Lynn Atuyambe

Barriers to male involvement in contraceptive uptake and reproductive health services: a qualitative study of men and women’s perceptions in two rural districts in Uganda

BackgroundSpousal communication can improve family planning use and continuation. Yet, in countries with high fertility rates and unmet need, men have often been regarded as unsupportive of their partner’s use of family planning methods. This study examines men and women’s perceptions regarding obstacles to men’s support and uptake of modern contraceptives.MethodsA qualitative study using 18 focus group discussions (FGDs) with purposively selected men aged 15–54 and women aged 15–49 as well as eight key informant interviews (KIIs) with government and community leaders was conducted in 2012 in Bugiri and Mpigi Districts, Uganda. Open-ended question guides were used to explore men and women’s perceptions regarding barriers to men’s involvement in reproductive health. All FGDs and KIIs were recorded, translated, and transcribed verbatim. Transcripts were coded and analyzed thematically using ATLAS.ti.ResultsFive themes were identified as rationale for men’s limited involvement: (i) perceived side effects of female contraceptive methods which disrupt sexual activity, (ii) limited choices of available male contraceptives, including fear and concerns relating to vasectomy, (iii) perceptions that reproductive health was a woman’s domain due to gender norms and traditional family planning communication geared towards women, (iv) preference for large family sizes which are uninhibited by prolonged birth spacing; and (v) concerns that women’s use of contraceptives will lead to extramarital sexual relations. In general, knowledge of effective contraceptive methods was high. However, lack of time and overall limited awareness regarding the specific role of men in reproductive health was also thought to deter men’s meaningful involvement in issues related to fertility regulation.ConclusionDecision-making on contraceptive use is the shared responsibility of men and women. Effective development and implementation of male-involvement family planning initiatives should address barriers to men’s supportive participation in reproductive health, including addressing mens negative beliefs regarding contraceptive services.

Uptake of family planning methods and unplanned pregnancies among HIV-infected individuals: a cross-sectional survey among clients at HIV clinics in Uganda

BackgroundPrevention of unplanned pregnancies among HIV-infected individuals is critical to the prevention of mother to child HIV transmission (PMTCT), but its potential has not been fully utilized by PMTCT programmes. The uptake of family planning methods among women in Uganda is low, with current use of family planning methods estimated at 24%, but available data has not been disaggregated by HIV status. The aim of this study was to assess the utilization of family planning and unintended pregnancies among HIV-infected people in Uganda.MethodsWe conducted exit interviews with 1100 HIV-infected individuals, including 441 men and 659 women, from 12 HIV clinics in three districts in Uganda to assess the uptake of family planning services, and unplanned pregnancies, among HIV-infected people. We conducted multivariate analysis for predictors of current use of family planning among women who were married or in consensual union and were not pregnant at the time of the interview.ResultsOne-third (33%, 216) of the women reported being pregnant since their HIV diagnoses and 28% (123) of the men reported their partner being pregnant since their HIV diagnoses. Of these, 43% (105) said these pregnancies were not planned: 53% (80) among women compared with 26% (25) among men. Most respondents (58%; 640) reported that they were currently using family planning methods. Among women who were married or in consensual union and not pregnant, 80% (242) were currently using any family planning method and 68% were currently using modern family planning methods (excluding withdrawal, lactational amenorrhoea and rhythm). At multivariate analysis, women who did not discuss the number of children they wanted with their partners and those who did not disclose their HIV status to sexual partners were less likely to use modern family planning methods (adjusted OR 0.40, range 0.20-0.81, and 0.30, range 0.10-0.85, respectively).ConclusionsThe uptake of family planning among HIV-infected individuals is fairly high. However, there are a large number of unplanned pregnancies. These findings highlight the need for strengthening of family planning services for HIV-infected people.

Reasons for Disclosure of HIV Status by People Living with HIV/AIDS and in HIV Care in Uganda: An Exploratory Study

Most studies of HIV disclosure in Africa have focused on disclosure to spouses and sexual partners, and particularly among women. Few have examined disclosure to family, friends, and others. Understanding the reasons for disclosure and nondisclosure and how these reasons differ by disclosure target is needed for effective prevention interventions. Using a case study design and content analysis, this study explored whether the reasons for disclosure decisions differ by the nature of the relationship to the disclosure target. Semistructured interviews were conducted with 40 HIV clients in Kampala, with even stratification by gender and age. Most (95%) respondents reported disclosing to someone; among these, 84% disclosed to family members, 63% to friends, 21% to workplace colleagues, and 18% to others. Of the 24 participants who had a spouse, 13 (54%) reported disclosing to a spouse. The most common reasons for disclosure were to receive support (76%), associated with disclosure to family members; relationship ties (76%), associated with disclosure to all target types; explaining change in behavior or appearance (61%), associated with disclosing to family and friends; and HIV prevention (50%), associated with disclosure to spouse/partner and friends. The most common reasons for nondisclosure were: fear of abandonment, particularly among young women disclosing to spouse/partner; inaccessibility to the disclosure target; and not wanting to worry/upset the disclosure target. This exploratory analysis suggests that reasons for disclosure and nondisclosure differ depending on the targets of disclosure, highlighting the need for tailoring interventions for improving disclosure decisions making and outcomes.

Maintaining quality of health services after abolition of user fees: A Uganda case study

BackgroundIt has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.MethodsA population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.ResultsDifferent quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.ConclusionThe levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.

Alcohol consumption and risky sexual behaviour in the fishing communities: evidence from two fish landing sites on Lake Victoria in Uganda

BackgroundThe fishing communities are among population groups that are most at risk of HIV infection, with some studies putting the HIV prevalence at 5 to 10 times higher than in the general population. Alcohol consumption has been identified as one of the major drivers of the sexual risk behaviour in the fishing communities. This paper investigates the relationship between alcohol consumption patterns and risky behaviour in two fishing communities on Lake Victoria.MethodsFace-to-face interviews were conducted among 303 men and 172 women at the fish landing sites; categorised into fishermen, traders of fish or fish products and other merchandise, and service providers such as casual labourers and waitresses in bars and hotels, including 12 female sexual workers. Stratified random sampling methodology was used to select study units. Multivariable analysis was conducted to assess independent relationship between alcohol consumption and sexual risky behaviour. Measures of alcohol consumption included the alcohol use disorder test score (AUDIT), having gotten drunk in previous 30 days, drinking at least 2 times a week while measures for risky behaviour included engaging in transactional sex, inconsistent condom use, having sex with non-regular partner and having multiple sexual partners.ResultsThe level of harmful use of alcohol in the two fishing communities was quite high as 62% of the male and 52% of the female drinkers had got drunk in previous 30 days. The level of risky sexual behaviour was equally high as 63% of the men and 59% of the women had unprotected sex at last sexual event. Of the 3 occupations fishermen had the highest levels of harmful use of alcohol and risky sexual behaviour followed by service providers judging from values of most indicators. The kind of alcohol consumption variables correlated with risky sexual behaviour variables, varied by occupation. Frequent alcohol consumption, higher AUDIT score, having got drunk, longer drinking hours and drinking any day of the week were strongly correlated with engaging in transactional sex among fishermen but fewer of the factors exhibited the same correlation among traders and service providers. Fishermen who drank 2 or more times a week were 7.9 times more likely to have had transactional sex (95% CI: 2.05-30.24) compared to those who never drank alcohol. A similar pattern was observed for traders and service providers at the landing sites. Inconsistent condom use or none use of condoms was not significantly correlated with any of the alcohol consumption indicator variables in multivariate analysis except for day of drinking among men.ConclusionAlcohol consumption is strongly correlated with having multiple sexual partners, sex with non-regular partner and engagement in transactional sex but not with consistent condom use at fish landing sites. However, the pattern and strength of this correlation differs by occupation. HIV risk reduction programs targeting the fishing communities should address alcohol consumption, particularly alcohol consumption before sexual contact. Different occupations may need different interventions.

Research translation to inform national health policies: learning from multiple perspectives in Uganda

BackgroundResearch and evidence can have an impact on policy and practice, resulting in positive outcomes. However, research translation is a complex, dynamic and non-linear process. Although universities in Africa play a major role in generating research evidence, their strategic approaches to influence health policies and decision making are weak. This study was conducted with the aim of understanding the process of translating research into policy in order to guide the strategic direction of Makerere University College of Health Sciences (MakCHS) and similar institutions in their quest to influence health outcomes nationally and globally.MethodsA case study approach using 30 in-depth interviews with stakeholders involved in two HIV prevention research project was purposively selected. The study sought to analyze the research-to-policy discourses for the prevention of mother-to-child transmission (PMTCT) and safe male circumcision (SMC). The analysis sought to identify entry points, strengths and challenges for research-to-policy processes by interviewing three major groups of stakeholders in Uganda – researchers (8), policy makers (12) and media practitioners (12).ResultsAmong the factors that facilitated PMTCT policy uptake and continued implementation were: shared platforms for learning and decision making among stakeholders, implementation pilots to assess feasibility of intervention, the emerging of agencies to undertake operations research and the high visibility of policy benefits to child survival. In contrast, SMC policy processes were stalled for over two years after the findings of the Uganda study was made public. Among other factors, policy makers demanded additional research to assess implementation feasibility of SMC within ordinary health system context. High level leaders also publicly contested the SMC evidence and the underlying values and messages – a situation that reduced the coalition of policy champions.ConclusionsThis study shows that effective translation of PMTCT and SMC research results demanded a “360 degree” approach to assembling additional evidence to inform the implementation feasibility for these two HIV prevention interventions. MakCHS and similar institutions should prioritize implementation research to guide the policy processes about the feasibility of implementing new and effective innovations (e.g. PMTCT or SMC) at a large scale in contexts that may be different from the research environments.

A Qualitative Study of Barriers to Enrollment into Free HIV Care:Perspectives of Never-in-Care HIV-Positive Patients and Providers in Rakai, Uganda

Background. Early entry into HIV care is low in Sub-Saharan Africa. In Rakai, about a third (31.5%) of HIV-positive clients who knew their serostatus did not enroll into free care services. This qualitative study explored barriers to entry into care from HIV-positive clients who had never enrolled in care and HIV care providers. Methods. We conducted 48 in-depth interviews among HIV-infected individuals aged 15–49 years, who had not entered care within six months of result receipt and referral for free care. Key-informant interviews were conducted with 12 providers. Interviews were audio-recorded and transcripts subjected to thematic content analysis based on the health belief model. Results. Barriers to using HIV care included fear of stigma and HIV disclosure, womens lack of support from male partners, demanding work schedules, and high transport costs. Programmatic barriers included fear of antiretroviral drug side effects, long waiting and travel times, and inadequate staff respect for patients. Denial of HIV status, belief in spiritual healing, and absence of AIDS symptoms were also barriers. Conclusion. Targeted interventions to combat stigma, strengthen couple counseling and health education programs, address gender inequalities, and implement patient-friendly and flexible clinic service hours are needed to address barriers to HIV care.

Land slide disaster in eastern Uganda: rapid assessment of water, sanitation and hygiene situation in Bulucheke camp, Bududa district

BackgroundOn 1st March 2010, a major landslide occurred on Mt. Elgon in Eastern Uganda. This was triggered by heavy rains that lasted over three months. The landslide buried three villages in Bududa district, killing over 400 and displacing an estimate of 5,000 people. A comprehensive assessment of water, sanitation and hygiene was urgently needed to inform interventions by the Ministries of Health, and Relief, Disaster Preparedness and Refugees, Uganda.MethodsThis was a cross-sectional study where both qualitative and quantitative data were collected two weeks after the disaster. Quantitative interviews involved 397 heads of households and qualitative methods comprised of 27 Key Informant interviews, four focus group discussions and observations. The survey quantified water safety (collection, treatment, storage) and hygiene practices. This was supplemented and triangulated with qualitative data that focused on community perceptions and beliefs regarding water and sanitation needs and practices. Quantitative data was entered in Epi-Info Version 3.2.2 software and then exported to SPSS Version 12 for analysis. Summary statistics and proportions were generated and bi-variable analysis performed for selected variables. Associations were assessed using odds ratios at 95% confidence intervals. Qualitative data was analyzed using content analysis.ResultsQualitative results showed that there were strong traditional beliefs governing water use and human excreta disposal. The use of river Manafwa water for household consumption was observed to potentially lead to disease outbreaks. Water from this river was reported tastier and the community culturally saw no need to boil drinking water. Latrines were few (23 for 5000 people), shallow, dirty (70% reported flies, 60% fecal littering), not separated by sex and had limited privacy and no light at night. This affected their use. Males were 3 times more likely to wash hands with soap after latrine use than females (OR = 3.584, 95%CI: 1.658-7.748). Of the 90% respondents who indicated that they always washed hands after latrine use, 76% said they used water and soap. Observations showed that water and soap were inconsistently available at the hand washing facilities. This situation influenced peoples sanitation and hygiene behaviours. Nearly half (48%) indicated that at least a member of their household had fallen sick at least once since arrival at the camp.ConclusionThere was inadequate access to safe water in the camp. Pit-latrines were inadequate, poorly maintained and not user-friendly for most people. Responsible authorities should design means of increasing and sustaining access to safe water, increase sanitation facilities and continuously educate the public on the need to observe good hygiene practices.

HIV/AIDS status disclosure increases support, behavioural change and, HIV prevention in the long term: a case for an Urban Clinic, Kampala, Uganda.

BackgroundDisclosure of HIV status supports risk reduction and facilitates access to prevention and care services, but can be inhibited by the fear of negative repercussions. We explored the short and long-term outcomes of disclosure among clients attending an urban HIV clinic in Uganda.MethodsQualitative semi-structured interviews were administered to a purposeful sample of 40 adult HIV clients that was stratified by gender. The information elicited included their lived experiences and outcomes of disclosure in the short and long term. A text data management software (ATLAS.ti) was used for data analysis. Codes were exported to MS Excel and pivot tables, and code counts made to generate statistical data.ResultsOf the 134 short-term responses elicited during the interview regarding disclosure events, most responses were supportive including encouragement, advice and support regarding HIV care and treatment. The results show on-disclosing to spouse, there was more trust, and use of condoms for HIV prevention. Only one third were negative responses, like emotional shock and feeling of distress. The negative reactions to the spouses included rejection, shock and distress in the short term. Even then, none of these events led to drastic change such as divorce. Other responses reflected HIV prevention and call for behavioural change and advice to change sexual behaviour, recipient seeking HIV testing or care. Women reported more responses of encouragement compared to men. Men reported more preventive behaviour compared to women. Of the 137 long-term outcomes elicited during disclosure, three quarters were positive followed by behavioral change and prevention, and then negative responses. Men reported increased care and support when they disclosed to fellow men compared to when women disclosed to women. There was better or not change in relationship when women disclosed to women than when women disclosed to men.ConclusionsThere is overwhelming support to individuals that disclose their HIV status, especially in the long term. Besides, gender appears to influence responses to HIV disclosure, highlighting the need for gender specific disclosure support strategies.

Exploring the focus of prenatal information offered to pregnant mothers regarding newborn care in rural Uganda

BackgroundNeonatal death accounts for one fifth of all under-five mortality in Uganda. Suboptimal newborn care practices resulting from hypothermia, poor hygiene and delayed initiation of breastfeeding are leading predisposing factors. Evidence suggests focused educational prenatal care messages to mitigate these problems. However, there is a paucity of data on the interaction between the service provider and the prenatal service user. This study aims to understand the scope of educational information and current practices on newborn care from the perspectives of prenatal mothers and health workers.MethodsA qualitative descriptive methodology was used. In-depth interviews were conducted with lactating mothers (n = 31) of babies younger than five months old across Masindi in western Uganda. Additional interviews with health workers (n = 17) and their employers or trainers (n = 5) were conducted to strengthen our findings. Data were audio-taped and transcribed verbatim. A thematic content analysis was performed using NVivo 8.ResultsVertical programmes received more attention than education for newborn care during prenatal sessions. In addition, attitudinal and communication problems existed among health workers thereby largely ignoring the fundamental principles of patient autonomy and patient-centred care. The current newborn care practices were largely influenced by relatives’ cultural beliefs rather than by information provided during prenatal sessions. There is a variation in the training curriculum for health workers deployed to offer recommended prenatal and immediate newborn care in the different tiers of health care.ConclusionsFindings revealed serious deficiencies in prenatal care organisations in Masindi. Pregnant mothers remain inadequately prepared for childbirth and newborn care, despite their initiative to follow prenatal sessions. These findings call for realignment of prenatal care by integrating education on newborn care practices into routine antenatal care services and be based on principles of patient-centred care.