Fred
    Atuyambe, Lynn
    Ajeani, Judith
    George, Asha
    Mutebi, Aloysuis
    Kakaire, Ayub
    Namazzi, Gertrude
    Paina, Ligia
    Kiwanuka, Suzanne Namusoke
    Maternal and neonatal implementation for equitable systems: a study design paper2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1346925Article in journal (Refereed)
    Abstract [en]

    Background: Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability. Objectives: The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach.

    Methods: The study consisted of a quasi-experimental design, with a participatory action research approach to implementation in three rural districts (Pallisa, Kibuku and Kamuli) in Eastern Uganda. The intervention had two main components; namely, community empowerment for comprehensive birth preparedness, and health provider and management capacity-building. We collected data using both quantitative and qualitative methods using household and facility-level structured surveys, record reviews, key informant interviews and focus group discussions. We purposively selected the participants for the qualitative data collection, while for the surveys we interviewed all eligible participants in the sampled households and health facilities. Descriptive statistics were used to describe the data, while the difference in difference analysis was used to measure the effect of the intervention. Qualitative data were analysed using thematic analysis.

    Conclusions: This study was implemented to generate evidence on how to increase access to quality maternal and newborn health services in a sustainable manner using a multisectoral participatory approach.

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  • 12. George, Asha
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University, Kampala, Uganda.
    Pariyo, George W.
    Peterson, Stefan S.
    Maternal and newborn health implementation research: programme outcomes, pathways of change and partnerships for equitable health systems in Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1359924Article in journal (Other academic)
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  • 13. Kananura, Rornald Muhumuza
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Bua, John
    Ekirapa-Kiracho, Elizabeth
    Mutebi, Aloysius
    Namazzi, Gertrude
    Kiwanuka, Suzanne Namusoke
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waiswa, Peter
    Effect of a participatory multisectoral maternal and newborn intervention on birth preparedness and knowledge of maternal and newborn danger signs among women in Eastern Uganda: a quasi-experiment study2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1362826Article in journal (Refereed)
    Abstract [en]

    Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization.

    Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda.

    Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre-post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs.

    Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7-39% vs. 7-36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7-69% vs. 10-64%, 0-11% vs. 0-5%, and 9-14% vs. 9-13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs' knowledge, respectively. Village health teams' home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs' knowledge.

    Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.

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  • 14. Kananura, Rornald Muhumuza
    et al.
    Wamala, Robert
    Ekirapa-Kiracho, Elizabeth
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Waiswa, Peter
    Atuhaire, Leonard K.
    A structural equation analysis on the relationship between maternal health services utilization and newborn health outcomes: a cross-sectional study in Eastern Uganda2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 98Article in journal (Refereed)
    Abstract [en]

    Background: Neonatal and maternal health services have a bearing on neonatal mortality. Direct and indirect factors affecting neonatal health outcomes therefore require understanding to enable well-targeted interventions. This study, therefore, assessed the interrelationship between newborn health outcomes and maternal service utilization factors.

    Methods: We investigated maternal health utilization factors using health facility delivery and at least four Antenatal Care (ANC) visits; and newborn health outcomes using newborn death and low birth weight (LBW). We used data from a household cross-sectional survey that was conducted in 2015 in Kamuli, Pallisa and Kibuku districts. We interviewed 1946 women who had delivered in the last 12 months. The four interrelated (Endogenous) outcomes were ANC attendance, health facility delivery, newborn death, and LBW. We performed analysis using a structural equation modeling technique.

    Results: A history of newborn death (aOR = 12.64, 95% CI 5.31–30.10) and birth of a LBW baby (aOR = 3.51, 95% CI 1.48–8.37) were directly related to increased odds of newborn death. Factors that reduced the odds of LBW as a mediating factor for newborn death were ANC fourth time attendance (aOR = 0.62, 95% CI 0.45–0.85), having post-primary level education (aOR = 0.68, 95% CI 0.46–0.98) compared to none and being gravida three (aOR = 0.49, 95% CI 0.26–0.94) compared to being gravida one. Mother’s age group, 20–24 (aOR = 0.24, 95% CI 0.08–0.75) and 25–29 years (aOR = 0.20, 95% CI 0.05–0.86) compared to 15–19 years was also associated with reduced odds of LBW. Additionally, ANC visits during the first trimester (aOR = 2.04, 95% CI 1.79–2.34), and village health teams (VHTs) visits while pregnant (aOR = 1.14, 95% CI 1.01–1.30) were associated with increased odds of at least four ANC visits, which is a mediating factor for health facility delivery, LBW and newborn death. Surprisingly, newborn death was not significantly different between health facility and community deliveries.

    Conclusions: Attending ANC at least four times was a mediating factor for reduced newborn death and low birth weight. Interventions in maternal health and newborn health should focus on factors that increase ANC fourth time attendance and those that reduce LBW especially in resource-limited settings. Targeting women with high-risk pregnancies is also crucial for reducing newborn deaths.

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  • 15. Kiracho, Elizabeth Ekirapa
    et al.
    Namuhani, Noel
    Apolot, Rebecca Racheal
    Aanyu, Christine
    Mutebi, Aloysuis
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Ayen, Faith Adong
    Mwesige, Dennis
    Bumbha, Ahmed
    Paina, Ligia
    Peters, David H.
    Influence of community scorecards on maternal and newborn health service delivery and utilization2020In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, no 1, article id 145Article in journal (Refereed)
    Abstract [en]

    Introduction: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators.

    Methods: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework.

    Results: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders.

    Conclusions and recommendations: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.

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  • 16. Kiwanuka, Suzanne Namusoke
    et al.
    Akulume, Martha
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Bua, John
    Ekirapa-Kiracho, Elizabeth
    Balancing the cost of leaving with the cost of living: drivers of long-term retention of health workers: an explorative study in three rural districts in Eastern Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1345494Article in journal (Refereed)
    Abstract [en]

    Background: Health worker retention in rural and underserved areas remains a persisting problem in many low and middle income countries, and this directly affects the quality of health services offered.

    Objective: This paper explores the drivers of long-term retention and describes health worker coping mechanisms in rural Uganda.

    Methods: A descriptive qualitative study explored the factors that motivated health workers to stay, in three rural districts of Uganda: Kamuli, Pallisa, and Kibuku. In-depth interviews conducted among health workers who have been retained for at least 10 years explored factors motivating the health workers to stay within the district, opportunities, and the benefits of staying.

    Results: Twenty-one health workers participated. Ten of them male and 11 female with the age range of 33-51 years. The mean duration of stay among the participants was 13, 15, and 26 years for Kamuli, Kibuku, and Pallisa respectively. Long-term retention was related to personal factors, such as having family ties, community ties, and opportunities to invest. The decentralization policy and pension benefits also kept workers in place. Opportunities for promotion or leadership motivated long stay only if they came with financial benefits. Workload reportedly increased over the years, but staffing and emoluments had not increased. Multiple job, family support, and community support helped health workers cope with the costs of living, and holding a secure pensionable government job was valued more highly than seeking uncertain job opportunities elsewhere.

    Conclusion: The interplay between the costs of leaving and the benefit of staying is demonstrated. Family proximity, community ties, job security, and pension enhance staying, while higher costs of living and an unpredictable employment market make leaving risky. Health workers should be able to access investment opportunities in order to cope with inadequate remuneration. Promotions and leadership opportunities only motivate if accompanied by financial benefits.

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  • 17.
    Lukyamuzi, Zubair
    et al.
    Makerere University, Johns Hopkins University Collaboration (MU-JHU), Upper Mulago Hill Road, Kampala, Uganda; Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
    Etajak, Samuel
    Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
    Katairo, Thomas
    Infectious Diseases Research Collaboration, Kampala, Uganda.
    Mukunya, David
    Busitema University Faculty of Health Sciences, Mbale, Uganda; Sanyu Africa Research Institute, Mbale, Uganda.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda; School of Pharmacy, Waterloo University, ON, Waterloo, Canada.
    Ssenyonjo, Aloysius
    Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
    Wanyenze, Rhoda K.
    Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
    Effect and implementation experience of intensive adherence counseling in a public HIV care center in Uganda: a mixed-methods study2021In: BMC Infectious Diseases, E-ISSN 1471-2334, Vol. 21, no 1, article id 1168Article in journal (Refereed)
    Abstract [en]

    Background: Intensive adherence counseling (IAC) is an intervention recommended by the World Health Organization to improve anti-retroviral therapy (ART) adherence among people living with HIV on ART with unsuppressed viral load; and in 2016, the intervention was implemented in Uganda. This study evaluated the effect and experiences of providing IAC in an urban HIV care center in Kampala, Uganda.

    Methods: This was a sequential explanatory mixed-method study that compared viral load suppression during IAC implementation (intervention) to the period before IAC at Kisenyi Health centre IV. Data were abstracted from patient files and viral load register. The effect of IAC on viral load suppression and associated factors were analyzed using modified Poisson regression with robust standard errors. Using in-depth interviews and an inductive analysis approach in Atlas-ti 8. We also explored experiences of providing IAC among healthcare workers.

    Results: A total of 500 records were sampled: 249 (49.8%) in the intervention period and 251 (51.2%) in the pre-intervention period. The mean age was lower during the intervention period 33.1 (± 12.0) than 36.5 (± 13.4) in the pre- intervention period, p = 0.002. More clients were currently on Protease-based regimen in the pre-intervention period 179 (71.3%) than 135 (54.2%) in the intervention period, p ≤ 0.001. In the intervention period, all eligible clients received IAC [249/249 (100.0%)]. Overall, 325 (65.0%) received IAC and of these, 143 (44.1%) achieved viral load suppression compared to 46 (26.3%) who received regular counseling. Receiving IAC significantly increased viral load suppression by 22% (aPR 1.22, 95% CI 1.01–1.47). Clients on Protease-based regimen were less likely to suppress than those on Efavirenz or Nevirapine-based regimens (aPR 0.11, 95% CI 0.08–0.15). All the interviewed healthcare workers lauded IAC for improving ART adherence. However, patient and health care system related factors hindered adherence during IAC.

    Conclusions: The full potential of IAC in achieving viral load suppression in this setting has not been reached due to a combination of the patient and health care system related factors. Provision of adequate IAC necessities and use of patient centered approach should be emphasized to obtain the maximum benefit of the intervention.

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  • 18.
    Lukyamuzi, Zubair
    et al.
    Makerere University, Johns Hopkins University Collaboration (MU-JHU), Kampala, Uganda.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, Waterloo University, Waterloo, ON, Canada; Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Fonseca Rodriguez, Osvaldo
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Atuyambe, Lynn
    Department of Community Health and Behavioural Sciences Makerere University School of Public Health, Kampala, Uganda.
    Makumbi, Fredrick Edward
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda.
    Baroudi, Mazen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Quality of care in family planning services: differences between formal and informal settlements of Kira municipality, Uganda2021In: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 2, article id 656616Article in journal (Refereed)
    Abstract [en]

    Background: Quality of care (QoC) of family planning (FP) affects contraceptive use, and it varies across types of urban settlement. This study assesses the difference in service delivery point (SDP) structural and process factors between formal and informal urban settlements, and the opinion of the client on the QoC in informal settlements. This is useful in creating an evidence base to advocate for better quality services for the most vulnerable in society.

    Methods: This was a cross-sectional survey that included SDPs of Kira municipality in Wakiso district, Uganda. Data were collected from all the service points in Kira municipality with the caretakers consented. In addition, using multi-stage sampling, 626 women of reproductive age (15–49 years) who lived in the informal settlements of Kira municipality were interviewed. Data were collected using structured questionnaires, descriptive analysis was carried out in Stata version 14.0, and Chi-square and t-tests were used to compare the informal with the formal settlements.

    Results: Formal settlements generally had more higher-level SDPs compared to informal settlements (value of p < 0.001). SDPs in the formal settlements provided more FP methods and had more community health workers (CHW) to support their work. Also, SDPs in the formal settlements were more likely to have long-term FP methods available and more likely to have trained personnel to insert and remove implants and IUDs compared to those in informal settlements. Additionally, more SDPs in the formal settlements provided counseling for permanent, long-term, and short-term FP methods. Of the 626 interviewed women, most of the women (68.6%) reported that they would not return to the previous FP provider or refer a friend to the same provider (72.7%).

    Conclusions: There is a lower quality FP services in the informal settlements with a commensurable effect on the client satisfaction with the services. Therefore, improving the quality of FP services in informal settlements should be a top priority. Improved quality of services could act as a motivation to increase the uptake of modern contraceptives in such settings.

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  • 19.
    Luwangula, Ahmed K.
    et al.
    FHI 360, Kampala, Uganda.
    McGough, Laura
    University Research Co., LLC, MD, Chevy Chase, United States.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, Kitchener, Canada; Makerere University, Kampala, Uganda.
    Wamani, Henry
    Makerere University, Kampala, Uganda.
    Ssennono, Mark
    Kampala, Uganda.
    Agabiirwe, Caroline N.
    Kampala, Uganda.
    Michaud-Létourneau, Isabelle
    Society for Improvement Science in Nutrition, Quebec, Canada.
    Tumwesigye, Nathan
    FHI 360, Kampala, Uganda.
    Baleeta, Keith
    University Research Co., LLC, Jinja, Uganda.
    Rwegyema, Twaha
    University Research Co., LLC, Jinja, Uganda.
    Muhwezi, Augustin
    University Research Co., LLC, Jinja, Uganda.
    Improving iron and folic acid supplementation among pregnant women: an implementation science approach in east-central Uganda2022In: Global Health: Science and Practice (GHSP), ISSN 2169-575X , Vol. 10, no 6, article id e2100426Article in journal (Refereed)
    Abstract [en]

    Introduction: To address maternal iron-deficiency anemia and low uptake of iron and folic acid supplementation (IFAS) among antenatal care (ANC) clinic attendees in East-Central Uganda, the Anemia Implementation Science Initiative embedded enhanced quality improvement (QI) activities into an integrated health project utilizing QI methodologies.

    Methods: To address 2 bottlenecks of stock-outs and inadequate health education for pregnant women during ANC, an enhanced QI intervention was implemented from July 2019 to September 2020 in 2 districts. We conducted a mixed-methods effectiveness quasi-experimental study to assess whether the intervention increased the availability of IFAS in the intervention districts. We used longitudinal facility-level data from 2 treatment districts and 1 comparison district for the quantitative results. Difference-in-difference estimation was used to measure the impact of the intervention on IFAS health education and IFA availability at the health facility. We used logistic regression modeling to control for factors associated with IFAS uptake and potential differences in baseline values. Researchers conducted exit interviews with ANC clients and in-depth interviews with providers and district managers for greater insights into the implementation process.

    Results: The intervention increased the probability, at a statistically significant level, of pregnant women both receiving IFAS and receiving health education on IFAS during ANC. According to interviewees, the intervention approach improved stakeholder engagement and buy-in, which brought about change at all levels of the health system.

    Discussion: The intervention successfully addressed the 2 main bottlenecks to availability of IFAS for pregnant women attending ANC-inadequate provision of IFAS education and a weak drug quantification process. Even without additional funds to purchase commodities, this approach improved district capacity to advocate for and manage IFAS commodities. It could also be used to strengthen overall ANC quality.

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  • 20. Morgan, Rosemary
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Ekirapa-Kiracho, Elizabeth
    George, A. S.
    Gender dynamics affecting maternal health and health care access and use in Uganda2017In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, p. V13-V21Article in journal (Refereed)
    Abstract [en]

    Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women's access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women's lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women's lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women's workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women's attitudes and behaviour during pregnancy, men's attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.

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  • 21.
    Mulubwa, Chama
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia.
    Munakampe, Margarate Nzala
    Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia.
    Namakula, Hilda
    Department of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Hernandez, Alison
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ssekamatte, Tonny
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Atuyambe, Lynn M.
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, College of Health Sciences New Mulago Hospital Complex, Kampala, Uganda.
    Birabwa, Catherine
    Department of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Chemonges, Denis
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Namatovu, Fredinah
    Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR). Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Makumbi, Fredrick
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda; School of Pharmacy, University of Waterloo, Waterloo, ON, Canada.
    Framing contraceptive use motivations among adolescents and young adults living in informal settlements in Kira municipality, Wakiso district, Uganda2021In: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 2, article id 658515Article in journal (Refereed)
    Abstract [en]

    Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not).

    Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda.

    Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives.

    Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

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  • 22. Mutebi, Aloysius
    et al.
    Kananura, Rornald Muhumuza
    Ekirapa-Kiracho, Elizabeth
    Bua, John
    Kiwanuka, Suzanne Namusoke
    Nammazi, Gertrude
    Paina, Ligia
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health, Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1347363Article in journal (Refereed)
    Abstract [en]

    Background: Rural populations in Uganda have limited access to formal financial Institutions, but a growing majority belong to saving groups. These saving groups could have the potential to improve household income and access to health services.

    Objective: To understand organizational characteristics, benefits and challenges, of savings groups in rural Uganda.

    Methods: This was a cross-sectional descriptive study that employed both quantitative and qualitative data collection techniques. Data on the characteristics of community-based savings groups (CBSGs) were collected from 247 CBSG leaders in the districts of Kamuli, Kibukuand Pallisa using self-administered open-ended questionnaires. To triangulate the findings, we conducted in-depth interviews with seven CBSG leaders. Descriptive quantitative and content analysis for qualitative data was undertaken respectively.

    Results: Almost a quarter of the savings groups had 5-14 members and slightly more than half of the saving groups had 15-30 members. Ninety-three percent of the CBSGs indicated electing their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent of the CBSGs had used metallic boxes to keep their money, while 10% of the CBSGs kept their money using mobile money and banks, respectively. The main reasons for the formation of CBSGs were to increase household income, developing the community and saving for emergencies. The most common challenges associated with CBSG management included high illiteracy (35%) among the leaders, irregular attendance of meetings (22%), and lack of training on management and leadership (19%). The qualitative findings agreed with the quantitative findings and served to triangulate the main results.

    Conclusions: Saving groups in Uganda have the basic required structures; however, challenges exist in relation to training and management of the groups and their assets. The government and development partners should work together to provide technical support to the groups.

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  • 23. Namazzi, Gertrude
    et al.
    Hanson, Claudia
    Nalwadda, Christine
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy,Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
    Nampijja, Margaret
    Waiswa, Peter
    Tumwine, James K.
    Hildenwall, Helena
    Caring for children with neurodevelopmental disability: Experiences from caretakers and health workers in rural eastern Uganda2020In: PLOS ONE, E-ISSN 1932-6203, Vol. 15, no 7, article id e0236488Article in journal (Refereed)
    Abstract [en]

    Background: Long term outcomes of children with neurodevelopmental disability are influenced by the condition itself, available health services and caretakers' coping ability to nurture the children which may be related to their beliefs and experiences. Most children with neurodevelopmental disabilities live in resource constrained settings. To inform design of contextually appropriate interventions, this study explored health workers' and caretakers' experiences in caring for infants with neurodevelopmental disability in rural eastern Uganda.

    Methods: A qualitative case study was carried out in December 2017 and involved in-depth interviews with 14 caretakers of infants with severe neurodevelopmental disability, and five health workers in Iganga/Mayuge Demographic Surveillance Site in eastern Uganda. The interviews with caretakers were conducted inLusoga, the local language, and in English for the health workers, using a pre-determined open-ended interview guide. Data were analyzed using latent content analysis.

    Results: Caretakers described the experience of caring for children with neurodevelopmental disability as impoverishing and 'imprisoning' due to high care costs, inability to return to income generating activities and nursing challenges. The latter resulted from failure in body control and several aspects of nutrition and maintaining vital functions, coupled with limited support from the community and the health system. Many caretakers expressed beliefs in supernatural causes of neurodevelopmental disability though they reported about complications during and shortly after the birth of the affected child. Care-seeking was often challenging and impeded by costs and the feeling of lack of improvement. The health care system was also found to be incapable of adequately addressing the needs of such children due to lack of commodities, and human resource limitations.

    Conclusion: The caretakers expressed a feeling of emotional stress due to being left alone with a high nursing burden. Improvement in the health services including a holistic approach to care, improved community awareness and parental support could contribute to nursing of children with NDD.

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  • 24. Namazzi, Gertrude
    et al.
    Okuga, Monica
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University, School of Public Health (MakSPH), Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Kakaire, Ayub
    Namutamba, Sarah
    Mutebi, Aloysius
    Kiwanuka, Suzanne Namusoke
    Ekirapa-Kiracho, Elizabeth
    Waiswa, Peter
    Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1345495Article in journal (Refereed)
    Abstract [en]

    Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation.

    Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy.

    Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences.

    Results: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (>= 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles.

    Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.

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  • 25.
    Nanyonjo, Agnes
    et al.
    Lincoln International Institute for Rural Health, UnaLincoln International Institute for Rural Health, University of Lincoln, Lincoln, Lincolnshire, UKivearsity of Lincoln, Brayford Pool, Lincoln, Lincolnshire, LN6 7TS, UK.
    Nelson, David
    Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, Lincolnshire, UK.
    Sayers, Emma
    School of Health and Social Care, College of Social Science, University of Lincoln, Lincoln, Lincolnshire, UK.
    Lall, Priya
    Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, Lincolnshire, UK.
    Vernon-Wilson, Elizabeth
    School of Pharmacy, University of Waterloo, Kitchener, Canada.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, Kitchener, Canada; School of Public Health Sciences, University of Waterloo, Waterloo, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, Kitchener, Canada.
    Kane, Ros
    School of Health and Social Care, College of Social Science, University of Lincoln, Lincoln, Lincolnshire, UK.
    Gussy, Mark
    Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, Lincolnshire, UK.
    Siriwardena, Niro
    Community and Health Research Unit, University of Lincoln, Lincoln, Lincolnshire, UK.
    Community efforts to promote vaccine uptake in a rural setting: a qualitative interview study2023In: Health Promotion International, ISSN 0957-4824, E-ISSN 1460-2245, Vol. 38, no 4, article id daad088Article in journal (Refereed)
    Abstract [en]

    Vaccine hesitancy has been identified as one of the top 10 threats to global health. The causes of low vaccine uptake are many and vary at micro and macro levels. However, rural and remote coastal areas in the UK experience unique vaccine inequalities due to high levels of deprivation and their unique and complex access-related problems. This study aimed to explore community efforts to promote vaccine uptake during the COVID-19 pandemic and understand how the COVID-19 vaccination campaign was experienced by the public. We conducted an exploratory descriptive qualitative study using semi-structured interviews with decision-makers, health professionals and community members in Lincolnshire, a predominantly rural county with a long coastline, a large population of white minority ethnicities, and those living in caravan and temporary housing. Data were analysed using conventional content analysis. Overcoming the various access barriers to vaccination uptake involved working with local media stations, local communities and local community groups, translation of information, bringing vaccines closer to the people through pop-up and mobile clinics and provision of transport and ensuring confidentiality. There is a need to employ inclusive targeted non-conventional care interventions whilst dealing with complex problems as occur in rural and remote coastal regions.

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  • 26. Paina, Ligia
    et al.
    Namazzi, Gertrude
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Complex, Kampala, Uganda.
    Mayora, Chrispus
    Kananura, Rornald Muhumuza
    Kiwanuka, Suzanne N.
    Waiswa, Peter
    Mutebi, Aloysius
    Ekirapa-Kiracho, Elizabeth
    Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda2019In: Globalization and Health, E-ISSN 1744-8603, Vol. 15, article id 38Article in journal (Refereed)
    Abstract [en]

    In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care - through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh's Model of Diffusion to reflect on these projects' approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.

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  • 27. Paina, Ligia
    et al.
    Wilkinson, Annie
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Barman, Debjani
    Ahmed, Tanvir
    Mahmood, Shehrin Shaila
    Bloom, Gerry
    Knezovich, Jeff
    George, Asha
    Bennett, Sara
    Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda2017In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, article id 109Article in journal (Refereed)
    Abstract [en]

    Background: The Theory of Change (ToC) is a management and evaluation too ! supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.

    Methods: This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams' experiences along four potential uses of ToCs, namely planning, communication, learning and. accountability.

    Results: The three teams developed ToCs for planning and. evaluation purposes as required for their initial plans for FHS in 2011 and. revised, them half-way through the project, based on assumptions informed, by and adjusted, through the teams' experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and. revision fostered, channels for both internal and external communication, among research team members and. with key stakeholders, respectively. The process of revising the ToCs challenged the teams' initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes.

    Conclusions: The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.

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  • 28. Sayinzoga, Felix
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    van der Velden, Koos
    van Dillen, Jeroen
    Bijlmakers, Leon
    Understanding variation in health service coverage and maternal health outcomes among districts in Rwanda - A qualitative study of local health workers' perceptions2019In: PLOS ONE, E-ISSN 1932-6203, Vol. 14, no 10, article id e0223357Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To obtain the perspectives of health professionals and community health workers on factors that determine health service coverage and maternal health outcomes so as to understand variations between districts.

    METHODS: 16 Focus group discussions involving four different groups of participants were conducted in May 2015 in four purposively selected districts, complemented by three key informant interviews in one of the districts.

    RESULTS: The solidarity support for poor people and the interconnectedness between local leaders and heads of health facilities were identified as enablers of health service utilization. Geographical factors, in particular location close to borders with mobile populations and migrants, and large populations with sparsely distributed health infrastructure, exacerbated by hilly topography and muddy roads were identified as barriers. Shortages of skilled health providers at the level of district hospitals were cited as contributing to poor maternal health outcomes.

    CONCLUSION: There is a need to take into account disparities between districts when allocating staff and financial resources in order to achieve universal coverage for high-quality maternal health services and better outcomes. Local innovations such as the use of SMS and WhatsApp text messages by health workers and financial protection schemes for poor patients improve solidarity and are worth to be scaled up.

  • 29.
    Sirili, Nathanael
    et al.
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Simba, Daudi
    Department of Community, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Zulu, Joseph M.
    School of Public Health, University of Zambia (UNZA), Lusaka, Zambia.
    Frumence, Gasto
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, Waterloo, ON, Canada; Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Accommodate or Reject: The Role of Local Communities in the Retention of Health Workers in Rural Tanzania2022In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 11, no 1, p. 59-66Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: While over 70% of the population in Tanzania reside in rural areas, only 25% of physicians and 55% of nurses serve these areas. Tanzania operates a decentralised health system which aims to bring health services closer to its people through collaborative citizen efforts. While community engagement was intended as a mechanism to support the retention of the health workforce in rural areas, the reality on the ground does not always match this ideal. This study explored the role local communities in the retention of health workers in rural Tanzania.

    METHODS: An exploratory qualitative study was completed in two rural districts from the Kilimanjaro and Lindi regions in Tanzania between August 2015 and September 2016. Nineteen key informant interviews (KIIs) were conducted with district health managers, local government leaders, and health facility in-charges. In addition, three focus group discussions (FGDs) were conducted with 19 members of the governing committees of three health facilities from the two districts. Data were analysed using the thematic analysis technique.

    RESULTS: Accommodation or rejection were the two major ways in which local communities influenced the quest for retaining health workers. Communities accommodated incoming health workers by providing them a good reception, assuming responsibility for resolving challenges facing health facilities and health workers, linking health workers to local communities and promoting practices that placed a high value on health workers. On the flip side, communities could also reject health workers by openly expressing lack of trust and labelling them as 'foreigners,' by practicing cultural rituals that health workers feared and discrimination based on cultural differences.

    CONCLUSION: Fostering good relationships between local communities and health workers may be as important as incentives and other health system strategies for the retention of health workers in rural areas. The role communities play in rural health worker retention is not sufficiently recognized and is worthy of further research.

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  • 30.
    Ssekamatte, Tonny
    et al.
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
    Kibira, Simon P. S.
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, Waterloo, Canada; Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Isunju, John Bosco
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
    Mugambe, Richard K.
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
    Wafula, Solomon Tsebeni
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
    Buregyeya, Esther
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
    Nalwadda, Christine Kayemba
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda.
    Bukenya, Justine Nnakate
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda.
    Wanyenze, Rhoda K.
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
    Do sexual expectancies and inhibitions predict high-risk sexual behaviours? Evidence from a cross-sectional survey among young psychoactive substance users in informal settlements in Kampala, Uganda2021In: BMC Public Health, E-ISSN 1471-2458, Vol. 21, no 1, article id 1506Article in journal (Refereed)
    Abstract [en]

    Background: Psychoactive substance use is a public health challenge among young people in informal settlements. Though rarely examined, psychoactive substance use is linked to sexual expectancies and inhibitions, and consequently high-risk sexual behaviours. This study examined the association between sexual expectancies and inhibitions, and high-risk sexual behaviours among young psychoactive substance users (PSUs) in informal settlements in Kampala, Uganda.

    Methods: This cross-sectional study recruited 744 young PSUs from informal settlements in Kampala. Respondent driven sampling was used to recruit respondents. A ‘modified’ Poisson regression model was used for inferential statistics. Data were analysed using the Stata 14 software.

    Results: Of the 744 study participants, 45.6% believed that psychoactive substance use improves sexual performance; 43.3% believed that psychoactive substances make sex more pleasurable, and 53.3% believed that psychoactive substances give courage or confidence to approach a partner for sex. The belief that psychoactive substance use improves sexual performance (PR 1.14, 95% CI: 1.01–1.30), increases the likelihood of engaging in sex (PR 1.20, 95% CI: 1.04–1.40) or gives courage or confidence to approach a sexual partner (PR 1.21, 95% CI: 1.05–1.39) were associated with having sex while under the influence of psychoactive substances. The belief that a psychoactive substance user under the influence of psychoactive substances is more likely to engage in sex (PR 1.48, 95% CI: 1.15–1.90), and likely to find it difficult to refuse sex (PR 1.28, 95% CI: 1.06–1.55) were positively associated with engaging in multiple sexual partnerships. The belief that one easily forgets to use a condom when under the influence of psychoactive substances was positively associated with inconsistent condom use (PR 1.26, 95% CI: 1.09–1.45).

    Conclusion: Psychoactive substance use expectancies associated with high-risk sexual behaviours included the belief that psychoactive substances improve sexual performance and improve confidence in approaching a sexual partner. Psychoactive substance use inhibitions associated with high-risk sexual behaviours included an increased likelihood of engaging in sexual intercourse, difficulties in refusing to engage in sexual intercourse, and forgetting to use condoms while intoxicated. Interventions targeting a reduction in high-risk sexual behaviour should integrate the impact of psychoactive substance use on sexual behaviour.

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  • 31. Ssekamatte, Tonny
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy and Planning, Makerere University School of Public Health.
    Kibira, Simon P. S.
    Isunju, John Bosco
    Mugambe, Richard K.
    Nabiwemba, Elizabeth
    Wafula, Solomon Tsebeni
    Buregyeya, Esther
    Bukenya, Justine Nnakate
    Multiple sexual partnerships and associated factors among young psychoactive-substance-users in informal settlements in Kampala, Uganda2020In: PLOS ONE, E-ISSN 1932-6203, Vol. 15, no 10, article id e0239323Article in journal (Refereed)
    Abstract [en]

    Background: Multiple sexual partnerships increase the risk of transmission of HIV and can be exacerbated by substance abuse. However, the association between psychoactive substance use and multiple sexual partnerships among young people in informal settlements of low-income countries is not well known. This study established the prevalence of multiple sexual partnerships and associated factors among young psychoactive-substance-users in informal settlements in Kampala, Uganda.

    Methods: This was a cross-sectional study involving 744 young (aged 18-24 years), sexually active, psychoactive substance-users selected from 12 of the 57 informal settlements of Kampala City. The prevalence of multiple sexual partnerships and their differential distribution by socio-demographic strata was established. Modified Poisson regression models were run in Stata 14 software to generate prevalence rate ratios for the factors associated with multiple sexual partnerships.

    Results: About 40.6% (37.9% of males and 50.0% of females) had engaged in multiple sexual partnerships in the last 30 days. Engaging in multiple sexual partnerships in the last 30 days was positively associated with being female (PR 1.29, 95% CI: 1.03-1.63); staying in the informal settlement for 6-10 years (PR 1.34, 95% CI: 1.02-1.75) and chewing khat in the last 30 days (PR 1.93, 95% CI: 1.10-3.40).

    Conclusion: Multiple sexual partnerships are highly prevalent among young psychoactive-substance-users, irrespective of the socio-demographic strata. Being female, having lived in the informal settlement for 6-10 years, and chewing khat were significantly associated with having multiple sexual partners in the last 30 days. In tackling this high-risk sexual behaviour, it is recommended that risk-reduction interventions are considered for the different socio-demographic strata identified in this study, i.e. females, those who have lived in the informal settlement for about 6-10 years, and those who chew khat.

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  • 32.
    Tennant, Ryan
    et al.
    Department of Systems Design Engineering, University of Waterloo, Ontario, Canada.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, Waterloo, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, Ontario, Canada.
    Burns, Catherine M.
    Department of Systems Design Engineering, University of Waterloo, Ontario, Canada.
    Multi-diciplinary design and implementation of a mass vaccination clinic mobile application to support decision-making2023In: IEEE Journal of Translational Engineering in Health and Medicine, E-ISSN 2168-2372, Vol. 11, p. 60-69Article in journal (Refereed)
    Abstract [en]

    Mass vaccination clinics are complex systems that combine professionals who do not typically work together. Coordinating vaccine preparation and patient intake is critically important to maintain patient flow equilibrium, requiring continuous communication and shared decision-making to reduce vaccine waste.

    Objectives: (1) To develop a mobile application (app) that can address the information needs of vaccination clinic stakeholders for end-of-day doses decision-making in mass immunization settings; and (2) to understand usability and clinical implementation among multi-disciplinary users.

    Methods: Contextual inquiry guided 71.5 hours of observations to inform design characteristics. Rapid iterative testing and evaluation were performed to validate and improve the design. Usability and integration were evaluated through observations, interviews, and the system usability scale.

    Results: Designing the app required consolidating contextual factors to support information and workload needs. Twenty-four participants used the app at four clinics who reported its effectiveness in reducing stress and improving communication efficiency and satisfaction. They also discussed positive workflow changes and design recommendations to improve its usefulness. The average system usability score was 87 (n=22).

    Discussion: There is significant potential for mobile apps to improve workflow efficiencies for information sharing and decision-making in vaccination clinics when designed for established cultures and usability, thereby providing frontline workers with greater time to focus on patient care and immunization needs. However, designing and implementing digital systems for dynamic settings is challenging when healthcare teams constantly adapt to evolving complexities. System-level barriers to adoption require further investigation. Future research should explore the implementation of the app within global contexts.

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  • 33.
    Tennant, Ryan
    et al.
    Department of Systems Design Engineering, Faculty of Engineering, University of Waterloo, ON, Waterloo, Canada.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Burns, Catherine M.
    Department of Systems Design Engineering, Faculty of Engineering, University of Waterloo, ON, Waterloo, Canada.
    Understanding human factors challenges on the front lines of mass Covid-19 vaccination clinics: human systems modeling study2022In: JMIR Human Factors, E-ISSN 2292-9495, Vol. 9, no 4, article id e39670Article in journal (Refereed)
    Abstract [en]

    Background: Implementing mass vaccination clinics for COVID-19 immunization has been a successful public health activity worldwide. However, this tightly coupled system has many logistical challenges, leading to increased workplace stress, as evidenced throughout the pandemic. The complexities of mass vaccination clinics that combine multidisciplinary teams working within nonclinical environments are yet to be understood through a human systems perspective.

    Objective: This study aimed to holistically model mass COVID-19 vaccination clinics in the Region of Waterloo, Ontario, Canada, to understand the challenges centered around frontline workers and to inform clinic design and technological recommendations that can minimize the systemic inefficiencies that contribute to workplace stress.

    Methods: An ethnographic approach was guided by contextual inquiry to gather data on work as done in these ad-hoc immunization settings. Observation data were clarified by speaking with clinic staff, and the research team discussed the observation data regularly throughout the data collection period. Data were analyzed by combining aspects of the contextual design framework and cognitive work analysis, and building workplace models that can identify the stress points and interconnections within mass vaccination clinic flow, developed artifacts, culture, physical layouts, and decision-making.

    Results: Observations were conducted at 6 mass COVID-19 vaccination clinics over 4 weeks in 2021. The workflow model depicted challenges with maintaining situational awareness about client intake and vaccine preparation among decision-makers. The artifacts model visualized how separately developed tools for the vaccine lead and clinic lead may support cognitive tasks through data synthesis. However, their effectiveness depends on sharing accurate and timely data. The cultural model indicated that perspectives on how to effectively achieve mass immunization might impact workplace stress with changes to responsibilities. This depends on the aggressive or relaxed approach toward minimizing vaccine waste while adapting to changing policies, regulations, and vaccine scarcity. The physical model suggested that the co-location of workstations may influence decision-making coordination. Finally, the decision ladder described the decision-making steps for managing end-of-day doses, highlighting challenges with data uncertainty and ways to support expertise.

    Conclusions: Modeling mass COVID-19 vaccination clinics from a human systems perspective identified 2 high-level opportunities for improving the inefficiencies within this health care delivery system. First, clinics may become more resilient to unexpected changes in client intake or vaccine preparation using strategies and artifacts that standardize data gathering and synthesis, thereby reducing uncertainties for end-of-day dose decision-making. Second, improving data sharing among staff by co-locating their workstations and implementing collaborative artifacts that support a collective understanding of the state of the clinic may reduce system complexity by improving shared situational awareness. Future research should examine how the developed models apply to immunization settings beyond the Region of Waterloo and evaluate the impact of the recommendations on workflow coordination, stress, and decision-making.

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  • 34.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Policy, Planning and Management, Makerere University, Uganda.
    Acland, olivia (Photographer)
    Mwangi, Njeri (Photographer)
    Lubowa, Abubaker (Photographer)
    Ekstromervia, Jonas (Photographer)
    Coronavirus in East Africa: Disease-induced divisions and challenges to regional blocs are set to deepen in the aftermath of the COVID-19 pandemic2020Other (Other (popular science, discussion, etc.))
  • 35.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Participatory approaches to strengthening district health managers' capacity: Ugandan and global experiences2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Introduction:

    Residents of low in-come countries have persistently suffered poor health outcomes, modest progress made over time notwithstanding. Weak health systems are one of the key reasons for the less than optimum progress. These health systems are constrained by inadequately equipped managers who play a main role in curbing this progress. Strengthening the capacity of health managers capacity is one of the known ways to improve the performance of health systems. This study examined strategies for strengthening the capacity of health managers at the sub-national level, with a special focus on the Participatory Action Research (PAR) approach.

    Methods:

    I used an emergent qualitative design which included both primary data collection and a literature review. Primary data collection techniques included individual interviews, Focus Group Discussions (FGDs), participant observations, and a review of project documents and meeting minutes, while searching for peer-reviewed databases was used for the literature review. Several analytical tools were adopted to answer the objectives, including the grounded theory, content and thematic analysis approaches. The Critical Interpretive Synthesis (CIS) method was used to analyze the literature reviewed.

    Findings:

    Stakeholders’ perceived the approaches to strengthening health managers’ capacity as an overarching process comprised of three interconnected subprocesses namely: the professionalizing of health managers, the use of engaging approaches to learning, and the availability of a supportive work environment. PAR as an engaging approach to learning was experienced by stakeholders as a nuanced awakening approach. On the one hand, stakeholders felt engaged, valued, responsible, awakened and a sense of ownership. On the other hand, they felt conflicted, stressed and uncertain. The PAR approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals, and review progress. Expanded spaces for interaction, the encouragement of flexibility, the empowerment of local managers and the promotion of reflection and accountability enabled this enhancement. Lastly, the literature reviewed revealed five interrelated elements for harnessing PAR to strengthen health managers capacity. These were: a shared purpose, skilled facilitation and social psychological safety, activity integration into organizational procedures, organizational support and supportive external monitoring.

    Conclusions:

    Health managers have a central role in strengthening health systems; hence the formalization of their role, especially within the public-sector, is needed. In addition, significant investments into developing and strengthening their capacity is required. Strengthening the capacity of health managers is an iterative process that draws synergies from different approaches. The process leans on formal trainings as well as more engaging means of learning, such as PAR. As an engaging approach to learning, PAR expands interaction spaces, provides inclusiveness and flexibility, promotes local ingenuity and shared responsibility, and allows for monitoring and learning. PAR had positive effects on the strengthening of the capacity of health managers while at the same time achieving other project outcomes. Participatory approaches are hence relevant for dealing with the complex challenges bedevilling health systems. The approach nonetheless should be applied with a more nuanced appreciation of the challenges when using it and the elements for harnessing it to strengthen health systems.

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  • 36.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, Waterloo University, Waterloo, ON, Canada; Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Baroudi, Mazen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ssekamatte, Tonny
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Birabwa, Catherine
    Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Kibira, Simon Peter
    Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Atuyambe, Lynn
    Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Delamou, Alexandre
    Africa Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Faculty of Science and Health Techniques, Gamal Abdel Nasser University of Conakry, Conakry, Guinea; National Training and Research Center in Rural Health of Maferinyah, Forecariah, Guinea.
    Makumbi, Fredrick Edward
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Total Demand, Use and Unmet Need for Modern Contraceptives Among Women Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda: Implications for Urban Health2021In: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 2, article id 655413Article in journal (Refereed)
    Abstract [en]

    Background: Update and utilization of modern contraceptives has public health benefits including reduction of unintended pregnancies, unsafe abortions, and related maternal mortality. However, paucity of evidence on key indicators of family planning in the informal settlements abounds. Data are usually collapsed within the larger urban communities that tend to mask peculiarities of informal settlements. This study determined the proportion of women using modern contraceptives, the unmet need for modern contraceptives and the total demand in informal settlements of an urban municipality.

    Methods: A cross-sectional study conducted among 626 women in the reproductive age (15–49 years)  in the informal settlements of Kira municipality (part of metropolitan Kampala). Multi-stage sampling was applied in the selection of the respondents. Descriptive and log-binomial regression analysis were conducted to determine percentage of women using modern contraceptives, unmet need, and total demand with their associated factors. All analyses were conducted using STATA version 15.0.

    Results: The total demand for modern contraceptives was 84.9%, modern contraceptive prevalence was 47.4% nearly meeting the national target of 50%, however the unmet need was 37.3%, which much higher than the national target of 10%. Lower total demand for contraceptives was associated with higher women’s education status and preference to have another child, while higher total demand was associated with having at least one living child. Higher modern contraceptives use was associated with older age, having at least one living child and high decision-making power, while lower modern contraceptives use was associated with higher education and undetermined fertility preference. Lower unmet need for modern contraceptives was associated with older age (PR 0.68, 95% CI: 0.48–0.97) and high decision-making power (PR 0.64, 95% CI: 0.50–0.81), while higher unmet need was found among those who having at least one living child (PR 1.40, 95% CI: 1.01–1.93) and undetermined fertility preference (PR 1.70, 95% CI: 1.24–2.34).

    Conclusions: Total demand and contraceptive use were found to be higher in the informal settlements of Kira municipality, however, the unmet need was much higher among this population as compared to the national urban estimates. This indicates a much higher demand for contraceptives and the need to consider the diverse socio-demographic characteristics of urban spaces. Development of Interventions need to critically consider the diverse urban space, associated explanatory variables and a collaborative systems lens to achieve sustained improvements.

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  • 37.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, Kampala, Uganda.
    Coe, Anna-Britt
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bennett, Sara
    Kiwanuka, Suzanne N.
    George, Asha
    Kiracho, Elizabeth Ekirapa
    A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda2017In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, article id 110Article in journal (Refereed)
    Abstract [en]

    Background: Many approaches to improving health managers' capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers' capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers' capacity in Eastern Uganda.

    Methods: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers' capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus.

    Results: The findings indicate that the participatory action research approach enhanced health managers' capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness.

    Conclusions: Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers' capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers' capacity.

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  • 38.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy, Planning and Management, Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Coe, Anna-Britt
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ekirapa-Kiracho, Elizabeth
    Kiwanuka, Suzanne N.
    Experiences of using a participatory action research approach to strengthen district local capacity in Eastern Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1346038Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To achieve a sustained improvement in health outcomes, the way health interventions are designed and implemented is critical. A participatory action research approach is applauded for building local capacity such as health management. Thereby increasing the chances of sustaining health interventions.

    OBJECTIVE: This study explored stakeholder experiences of using PAR to implement an intervention meant to strengthen the local district capacity.

    METHODS: This was a qualitative study featuring 18 informant interviews and a focus group discussion. Respondents included politicians, administrators, health managers and external researchers in three rural districts of eastern Uganda where PAR was used. Qualitative content analysis was used to explore stakeholders' experiences.

    RESULTS: 'Being awakened' emerged as an overarching category capturing stakeholder experiences of using PAR. This was described in four interrelated and sequential categories, which included: stakeholder involvement, being invigorated, the risk of wide stakeholder engagement and balancing the risk of wide stakeholder engagement. In terms of involvement, the stakeholders felt engaged, a sense of ownership, felt valued and responsible during the implementation of the project. Being invigorated meant being awakened, inspired and supported. On the other hand, risks such as conflict, stress and uncertainty were reported, and finally these risks were balanced through tolerance, risk-awareness and collaboration.

    CONCLUSIONS: The PAR approach was desirable because it created opportunities for building local capacity and enhancing continuity of interventions. Stakeholders were awakened by the approach, as it made them more responsive to systems challenges and possible local solutions. Nonetheless, the use of PAR should be considered in full knowledge of the undesirable and complex experiences, such as uncertainty, conflict and stress. This will enable adequate preparation and management of stakeholder expectations to maximize the benefits of the approach.

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  • 39.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, Waterloo, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, Waterloo, Canada.
    Waite, Nancy
    School of Pharmacy, University of Waterloo, Waterloo, Canada.
    VanderDoes, Jeremy
    Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada.
    Taddio, Anna
    Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.
    Integrating the CARD (Comfort Ask Relax Distract) system in a mass vaccination clinic to improve the experience of individuals during COVID-19 vaccination: a pre-post implementation study2022In: Human Vaccines & Immunotherapeutics, ISSN 2164-5515, E-ISSN 2164-554X, Vol. 18, no 5, article id 2089500Article in journal (Refereed)
    Abstract [en]

    Many people have negative experiences with vaccination due to stress-related reactions including fear and pain. We used a pre-post study design to evaluate the impact of implementing a modified version of the CARD (Comfort-Ask-Relax-Distract) system on stress-related reactions in individuals aged 12 y or older undergoing COVID-19 vaccinations in mass vaccination clinics. Vaccine recipients reported their level of pain, fear and dizziness during vaccination. Clinic staff reported their attitudes about CARD and use of CARD interventions. CARD improved client symptoms across genders and ages with an average reduction in needle pain, fear and dizziness of 75%, 40% and 44%, respectively. CARD was more effective in younger individuals. Clinic staff reported positive attitudes about CARD and uptake of selected CARD interventions. In summary, the modified CARD system reduced stress-related responses in a general population undergoing COVID-19 vaccinations in a mass vaccination clinic, was feasible and acceptable to staff. Future implementation efforts are recommended that include more diverse cultural contexts and incorporate education of individuals about CARD ahead of time.

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  • 40.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, P.O. B0X 7072, Kampala, Uganda.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ekirpa-Kiracho, Elizabeth
    Kiwanuka, Suzanne N.
    Coe, Anna-Britt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Building a competent health manager at district level: a grounded theory study from Eastern Uganda2016In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 16, article id 665Article in journal (Refereed)
    Abstract [en]

    Background: Health systems in low-income countries are often characterized by poor health outcomes. While many reasons have been advanced to explain the persistently poor outcomes, management of the system has been found to play a key role. According to a WHO framework, the management of health systems is central to its ability to deliver needed health services. In this study, we examined how district managers in a rural setting in Uganda perceived existing approaches to strengthening management so as to provide a pragmatic and synergistic model for improving management capacity building.

    Methods: Twenty-two interviews were conducted with district level administrative and political managers, district level health managers and health facility managers to understand their perceptions and definitions of management and capacity building. Kathy Charmaz's constructive approach to grounded theory informed the data analysis process.

    Results: An interative, dynamic and complex model with three sub-process of building a competent health manager was developed. A competent manager was understood as one who knew his/her roles, was well informed and was empowered to execute management functions. Professionalizing health managers which was viewed as the foundation, the use of engaging learning approaches as the inside contents and having a supportive work environment the frame of the model were the sub-processes involved in the model. The sub-processes were interconnected although the respondents agreed that having a supportive work environment was more time and effort intensive relative to the other two sub-processes.

    Conclusions: The model developed in our study makes four central contributions to enhance the WHO framework and the existing literature. First, it emphasizes management capacity building as an iterative, dynamic and complex process rather than a set of characteristics of competent managers. Second, our model suggests the need for professionalization of health managers at different levels of the health system. Third, our model underscores the benefits that could be accrued from the use of engaging learning approaches through prolonged and sustained processes that act in synergy. Lastly, our model postulates that different resource investments and a varied range of stakeholders could be required at each of the sub-processes.

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  • 41.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, Waterloo, ON, Canada; Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Jonsson, Frida
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Whyle, Eleanor
    School of Public Health & Family Medicine (SPHFM), University of Cape Town, Cape Town, South Africa.
    Zulu, Joseph
    School of Public Health & Family Medicine (SPHFM), University of Cape Town, Cape Town, South Africa.
    Schneider, Helen
    School of Public Health, University of the Western Cape, Cape Town, South Africa; South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa.
    Hernandez, Alison
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Centre for the Study of Equity and Governance in Health Systems, Guatemala City, Guatemala.
    Strengthening Research and Practice in Community Health Systems: A Research Agenda and Manifesto2022In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 11, no 1, p. 17-23Article in journal (Refereed)
    Abstract [en]

    While there have been increased calls for strengthening community health systems (CHSs), key priorities for this field have not been fully articulated. This paper seeks to fill this gap, presenting a collaboratively defined research agenda, accompanied by a 'manifesto' on strengthening research and practice in the CHS. The CHS research agenda domains were developed through a modified concept mapping process with a team of 33 experts on the CHS including policy-makers, implementers and researchers from institutions in six countries: Uganda, Guatemala, South Africa, Sweden, Tanzania and Zambia. The process began remotely with brainstorming research priorities and concluded in a one-week workshop that was held in Zambia where priorities for strengthening CHS were discussed, grouped into domains, interpreted, and drafted into a collective declaration. Eight domains of research priorities for CHSs were identified: clarifying the purpose and values of the CHS, ensure inclusivity; design, implementation and monitoring of strategies to strengthen the CHS; social, political and historical contexts of CHS; community health workers (CHWs); social accountability; the interface between the CHS and the broader health system; governance and stewardship; and finally, the ethical methodologies forresearching the CHS. By harnessing a set of diverse and rich experiences and perspectives on CHS through a structured process, a multifaceted research agenda and manifesto that transcend context, disciplines and time were developed. We posit this as an entry into greater debate and diversity in the field as we continue to find ways to strengthen research and practice in the CHS. 

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  • 42.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, Waterloo University, Waterloo, ON, Canada; Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Ssekamatte, Tonny
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Akilimali, Pierre
    Department of Nutrition Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
    Sirike, Judith
    Division of Social Development, Intergovernmental Authority on Development, Kampala, Uganda.
    Fonseca-Rodríguez, Osvaldo
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Atuyambe, Lynn
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Makumbi, Fredrick Edward
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Geospatial distribution of family planning services in Kira Municipality, Wakiso District, Uganda2020In: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 1, article id 599774Article in journal (Refereed)
    Abstract [en]

    Introduction: Access to family planning (FP) services remains a challenge, particularly in informal urban settlements. The unmet need for FP in these settings is high, with a correspondingly high prevalence of unintended pregnancies that may lead to unsafe abortions. However, there is a paucity of quality data on the distribution of FP services in such settings in Uganda. This paper described the geospatial distribution of FP services in Kira Municipality, Wakiso District, Uganda.

    Methods: This was a cross-sectional study in which we determined the availability and distribution of FP services in Kira Municipality. Community mapping and analysis were conducted using ArcGIS (version 10.1) and ArcGIS Online. Stata version 13.1 was used for data analysis. Chi-square test was used to compare the contraceptive provision and availability among facilities from informal and formal settlements.

    Results: Of the 176 healthcare facilities surveyed, only 42% (n = 74) offered contraceptives in informal settlements. The majority of the facilities were privately owned small clinics (95%). At least 80% of the facilities provided three or more modern contraceptive methods, with no difference (p = 0.107) between facilities in informal and formal settlements. Only 30.7% (p = 0.001) of the facilities provided at least one long-acting contraceptive. Similarly, 20 and 12% (p = 0.001) of the facilities had implants and intrauterine devices (IUDs) on the day of the survey. Almost 25% of the facilities did not offer contraceptive services (counseling and commodities) to unmarried adolescents.

    Conclusions: Most facilities were small privately-owned clinics, offering at least three modern contraceptive methods. The unavailability of long-acting reversible methods in the informal settings may affect the quality of FP services due to limited choice. The inequity in service provision that disfavors the unmarried adolescent may increase unwanted/unintended pregnancies. We recommend that local governments and partners work toward filling the existing commodities gap and addressing the discrimination against unmarried adolescents in such settings.

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  • 43.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, ON, Kitchener, Canada; School of Public Health Sciences, University of Waterloo, ON, Waterloo, Canada.
    Tennant, Ryan
    Systems Design Engineering, Faculty of Engineering, University of Waterloo, ON, Waterloo, Canada.
    Adil, Maisha
    School of Public Health Sciences, University of Waterloo, ON, Waterloo, Canada.
    Bala, Arthi
    School of Public Health Sciences, University of Waterloo, ON, Waterloo, Canada.
    Burns, Catherine
    Systems Design Engineering, Faculty of Engineering, University of Waterloo, ON, Waterloo, Canada.
    Waite, Nancy
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    "Flying a plane and building it at the same time": Lessons learned from the dynamic implementation of mass vaccination clinics in the Region of Waterloo, Ontario, Canada2023In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 21, no 1, article id 102Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Vaccination plays a critical role during pandemics, and mass vaccination clinics are often an imperative public health measure. These clinics usually consist of multi-disciplinary teams, which can pose significant coordination challenges, yet also present an opportunity for collectively contributing towards mitigating the impact of infection within communities. This study explores the coordination dynamics of the Region of Waterloo's coronavirus disease of 2019 (COVID-19) mass vaccination clinics in Ontario, Canada, between July 2021 and April 2022.

    METHODS: This qualitative study included 16 purposively selected participants working in mass vaccination clinics. Participants were individually interviewed for 40-60 min. An inductive and iterative thematic analysis was undertaken, including open coding, grouping, labelling, regrouping and making sense of the themes.

    RESULTS: Three interrelated themes were created: (1) unpredictable work environment, which was comprised of changing clinic processes and the impact of clinic adjustments to the running of the clinics; (2) clinic cohesion challenges, which included staff role disparities, limited job preparation and clinic system silos; and (3) adaptable and supportive work environment, which was comprised of staff adaptability, dispositional flexibility and a supportive work environment. While the first two themes created a precarious situation in the clinics, the third countered it, leading to a largely successful clinic implementation.

    CONCLUSIONS: The rapid evolution and high transmissibility of COVID-19 in communities required a public health response that felt like flying and building a plane simultaneously - a seemingly impossible yet necessary task. However, an adaptable and supportive work environment was critical for establishing an atmosphere that can overcome challenges from a constantly changing pandemic and the guidance of public health officials. Such lessons gained from understanding the dynamic experiences in mass vaccination clinics are essential for improving the development and operation of future immunization campaigns.

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  • 44.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Tennant, Ryan
    Systems Design Engineering, Faculty of Engineering, University of Waterloo, ON, Waterloo, Canada.
    Patten, Alexander
    Department of Biology, University of Waterloo, ON, Waterloo, Canada.
    Giilck, Ben
    Department of Physics and Astronomy, Faculty of Science, University of Waterloo, ON, Waterloo, Canada.
    Burns, Catherine M
    Systems Design Engineering, Faculty of Engineering, University of Waterloo, ON, Waterloo, Canada.
    Waite, Nancy
    School of Pharmacy, Faculty of Science, University of Waterloo, ON, Kitchener, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, ON, Kitchener, Canada.
    Role satisfaction among community volunteers working in mass COVID-19 vaccination clinics, Waterloo Region, Canada2023In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, no 1, article id 1199Article in journal (Refereed)
    Abstract [en]

    Introduction: Unpaid community volunteers are a vital public health resource in times of crisis. In response to the COVID-19 pandemic, community volunteers were mobilized to support mass vaccination efforts in many countries. To have this group’s continued engagement, it is essential to understand the community volunteer experience, including the opportunities and challenges they encounter and how these contribute to their role satisfaction. This qualitative study investigated the factors contributing to community volunteers’ role satisfaction at COVID-19 mass vaccination clinics in the Region of Waterloo, Canada.

    Methods: Qualitative data were analyzed from 20 volunteers (aged 48–79 years) who had worked at one of four COVID-19 vaccination clinics in the Region of Waterloo, Canada. Data were analyzed thematically using an inductive coding process followed by an iterative process of grouping and identifying linkages and relationships within the themes.

    Results: Four interrelated themes were developed from the inductive analysis process. The theme of community volunteers feeling valued or disesteemed in their role depends on the interaction between the three themes of role description, role preparation, and clinic context.

    Conclusions: For volunteers in crises such as the COVID-19 pandemic, volunteer role satisfaction depends on how their contributions are valued, the clarity of their role descriptions, volunteer-specific training, and the sentiments of volunteers and staff within the clinic context. Greater role satisfaction can help with retention as volunteers become more resilient and adaptable to the complex dynamic circumstances of a crisis response. Activities such as training and materials development for role preparations should be explicitly planned and well-resourced, even in crisis/pandemic situations. Building clinic managers’ or supervisors’ skills in communication during crisis/pandemic situations and the skills for the creation of team cohesion are critical investment areas.

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  • 45.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Zulu, Joseph Mumba
    School of Public Health, University of Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ekirapa-Kiracho, Elizabeth
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Coe, Anna-Britt
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Elements for harnessing participatory action research to strengthen health managers' capacity: a critical interpretative synthesis2018In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 16, article id 33Article, review/survey (Refereed)
    Abstract [en]

    Background: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers’ capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers’ capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter.

    Methods: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers’ capacity. The critical interpretive synthesis method’s approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104–111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains.

    Results: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers’ capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning.

    Conclusions: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers’ capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.

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  • 46.
    Vernon-Wilson, Elizabeth
    et al.
    School of Pharmacy, University of Waterloo, ON, Waterloo, Canada.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Pharmacy, University of Waterloo, ON, Waterloo, Canada.
    Nanyonjo, Agnes
    Lincoln International Institute for Rural Health, University of Lincoln, Brayford Pool, Lincolnshire, Lincoln, United Kingdom.
    Adil, Maisha
    School of Pharmacy, University of Waterloo, ON, Waterloo, Canada.
    Bala, Arthi
    School of Pharmacy, University of Waterloo, ON, Waterloo, Canada.
    Nelson, David
    Lincoln International Institute for Rural Health, University of Lincoln, Brayford Pool, Lincolnshire, Lincoln, United Kingdom.
    Sayers, Emma
    Lincoln International Institute for Rural Health, University of Lincoln, Brayford Pool, Lincolnshire, Lincoln, United Kingdom.
    Waite, Nancy
    School of Pharmacy, University of Waterloo, ON, Waterloo, Canada.
    Grindrod, Kelly
    School of Pharmacy, University of Waterloo, ON, Waterloo, Canada.
    Unintended consequences of communicating rapid COVID-19 vaccine policy changes: a qualitative study of health policy communication in Ontario, Canada2023In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, no 1, article id 932Article in journal (Refereed)
    Abstract [en]

    Background: The success of the COVID-19 vaccination roll-out depended on clear policy communication and guidance to promote and facilitate vaccine uptake. The rapidly evolving pandemic circumstances led to many vaccine policy amendments. The impact of changing policy on effective vaccine communication and its influence in terms of societal response to vaccine promotion are underexplored; this qualitative research addresses that gap within the extant literature.

    Methods: Policy communicators and community leaders from urban and rural Ontario participated in semi-structured interviews (N = 29) to explore their experiences of COVID-19 vaccine policy communication. Thematic analysis was used to produce representative themes.

    Results: Analysis showed rapidly changing policy was a barrier to smooth communication and COVID-19 vaccine roll-out. Continual amendments had unintended consequences, stimulating confusion, disrupting community outreach efforts and interrupting vaccine implementation. Policy changes were most disruptive to logistical planning and community engagement work, including community outreach, communicating eligibility criteria, and providing translated vaccine information to diverse communities.

    Conclusions: Vaccine policy changes that allow for prioritized access can have the unintended consequence of limiting communities’ access to information that supports decision making. Rapidly evolving circumstances require a balance between adjusting policy and maintaining simple, consistent public health messages that can readily be translated into action. Information access is a factor in health inequality that needs addressing alongside access to vaccines.

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  • 47.
    Wanduru, Phillip
    et al.
    Makerere University School of Public Health, Kampala, Uganda.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Makerere University School of Public Health, Kampala, Uganda.
    COVID-19 response in Uganda: notes and reflections2021Other (Other (popular science, discussion, etc.))
    Abstract [en]

    Uganda typically experiences recurring disease outbreaks throughout the year is in a state of continuous alerts (1). The country has invested in the Integrated Disease Surveillance and Response (IDSR) system which has helped to mitigate numerous outbreaks. Despite our fairly advanced surveillance system, the threat of an outbreak of the scale of COVID-19 poses a challenge. COVID-19 has a higher rate of spread when compared to previous outbreaks (2). The disease is difficult to identify as its symptoms are like many endemic diseases – common flu, malaria, and pneumonia being a few examples. Testing and treating the disease is expensive and are overwhelming even well-resourced health system.

  • 48. Wanduru, Phillip
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University, Kampala, Uganda.
    Tuhebwe, Doreen
    Ediau, Michael
    Okuga, Monica
    Nalwadda, Christine
    Ekirapa-Kiracho, Elizabeth
    Waiswa, Peter
    Rutebemberwa, Elizeus
    The performance of community health workers in the management of multiple childhood infectious diseases in Lira, northern Uganda: a mixed methods cross-sectional study2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 33194Article in journal (Refereed)
    Abstract [en]

    Background: Community health workers (CHWs) have the potential to reduce child mortality by improving access to care, especially in remote areas. Uganda has one of the highest child mortality rates globally. Moreover, rural areas bear the highest proportion of this burden. The optimal performance of CHWs is critical. In this study, we assess the performance of CHWs in managing malaria, pneumonia, and diarrhea in the rural district of Lira, in northern Uganda.

    Designs: A cross-sectional mixed methods study was undertaken to investigate the performance of 393 eligible CHWs in the Lira district of Uganda. Case scenarios were conducted with a medical officer observing CHWs in their management of children suspected of having malaria, pneumonia, or diarrhea. Performance data were collected using a pretested questionnaire with a checklist used by the medical officer to score the CHWs. The primary outcome, CHW performance, is defined as the ability to diagnose and treat malaria, diarrhea, and pneumonia appropriately. Participants were described using a three group performance score (good vs. moderate vs. poor). A binary measure of performance (good vs. poor) was used in multivariable logistic regression to show an association between good performance and a range of independent variables. The qualitative component comprised seven key informant interviews with experts who had informed knowledge with regard to the functionality of CHWs in Lira district.

    Results: Overall, 347 CHWs (88.3%) had poor scores in managing malaria, diarrhea, and pneumonia, 26 (6.6%) had moderate scores, and 20 (5.1%) had good scores. The factors that were positively associated with performance were secondary-level education (adjusted odds ratio [AOR] 2.72; 95% confidence interval [CI] 1.50-4.92) and meeting with supervisors in the previous month (AOR 2.52; 95% CI 1.12-5.70). Those factors negatively associated with CHW performance included: serving 100-200 households (AOR 0.24; 95% CI 0.12-0.50), serving more than 200 households (AOR 0.22; 95% CI 0.10-0.48), and an initial training duration lasting 2-3 days (AOR 0.13; 95% CI 0.04-0.41). The qualitative findings reinforced the quantitative results by indicating that refresher training, workload, and in-kind incentives were important determinants of performance.

    Conclusions: The performance of CHWs in Lira was inadequate. There is a need to consider pre-qualification testing before CHWs are appointed. Providing ongoing support and supervision, and ensuring that CHWs have at least secondary education can be helpful in improving their performance. Health system managers also need to ensure that the CHWs' workload is moderated as work overload will reduce performance. Finally, although short training programs are beneficial to some degree, they are not sufficient and should be followed up with regular refresher training.

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