Denis Muhangi

Selection and performance of village health teams (VHTs) in Uganda: lessons from the natural helper model of health promotion

BackgroundCommunity health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion.MethodsAs part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members.ResultsThe VHT selection process created distrust, damaging the programme’s legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community’s members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work.ConclusionAs the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.

The effectiveness of educational support to orphans and vulnerable children in Tanzania and Uganda

Little evidence is available to assist policy makers and donors in deciding what kinds of programs in developing countries are more likely to be effective in supporting the entry and continuation of OVC in secondary schools. This is particularly important for females whose education has direct bearing on child mortality in the next generation. This study gathered four kinds of educational outcome measures in two East African countries ravaged by the AIDS/HIV pandemic. The goal was to determine whether direct scholarship aid to individual students versus various forms of block grants would be more effective in promoting lower rates of absenteeism, lower dropout rates, higher national examination scores, and higher pass rates for OVC of both genders. Insufficient evidence was available for recipients of scholarships, but OVC with block grant support performed as well or better than their non-OVC counterparts, and significantly better than OVC without support. Contrary to popular belief, girls had lower rates of absenteeism. There were no gender differences in dropout. However, boys consistently outperformed girls on academic tests. Insufficient data systems continue to impede more detailed analysis.

Anthelmintic resistance in gastrointestinal nematodes in goats and evaluation of FAMACHA diagnostic marker in Uganda

Gastrointestinal nematodes (GIN) are a challenge to goat production globally causing reduced growth, morbidity and mortality. We report here results of the first nation-wide anthelmintic resistance (AR) study and validation of assessment of clinical anaemia with FAMACHA eye scores in goats in Uganda. From August to December 2012 the efficacy of albendazole (7.5mg/kg), levamisole (10.5mg/kg) and ivermectin (0.3mg/kg) against strongyle nematodes was tested on 33 goat farms in Soroti, Gulu, Mpigi, Mbarara and Ssembabule districts of Uganda. Altogether 497 goats were subjected to a total of 45 different faecal egg count reduction tests (FECRT), each involving 5-20 goats. On one farm all substances were tested. Faecal and blood samples were collected and FAMACHA eye scores evaluated on the day of treatment and 15 days later. A questionnaire survey was conducted on frequency, type and dose of anthelmintics used, farm size and grazing management system. Examination of infective third stage larvae (L3) from pooled faecal cultures demonstrated Haemonchus to be the predominant genus (>75%). Resistance to at least one anthelmintic group was detected on 61% of the 33 farms and in 49% of the 45 test groups. Prevalence of resistance to ivermectin, levamisole and albendazole was respectively 58%, 52% and 38%. Correlation between pre-treatment packed cell volume determinations and FAMACHA scores (r(498) = -0.89) was significant. Paddock grazing system (Odds ratio 4.9, 95% CI 1.4-17.3) and large farm size of >40 goats (odds ratio 4.4, 95% CI 1.2-16.1) were significant predictors of AR. In all districts, resistance to all three anthelmintics was higher on large-scale goat farms practising mostly paddock grazing. Interestingly, resistance to albendazole, the most commonly used anthelmintic in Uganda, was lower than that to ivermectin and levamisole. We recommend adaptation of FAMACHA to goats to help restrict anthelmintic treatment to heavily infected individuals. This will limit selection pressure and hence delay development of anthelmintic resistance.

People will say that I am proud: a qualitative study of barriers to bed net use away from home in four Ugandan districts

BackgroundDespite increased access and ownership, barriers to insecticide-treated bed net (ITN) use persist. While barriers within the home have been well documented, the challenges to net use when sleeping away from home remain relatively unexplored. This study examines common situations in which people sleep away from home and the barriers to ITN use in those situations.MethodsTo explore these issues, a group of researchers conducted 28 in-depth interviews and four focus groups amongst adults from net-owning households in four Ugandan districts.ResultsIn addition to sleeping outside during hot season, participants identified social events, livelihood activities, and times of difficulty as circumstances in which large numbers of people sleep away from home. Associated challenges to ITN use included social barriers such as fear of appearing proud, logistical barriers such as not having a place to hang a net, and resource limitations such as not having an extra net with which to travel. Social disapproval emerged as an important barrier to ITN use in public settings.ConclusionsUnique barriers to ITN use exist when people spend the night away from home. It is essential to identify and address these barriers in order to reduce malaria exposure in such situations. For events like funerals or religious “crusades” where large numbers of people sleep away from home, alternative approaches, such as spatial repellents may be more appropriate than ITNs. Additional research is required to identify the acceptability and feasibility of alternative prevention strategies in situations where ITNs are unlikely to be effective.

East African pigs have a complex Indian, Far Eastern and Western ancestry

In this study, we have characterized the mitochondrial diversity of 81 swine from Uganda. Median-joining network analysis of D-loop sequences from these individuals and others characterized in previous studies allowed us to determine that Ugandan pigs cluster with populations from the West (Europe/North Africa), Far East and India. In addition, partial sequencing of the Y-chromosome UTY locus in 18 Ugandan domestic pigs revealed the segregation of a single HY1 lineage that has a cosmopolitan distribution. A Western and Far Eastern ancestry for East African pigs had been already reported, but this is the first study demonstrating an additional contribution from the Indian porcine gene pool. This result is consistent with the high frequency of zebuine alleles in cattle from East Africa. The geographic coordinates of East Africa, at the crossroads of many trading routes that, through the ages, linked Europe, Africa and Asia, might explain the rich and complex genetic heritage of livestock native to this area.

Linking communities to formal health care providers through village health teams in rural Uganda: lessons from linking social capital

BackgroundCommunity-based programmes, particularly community health workers (CHWs), have been portrayed as a cost-effective alternative to the shortage of health workers in low-income countries. Usually, literature emphasises how easily CHWs link and connect communities to formal health care services. There is little evidence in Uganda to support or dispute such claims. Drawing from linking social capital framework, this paper examines the claim that village health teams (VHTs), as an example of CHWs, link and connect communities with formal health care services.MethodsData were collected through ethnographic fieldwork undertaken as part of a larger research program in Luwero District, Uganda, between 2012 and 2014. The main methods of data collection were participant observation in events organised by VHTs. In addition, a total of 91 in-depth interviews and 42 focus group discussions (FGD) were conducted with adult community members as part of the larger project. After preliminary analysis of the data, we conducted an additional six in-depth interviews and three FGD with VHTs and four FGD with community members on the role of VHTs. Key informant interviews were conducted with local government staff, health workers, local leaders, and NGO staff with health programs in Luwero. Thematic analysis was used during data analysis.ResultsThe ability of VHTs to link communities with formal health care was affected by the stakeholders’ perception of their roles. Community members perceive VHTs as working for and under instructions of “others”, which makes them powerless in the formal health care system. One of the challenges associated with VHTs’ linking roles is support from the government and formal health care providers. Formal health care providers perceived VHTs as interested in special recognition for their services yet they are not “experts”. For some health workers, the introduction of VHTs is seen as a ploy by the government to control people and hide its inability to provide health services. Having received training and initial support from an NGO, VHTs suffered transition failure from NGO to the formal public health care structure. As a result, VHTs are entangled in power relations that affect their role of linking community members with formal health care services. We also found that factors such as lack of money for treatment, poor transport networks, the attitudes of health workers and the existence of multiple health care systems, all factors that hinder access to formal health care, cannot be addressed by the VHTs.ConclusionsAs linking social capital framework shows, for VHTs to effectively act as links between the community and formal health care and harness the resources that exist in institutions beyond the community, it is important to take into account the power relationships embedded in vertical relationships and forge a partnership between public health providers and the communities they serve. This will ensure strengthened partnerships and the improved capacity of local people to leverage resources embedded in vertical power networks.

Decision-making on intra-household allocation of bed nets in Uganda: Do households prioritize the most vulnerable members?

BackgroundAccess to insecticide-treated bed nets has increased substantially in recent years, but ownership and use remain well below 100% in many malaria endemic areas. Understanding decision-making around net allocation in households with too few nets is essential to ensuring protection of the most vulnerable. This study explores household net allocation preferences and practices across four districts in Uganda.MethodsData collection consisted of eight focus group discussions, twelve in-depth interviews, and a structured questionnaire to inventory 107 sleeping spaces in 28 households.ResultsIn focus group discussions and in-depth interviews, participants almost unanimously stated that pregnant women, infants, and young children should be prioritized when allocating nets. However, sleeping space surveys reveal that heads of household sometimes receive priority over children less than five years of age when households have too few nets to cover all members.ConclusionsWhen asked directly, most net owners highlight the importance of allocating nets to the most biologically vulnerable household members. This is consistent with malaria behaviour change and health education messages. In actual allocation, however, factors other than biological vulnerability may influence who does and does not receive a net.

Traditional birth attendants (TBAs) as potential agents in promoting male involvement in maternity preparedness: insights from a rural community in Uganda

BackgroundSince the 1994 International Conference on Population and Development, male involvement in reproductive health issues has been advocated as a means to improve maternal and child health outcomes, but to date, health providers have failed to achieve successful male involvement in pregnancy care especially in rural and remote areas where majority of the underserved populations live. In an effort to enhance community participation in maternity care, TBAs were trained and equipped to ensure better care and quick referral. In 1997, after the advent of the World Health Organization’s Safe Motherhood initiative, the enthusiasm turned away from traditional birth attendants (TBAs). However, in many developing countries, and especially in rural areas, TBAs continue to play a significant role. This study explored the interaction between men and TBAs in shaping maternal healthcare in a rural Ugandan context.MethodsThis study employed ethnographic methods including participant observation, which took place in the process of everyday life activities of the respondents within the community; 12 focus group discussions, and 12 in-depth interviews with community members and key informants. Participants in this study were purposively selected to include TBAs, men, opinion leaders like village chairmen, and other key informants who had knowledge about the configuration of maternity services in the community. Data analysis was done inductively through an iterative process in which transcribed data was read to identify themes and codes were assigned to those themes.ResultsContrary to the thinking that TBA services are utilized by women only, we found that men actively seek the services of TBAs and utilize them for their wives’ healthcare within the community. TBAs in turn sensitize men using both cultural and biomedical health knowledge, and become allies with women in influencing men to provide resources needed for maternity care.ConclusionIn this study area, men trust and have confidence in TBAs; closer collaboration with TBAs may provide a suitable platform through which communities can be sensitized and men actively brought on board in promoting maternal health services for women in rural communities.

Gender analysis of educational support programs for OVC in Uganda and Tanzania: are they helping girls in secondary school?

Gender plays an important role in education as most traditional societies give preference to boys over girls when it comes to educational opportunity. Increasing access to education for girls is important to the health and well-being of the individual, their future children, families, and communities. The objective of this paper is to understand the gender differences in educational outcomes for orphans and vulnerable children (OVC) attending secondary schools in Uganda and Tanzania. The study employed a four-year, retrospective record review utilizing both qualitative and quantitative methodologies. A total of 5738 student records were collected as part of the study. Students were grouped as “ever supported” OVC (receiving educational support from either a block grant or scholarship program during their secondary school education), “never supported OVC” (OVC students who did not receive any educational support), and “nonOVC students” (students identified by the school as neither orphaned nor vulnerable). Results of the study indicate that investment in secondary school education for OVC in Uganda and Tanzania can make a difference in educational outcomes, both for boys and girls. Although there was no gender difference in absenteeism or dropout rate among students those who received educational support, stark differences were found in secondary school Year IV national examination pass rates with girls significantly less likely to pass compared to boys. The disparity in secondary school learning achievement between male and female students is of concern and warrants further investigation.

Child Maltreatment in Uganda: Discourses and Representations in the Ugandan Print Media

The reporting of child maltreatment in the media provides information about the nature and extent of this phenomenon, while also influencing public opinion. Media reporting of child maltreatment is often not neutral, but rather embeds assumptions, stereotypes and judgements rooted in different socio-economic and cultural contexts. This chapter, drawing from two print daily newspapers in Uganda from the year 2013, analyses the discourses and representations of child maltreatment in Uganda. A total of 346 newspaper issues were reviewed. Four main discourses are identified with respect to abused children: abused children as innocent vulnerable victims; children as active agents in contributing to their abuse; children as active agents in addressing abuse; and the abused children’s future as a ruined future. The parents of maltreated children are portrayed as unsuspecting and negligent, as active abusers, and in some cases as active agents in addressing child abuse. Other key discourses identified are those that portray the government child protection system as a failed system. The media reports give more prominence to the voices of the police and courts of law, while marginalizing those of children, parents and communities. This paper identifies the need to engage the media in order to promote a more balanced coverage of stories of child maltreatment, to give more voice to children and their families, and to report more about the community and other contexts where abuse takes place beyond the point of view based on the police and courts.