Research Articles

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Assessing the impact of cervical cancer integration into reproductive health networks: operations research from Uganda
(International Population Conference, 2017) Nuccio, Olivia; Chowdhury, Raveena; Penfold-Taylor, Suzanne; Mesele, Tesfaye; Church, Kathryn; Meglioli, Alejandra; White, Heather; Kumakech, Edward
The Cervical Cancer Screening and Preventive Therapy (CCS&PT) via Reproductive Health Networks initiative started in 2012, with the aim of improving health outcomes through the provision of services targeted at women at highest risk of cervical cancer (those aged 30-49). The project integrates CCS&PT into existing sexual and reproductive health service networks in four sub-Saharan African countries (Nigeria, Kenya, Tanzania, and Uganda). Operations research was conducted in Uganda to assess how well screening services were being provided within the existing networks and to describe the modes and effectiveness of referral methods for further treatment when required. A mixed-methods observational study design included analysis of routine data, quantitative cross-sectional surveys, in-depth interviews, and a referral assessment survey. Data were collected between October and November 2015. Public health impacts were demonstrated, with high proportions of clients reached who had never been screened before, and were in the target age group of 30-49. Opportunities to expand access to treatment were highlighted, with a need to overcome cost and other barriers. Providers reported both benefits and drawbacks of CCS introduction. Encouragingly, integrating CCS&PT provision into SRH care appeared to increase demand for other, complementary services, specifically family planning.
Beliefs, perceptions and health-seeking behaviours in relation to cervical cancer: a qualitative study among women in Uganda following completion of an HPV vaccination campaign
(Global Health Action, 2016) Hasahya, Olivia Topister; Berggren, Vanja; Sematimba, Douglas; Nabirye, Rose Chalo; Kumakech, Edward
Background: Cervical cancer remains a leading cause of morbidity and mortality in Uganda. Despite earlier information campaigns to introduce human papilloma virus (HPV) vaccination, which also targeted cervical cancer, misinterpretation and misunderstanding of the subject remain high. Women in Uganda present with cervical cancer at an advanced stage due to poor health-seeking behaviours, with an associated high mortality rate. This project explored beliefs, attitudes, perceptions, and health-seeking behaviours in relation to cervical cancer among women in Uganda after an HPV vaccination project had been rolled out. Design: A qualitative study design was used, with six focus group discussions (FGDs) that included 36 women, aged 25 49 years, with no previous history of cervical cancer symptoms or diagnosis. The women were interviewed in February and March 2013. The transcribed data was analysed using content analysis. Results: Three themes emerged: feeling unprotected and unsafe, misbelief and wondering about cervical cancer, and fear of the testing procedure. Participating women had heard of cervical cancer but preferred to wait to access cervical cancer screening until symptom debut. Conclusions: There are still barriers to cervical cancer screening among women in Uganda, where there is a need for culture-specific, sensitive information and interventions to address the issues of improving the cervical cancer screening uptake among these women. Societal context needs to be taken into account when implementing community-based health education.
Caregiver’s perspectives on the Central Nervous System infection illness trajectory among older persons with dementia in Northern Uganda—a qualitative community‑based study
(BMC Geriatrics, 2022) Benyumiza, Deo; Kumakech, Edward; Gutu, Jastine; Banihani, Jude; Mandap, Joshua; Talib, Zohray M.; Wakida, Edith K.; Maling, Samuel; Obua, Celestino
Background: Few studies have explored the Central Nervous System (CNS) infection illness trajectory among older persons with dementia in sub-Saharan African (SSA) settings. This study explored the Caregiver’s perspectives on the Central Nervous System infection illness trajectory among the older persons with dementia in Northern Uganda. Methods: This was a qualitative study conducted in Lira District northern Uganda in March 2022 amongst purposively selected 20 caregivers of the older persons aged 50 + years with a positive history of CNS infection and later life dementia. Data were collected using an in-depth interview guide. Audio recordings and field notes of the interviews were undertaken. The interviews generated data on the CNS infection illness trajectory from onset to the current demented state of the older persons. The audio-recorded interviews were transcribed verbatim before manual reflective thematic analysis. Results: Older persons with a positive history of CNS infection illness and later life dementia in rural northern Uganda presented with symptoms of early life CNS infection illness ranging from neck pain, back pain, chronic headache, and fatigue. There were also manifestations of comorbidities particularly road traffic accidents involving traumatic injury to the head, neck, and spine, high blood pressure, chronic headache, and or their medications in the older person’s trajectory to later life dementia. A plurality of healthcare which included both formal and informal healthcare medicines was sought and utilized for the treatment and care of the CNS infection illness and dementia by the older persons amidst improper diagnosis and mismanagement. Conclusions and recommendations: Older persons with early-life CNS infections illness and later-life dementia were reported to present with symptoms including neck pain, back pain, chronic headache, high blood pressure, and fatigue. The reported symptoms of CNS infection illness may be intertwined with co-morbidities particularly traumatic injury involving the head, neck, and spine, high blood pressure, and chronic headache. Healthcare professionals should integrate routine screening of older persons for the history of CNS infections, chronic headache, high blood pressure, trauma to the head, neck, and spine, and dementia and early treatment
Cervical cancer risk perceptions, sexual risk behaviors and sexually transmitted infections among Bivalent Human Papillomavirus vaccinated and nonvaccinated young women in Uganda - 5 year follow up study
(BMC women's health, 2017) Kumakech, Edward; Andersson, Sören; Wabinga, Henry; Musubika, Caroline; Kirimunda, Samuel; Berggren, Vanja
Background: Previous studies were conflicting regarding the associations between HPV vaccination, cervical cancer risk perceptions, high-risk sexual behaviors and STIs. This study compared the HPV-vaccinated and non-vaccinated young women in Uganda regarding cervical cancer risk perceptions, high-risk sexual behaviors, syphilis and HIV infections 5 years after vaccine implementation. Methods: This was a population-based comparative cross-sectional survey conducted in Uganda. The 438 participants were sexually active young women aged 15–24 years and mean age was 18.6 (SD 1.4). The majority (53.0%) were HPV-vaccinated in 2008 without assessment of sexual activity prior to HPV vaccination. Upon verbal assessment of sexual activity at the time of follow-up, data were collected using a questionnaire and laboratory testing of blood samples for syphilis and HIV infections. Results: There were no significant differences between the HPV-vaccinated and non-vaccinated groups regarding the prevalence of high-risk sexual behaviors, syphilis and HIV infections. Cervical cancer risk perceptions and age at sexual debut were nonetheless significantly lower among the vaccinated group compared to their non-vaccinated counterparts. However, HPV vaccination was not significantly associated to cervical cancer risk perceptions and early age at sexual debut in multivariate logistic regression analysis. Conclusions: We found no associations between HPV vaccination, cervical cancer risk perceptions, high-risk sexual behaviors, syphilis and HIV infections among young women in Uganda 5 years after vaccine implementation. Young girls in the study population were found to be sexually active at a young age, affirming the importance of targeting girls of younger age for HPV vaccination.
Consumer Perspectives on a Pericoital Contraceptive Pill in India and Ugand
(2013) Cover, Jane K.; Drake, Jennifer Kidwett; Kyamwanga, Imelda T.; Turyakira, Eleanor; Dargan, Tanya; Kumakech, Edward; Harner-Jay, Claudia
CONTEXT: Studies suggest that women in some countries have adopted emergency contraceptive pills as a routine method of family planning. This practice indicates there may be latent demand for a pericoital contraceptive pill taken only when a woman has sexual intercourse, and labeled and marketed for use as a regular contraceptive method. METHODS: To understand the appeal and potential market for a pericoital contraceptive pill, 39 focus groups and 23 in-depth interviews were conducted with women and men in Lucknow, Uttar Pradesh, India, and Kampala, Uganda. A total of 281 individuals participated in this qualitative study. RESULTS: In general, women embraced the idea of a female-controlled method that would be easier than taking a daily oral contraceptive pill and that could be taken either before or after sexual intercourse; in Uganda, especially, women approved of the fact that the method could be taken without a partner's knowledge. Although we do not yet know the extent of side effects for this method, women expressed some concerns about the level and nature of potential side effects. CONCLUSIONS: The results suggest that a pericoital contraceptive pill would be well-received by consumers in both country settings. If its efficacy and side effects are acceptable, a pericoital contraceptive pill could fill a gap for female-controlled, discreet, coitus-related contraception, particularly among women who do not have sex very frequently.
Depression, suicidality, substance-use and associated factors among people living with HIV the COVID-19 pandemic in Uganda
(PLOS ONE, 2023) Rukundo, Godfrey Zari; Wakida, Edith K.; Karungi, Christine K.; Asasira, Jenipher; Kumakech, Edward; Obua, Celestino
Background Mental disorders are common in people living with HIV (PLHIV) but they are often unrecog nized and untreated. Furthermore, the COVID-19 pandemic has disrupted the already lim ited mental health services in low resource countries such as Uganda, and yet the extent to which the COVID-19 mitigation measures have affected the mental health of PLHIV is not fully known. We aimed to determine the burden of depression, suicidality, substance use and associated factors among adult PLHIV who were seeking care at two HIV clinics in northern and southwestern Uganda. Methods We conducted a phenomenological qualitative and quantitative cross-sectional study among 431 PLHIV to determine the burden of depression, suicidality and substance-use disorders at two HIV clinics, at Lira Regional Referral Hospital and Mbarara Regional Refer ral Hospital in northern and southwestern Uganda respectively, during the COVID-19 lock down. We used the Patient Health Questionnaire (PHQ-9) to assess for depression and suicidality, and the Michigan Assessment-Screening Test for Alcohol and drugs (MAST-AD) to assess for substance use disorder. We conducted descriptive statistics analysis to deter mine the burden of the disorders, and logistic regression to determine the associated fac tors. For the qualitative method we conducted in-depth interviews with 30 PLHIV and did thematic analysis. Results Of the 431 PLHIV surveyed, mean age was 40.31 ± 12.20 years; 53.1% (n = 229) had depression; 22.0% (n = 95) had suicidality; and 15.1% (n = 65) had substance-use disorder. Female gender (PR = 1.073, 95%CI 1.004–1.148, P = 0.038), lack of formal education (PR0.859–0.994, P = 0.034) and suicidality (PR = 0.757, 95%CI 0.722–0.794, p = 0.000) were associated with depression after adjusting for confounders. Further analysis showed that being female (PR = 0.843, 95% CI 0.787–0.903, P = 0.000*) and having depression (PR = 0.927, 95% CI 0.876–0.981, P = 0.009) and owning a large business (PR = 0.886, 95% CI 0.834–0.941, p = 0.000*) were significantly associated with having a substance-use disor der. Only depression was independently associated with suicidality after adjusting for con founding factors (PR 0.108, 95%CI 0.054–0.218, p = 0.000*). For the qualitative results, there were three apriori themes: a) Burden of depression, b) substance-use, and c) suicidal ity among the PLHIV during the COVID-19 containment measures. Conclusion There was high prevalence of depression, suicidality and substance-use disorder in adult PLHIV in Uganda during the COVID-19 pandemic and the associated lockdown measures. The three mental health problems seem to have bidirectional relationships and gender has a lot of contribution to the relationships. Interventions aimed at any of the disorders should consider these bidirectional relationships.
Depression, suicidality, substance-use and associated factors among people living with HIV the COVID-19 pandemic in Uganda.
(Plos one, 2023) Rukundo, Godfrey Zari; Wakida, Edith K.; Karungi, Christine K.; Asasira, Jenipher; Kumakech, Edward; Obua, Celestino
Background Mental disorders are common in people living with HIV (PLHIV) but they are often unrecog nized and untreated. Furthermore, the COVID-19 pandemic has disrupted the already lim ited mental health services in low resource countries such as Uganda, and yet the extent to which the COVID-19 mitigation measures have affected the mental health of PLHIV is not fully known. We aimed to determine the burden of depression, suicidality, substance use and associated factors among adult PLHIV who were seeking care at two HIV clinics in northern and southwestern Uganda. Methods We conducted a phenomenological qualitative and quantitative cross-sectional study among 431 PLHIV to determine the burden of depression, suicidality and substance-use disorders at two HIV clinics, at Lira Regional Referral Hospital and Mbarara Regional Refer ral Hospital in northern and southwestern Uganda respectively, during the COVID-19 lock down. We used the Patient Health Questionnaire (PHQ-9) to assess for depression and suicidality, and the Michigan Assessment-Screening Test for Alcohol and drugs (MAST-AD) to assess for substance use disorder. We conducted descriptive statistics analysis to deter mine the burden of the disorders, and logistic regression to determine the associated fac tors. For the qualitative method we conducted in-depth interviews with 30 PLHIV and did thematic analysis. Results Of the 431 PLHIV surveyed, mean age was 40.31 ± 12.20 years; 53.1% (n = 229) had depression; 22.0% (n = 95) had suicidality; and 15.1% (n = 65) had substance-use disorder. Female gender (PR = 1.073, 95%CI 1.004–1.148, P = 0.038), lack of formal education (PR= 1.197, 95% CI 1.057–1.357, P = 0.005), substance-use disorder (PR = 0.924, 95%CI 0.859–0.994, P = 0.034) and suicidality (PR = 0.757, 95%CI 0.722–0.794, p = 0.000) were associated with depression after adjusting for confounders. Further analysis showed that being female (PR = 0.843, 95% CI 0.787–0.903, P = 0.000*) and having depression (PR = 0.927, 95% CI 0.876–0.981, P = 0.009) and owning a large business (PR = 0.886, 95% CI 0.834–0.941, p = 0.000*) were significantly associated with having a substance-use disor der. Only depression was independently associated with suicidality after adjusting for con founding factors (PR 0.108, 95%CI 0.054–0.218, p = 0.000*). For the qualitative results, there were three apriori themes: a) Burden of depression, b) substance-use, and c) suicidal ity among the PLHIV during the COVID-19 containment measures. Conclusion There was high prevalence of depression, suicidality and substance-use disorder in adult PLHIV in Uganda during the COVID-19 pandemic and the associated lockdown measures. The three mental health problems seem to have bidirectional relationships and gender has a lot of contribution to the relationships. Interventions aimed at any of the disorders should consider these bidirectional relationships.
Developing a Gap Analysis tool to improve Ebola vaccine acceptance and compliance in sub-Saharan Africa
(Humanitarian Policy Group, 2020) Kumakech, Edward; Maurice, Sadlier; Aidan, Sinnott; Dan, Irvine
Evaluation of a data-informed community engagement strategy to increase immunisation coverage in northern Uganda: a cluster-randomised controlled trial with an embedded process evaluation
(The Lancet Global Health, 2018) Bruce, Jane; Chantler, Tracey; Kumakech, Edward; Mawanda, Ashiraf; Olorunsaiye, Comfort; Schmucker, Laura; Kiapi, Lilian; Landegger, Justine; Webster, Jayne
Background The 2016 Ugandan Demographic and Health Survey indicated that only 86% of children (aged 12–23 months) in northern Uganda had received the third dose of diphtheria-tetanus-pertussis vaccine (DTP3) and only 65% were fully immunised. To help close this gap, the International Rescue Committee developed a data-informed community engagement intervention, the Fifth Child Project, informed by a theory of change and including: (1) an mhealth tool used by health-facility-based staff and defaulter tracing forms used by community health workers aimed at improving data accuracy, (2) training of health workers in interpersonal skills, and (3) involvement of community leaders in planning vaccine outreaches. To test the impact of this intervention and examine its underlying hypothesis that a data-informed community engagement strategy will increase immunisation coverage, we conducted a clusterrandomised controlled trial with an embedded process evaluation. Methods At baseline, a household two-stage cluster survey was conducted in 32 clusters (16 intervention and 16 control health facility catchment areas) from mid-June to mid-July, 2016. The survey collected information on vaccinations, caregivers’ interactions with community-based and facility-based health workers, and reasons for non-vaccination of eligible children. The primary outcome was DPT3 and measles coverage in children aged 9–23 months. Process evaluation activities included: quarterly monitoring reports, interviews, focus group discussions, and observations conducted in four intervention and two control clusters (March–April, 2017). The endline survey was conducted from Sept 19, 2017, to Oct 2, 2017. Findings The sample included 916 households (935 children aged 9–23 months) in the intervention clusters and 881 households (897 children aged 9–23 months) in control clusters. Baseline estimates of immunisation coverage were similar for intervention and control arms. Both arms combined baseline coverage of DTP3 and measles vaccines using information from child immunisation cards, and caregiver recall was 78·3% (95% CI 76·0–81·5) and 64·6% (95% CI 60·9–67·3%), respectively. About 19% of children who received DTP1 had not received the measles vaccine in the intervention arm, compared with 21% of children in the control arm at baseline. The major barriers to complete immunisation included caregivers’ lack of awareness of immunisation schedule and vaccine stock-outs. Interpretation Endline and process evaluation findings will be available in March 2018 and will provide a more complete assessment of the impact of the Fifth Child Project.
Factors associated with uptake of human papilloma virus vaccine among school girls aged 9–14 years in Lira City northern Uganda: a cross-sectional study
(BMC Women's Health, 2023) Nakayita, Renniter Mirembe; Benyumiza, Deo; Nekesa, Catherine; Misuk, Ivan; Kyeswa, Julius; Nalubuuka, Aisha; Murungi, Tom; Udho, Samson; Kumakech, Edward
Abstract Background Cervical cancer is the most common Human Papilloma Virus (HPV)-related disease among women. Since 2008, HPV vaccination has been routinely recommended for pre-adolescent and adolescent girls in Uganda as the primary preventive measure for cervical cancer. However, in Uganda, most especially in Lira district, there is limited literature on HPV vaccination uptake and associated factors among girls aged 9-14years. This study assessed the uptake of HPV vaccine and associated factors among in-school girls aged 9–14 years in Lira City, northern Uganda. Methods A cross-sectional study was conducted among 245 primary school girls aged 9–14 years in Lira City, northern Uganda. Multistage sampling technique was used to sample eligible participants and data was collected using interviewer administered questionnaire. Data was analysed using SPSS version 23.0. Descriptive statistics and multivariate logistic regression at 95% level of significance were used to identify the level of HPV vaccine uptake and predictors respectively. Results HPV vaccination uptake was at 19.6% (95% CI,14.8–25.1) among the school girls aged 9–14 years in Lira City, northern Uganda. The mean age of the girls was 12.11 (±1.651) years. Predictors that were independently associated with HPV vaccine uptake included; recommendation from health worker [aOR 9.09, 95% CI (3.19–25.88), P≤0.001], taught about cervical cancer at school [aOR,12.56, 95% CI (4.60–34.28), P≤0.001], and exposure to outreach clinics [aOR, 4.41, 95% CI (1.37–14.19), P=0.013]. Conclusion The study found that one in five of the school girls in Lira City, northern Uganda. received HPV vaccine. Girls who were taught about cervical cancer at school, exposure to outreach clinics and received health worker recommendation had more odds of receiving HPV vaccine than their counter parts. The Ministry of Health should strengthen school based cervical cancer education, awareness raising about HPV vaccination and health worker recommendations to improve HPV vaccine uptake among school girls in Uganda.
Factors Associated with Utilization of Sexual and Reproductive Health Services among the Youth in Lira City West, Northern Uganda: A Cross-Sectional Study
(BioMed Research International, 2023) Murungi, Tom; Benyumiza, Deo; Apio, Juliet; Nekesa, Catherine; Nalubuuka, Aisha; Misuk, Ivan; Kumakech, Edward
Background. The youth in Uganda, as in much of sub-Saharan Africa, face numerous sexual and reproductive health (SRH) challenges, from human immunodeficiency virus HIV infection, and unsafe abortions to unwanted pregnancies. This study, therefore, assessed the utilization of sexual and reproductive health services and associated factors among the youth in Lira city west, northern Uganda. Methods. This was a cross-sectional study conducted in January 2023 among 386 young people (15-24 years) in Lira city west division, Lira city. Multistage cluster sampling technique was used to recruit our study participants. Data were collected using an interviewer-administered questionnaire. Data were analyzed using SPSS version 23, descriptive statistics, cross-tabulation, bivariate, and multivariate logistic regression analyses. All variables were set by p values less than 0.05 and reported adjusted odds ratio with its 95% confidence interval. Results. The utilization of SRH services was 42.0% (162/386) among the study participants. Family planning, voluntary HIV counseling and testing (VCT), and general counseling services were the most utilized SRH services in the past 12 months. Young people who were aware of SRH services (AOR: 0.24; 95% CI: 0.08-0.74), were aware of a reproductive health facility (AOR, 4.24; 95% CI: 1.62-11.09), discussed SRH issues with peers/friends (AOR, 3.98; 95% CI: 1.53-10.33), had a sexual partner (AOR, 10.00; 95% CI: 4.05-24.69), had sexual intercourse (AOR, 4.59; 95% CI: 2.18-9.69), and had access to SRH services (AOR, 2.68; 95% CI: 1.12-6.40) were more likely to utilize SRH services compared to their counterparts. Conclusion. This study showed a low utilization of sexual and reproductive health services among youth in Lira city west, northern Uganda. Being aware of SRH services, awareness of reproductive health facilities, discussing SRH issues with peers, having sexual intercourse, having a sexual partner, and access to SRH services were independently associated with the utilization of SRH services. Therefore, there is a need to strengthen sustainable multisector approaches aimed at improving awareness and access to sexual and reproductive health services among the youth
Factors influencing the use of multiple HIV prevention services among transport workers in a city in southwestern Uganda
(PLOS Glob Public Health, 2023) Betunga, Benjamin; Atuhaire, Phionah; Nakasiita, Catherine; Kanyamuneza, Christa; Namiiro, Proscovia; Tugume, Joseph; Matovu, Hairat; Sark, Ahmed M.; Mugabi, Benedicto; Lilian, Birungi; Mugisha, Richard; Kumakech, Edward; Asiimwe, John Baptist
The use of multiple HIV prevention services has been found to decrease the risk of acquiring HIV when tailored to individuals at risk of HIV exposure, including transport workers. There- fore, we assessed the uptake of multiple HIV prevention services (�2) and associated fac- tors among transport workers in a city in Southwestern Uganda. This cross-sectional study comprised motorcycle taxi riders, motor vehicle and truck drivers, aged 18 to 55 years who were selected and responded to an interviewer-administered questionnaire, between November 2021 and February 2022. Data was analyzed using descriptive statistical and modified Poisson regression analyses. Out of 420 participants, 97.6% were male, with a median age of 28 years and the majority were aged <34 years (84.6%). Overall, less than half (45.3%) of the participants had used multiple (�2) HIV prevention services within a one- year period. Many participants had used condoms (32.2%) followed by voluntary HIV counseling and testing (27.1%), and safe male circumcision (17.3%). Most participants who tested for HIV had ever used condoms (16.2%), followed by those who received safe male circumcision and had ever used condoms (15%), and those who tested for HIV and had started on antiretroviral therapy (ART) (9.1%). In the adjusted model, factors that were sig- nificantly associated with the use of multiple HIV prevention services included religion (aPR = 1.25, 95% CI = 1.05–1.49), the number of concurrent sex partners (aPR = 1.33, 95% CI = 1.10–1.61), prior HIV testing and awareness of HIV serostatus (aPR = 0.55, 95% CI = 0.43– 0.70), awareness of HIV prevention services (aPR = 2.49, 95% CI = 1.16–5.38), and finan- cial payment to access HIV services (aPR = 2.27, 95% CI = 1.47–3.49). In conclusion, the uptake of multiple HIV prevention services among transport workers remains suboptimal. Additionally, individual behavioral factors influence the use of multiple HIV services com- pared with other factors. Therefore, differentiated strategies are needed to increase the utili- zation of HIV prevention services among transport workers
Feasibility of delivering HPV vaccine to girls aged 10 to 15 years in Uganda
(African health sciences, 2015) Mugisha, Emmanuel; LaMontagne, Scott; Katahoire, Anne R; Murokora, Daniel; Kumakech, Edward; Seruyange, Rachel; Tsu, Vivien Davis
Background: Cervical cancer is a leading cause of mortality among women in Uganda. The availability of the human papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. The Government of Uganda conducted a demonstration project exploring the feasibility of two delivery strategies. Objective: To explore the feasibility of two HPV vaccine delivery strategies: 1) a stand-alone school-based strategy that selected girls based on their enrolment in grade 5 (known as the “grade-based” strategy; and 2) an age-based strategy that delivered the HPV vaccine based on the girls’ age (10-year-olds). This strategy combined the delivery of the vaccine with the distribution of deworming medication and vitamin A through an existing Child Days Plus program. Methods: A qualitative study that explored the feasibility of the two delivery strategies from the perspective of health workers, district leaders, and staff of the Uganda National Expanded Programme on Immunization, utilizing in-depth interviews and focus group discussions. Results: Coverage data showed that more girls (88%) were vaccinated using the grade-based strategy and completed all three doses compared to those (73%) vaccinated using the age-based strategy. Health workers and teachers indicated that determining vaccination eligibility was easier by grade than by age and there were minor disruptions to health services and school programs during vaccinations, as reported by health workers and teachers using the grade-based strategy. Conclusion: HPV vaccine delivery at schools using grade eligibility was more feasible than selecting girls by age. Lessons learned in Uganda could be relevant for countries considering implementing HPV vaccinations.
Female-controlled dual protection methods: Prevalence, predictors, experiences and perceptions among young women living with HIV in northern Uganda–A mixed-method study protocol
(PLoS ONE, 2023) Kumakech, Edward; Acen, Joy; Musinguzi, Marvin; Ebong, Doryn; Okello, James
Study background The use of dual protection methods among young women living with HIV (YWLHIV) aged 15–24 years in sub-Saharan Africa (SSA) is poorly researched despite the double risk of unintended pregnancy and HIV. Even more scanty is literature on the use of female-controlled dual protection methods. We propose to determine the female-controlled dual protection prevalence, and the predictors among YWLHIV in northern Uganda. The study will also explore the YWLHIV’s experiences and perceptions regarding the female-controlled dual protection methods. Materials and methods This study will employ a mixed-methods design. The study area will be Lira district and Lira city located in northern Uganda. The setting for recruitment of participants will be the public health facility–based anti-retroviral therapy (ART) clinics. These ART clinics serves a total of about 1,771 YWLHIV. A sample of 425 YWLHIV will be selected by stratified random sampling from the ART clinic registers. The three strata of interest will be the YWLHIV attending the ART clinic at referral hospitals, health centers level IV (primary healthcare centers), and health centers level III (dispensaries). The primary outcome will be the use of the femalecontrolled dual protection methods. The outcome will be measured by asking the YWLHIV ‘what methods under their control as YWLHIV do they use to protect against both unintended pregnancy and HIV during sexual intercourse with their male partners.’ The questionnaire also has measures for the unintended pregnancy, HIV status, and the potential predictors. Qualitative component of the study will be in-depth interviews of the participants about their experiences and perceptions regarding the female-controlled dual protection. methods. Data collection was still ongoing at the time of first submission of this study protocol to the journal (14th March 2023). The Statistical Package for Social Sciences (SPSS) version 23.0 will be used for the statistical analyses. Descriptive statistics, bivariate and multivariate regression analyses will be used to establish the prevalence, associated factors and the predictors of the outcome respectively. The statistical significance level of 5% and 95% confidence interval will be considered. In-depth interviews will be manually analyzed using a thematic analysis approach for codes, themes, and categories.
Graduate Midwifery Education in Uganda Aiming to Improve Maternal and Newborn Health Outcomes
(Annals of Global Health, 2020) Kumakech, Edward; Anathan, Julie; Udho, Samson; Auma, Anna Grace; Atuhaire, Irene; Nsubuga, Allan G.; Ahaisibwe, Bonaventure
Background: Maternal and newborn health outcomes in Uganda have remained poor. The major challenge affecting the implementation of maternal and newborn interventions includes a shortage of skilled midwives. In 2013, Lira University, a Ugandan Public University, in partnership with Seed Global Health, started the first Bachelor of Science in Midwifery (BScM) in Uganda with a vision to develop a Master of Science in Midwifery (MScM) in the future. Objective: Evaluate results of Lira University’s Bachelors in Midwifery program to help inform the development of a Masters in Midwifery program, which would expand midwifery competencies in surgical obstetric and newborn care. Methods: Lira University and Ministry of Health records provided data on curriculum content, student enrollment and internships. The internship reports of the graduate midwives were reviewed to collect data on their employment and scope of practice. Interviews were also conducted with the graduates to confirm the added skills they were able to apply and their outcomes. Findings: The critical competences incorporated into the Bachelor in Midwifery curriculum included competences to care for pre- and post-operative caesarian section patients or assist in a caesarean section, newborn care (e.g. resuscitation from birth asphyxia), anesthesia, and theatre techniques, among others. Overall, 356 students (40.2% male, 59.8% female) enrolled in the BScM program over the period 2013–2018. Annual data shows an increasing trend in enrollment. Of the 32 graduates in January 2019, 87.6% were employed in maternal and newborn healthcare facilities, and 12.4% were employed in midwifery private practice. Follow-up interviews revealed that the graduate midwives reported positive maternal and newborn outcomes and the ability to practice advanced obstetrics and newborn care skills they acquired from the training. Conclusion: There is growing interest in a graduate midwifery education program in Uganda for both male and female students. The retention of the graduate midwives in healthcare facilities gives a renewed hope for mothers and newborns, who benefit from their extra obstetrics and newborn care competences in settings where there are neither medical doctors nor obstetricians and gynecologists. Recommendations: Further, larger tracer studies of the graduate midwives to identify the kinds of obstetric surgeries and newborn care services they ably performed and their corresponding maternal and newborn health outcomes is recommended. Also recommended is advocacy for recognition of extra skills of graduate midwives by health authorities in Uganda and the region.
HIV-related stigma experiences and coping strategies among pregnant women in rural Uganda: A qualitative descriptive study
(PloS one, 2022) Jolle, Judith; Kabunga, Amir; Okello, Tonny Owili; Kadito, Esther Oloi; Aloka, Jimmy; Otiti, Geoffrey; Aluku, Agnes Adong; Kumakech, Edward; Udho, Samson
Background HIV-related stigma is a global problem among HIV clients with far-reaching effects including increased rates of mother-to-child transmission of HIV. However, HIV-related stigma experiences and coping strategies have received little attention, especially among pregnant women in rural settings. We explored the HIV-related stigma experiences and coping strategies among pregnant women in rural northern Uganda. Methods This was a qualitative descriptive study conducted among HIV-positive pregnant women seeking care at Aboke Health Center IV, Kole district, northern Uganda. We conducted 12 in-depth interviews using a semi-structured interview guide. Data were analyzed using the inductive thematic approach of Braun and Clarke. Results The age range of the 12 participants was 17 to 35 years while the average duration with HIV since diagnosis was five years. The majority of the participants were subsistence farmers who had attained a primary level of education. Social rejection and public ridicule were identified as HIV-related stigma experiences while ignoring, social support, and prayers were identified as HIV-related coping strategies among the study participants. Conclusion Enacted HIV-related stigma is common among pregnant women in rural northern Uganda. Healthcare providers should work closely with HIV-positive women and other stakeholders to identify and strengthen HIV-related stigma coping strategies among pregnant women in rural settings.
Human Immunodeficiency Virus (HIV), Human Papillomavirus (HPV) and Cervical Cancer Prevention in Uganda
(Örebro university, 2015) Kumakech, Edward
Background: HIV-positive women have an increased risk of developing cervical cancer (CC) compared to the HIV-negative women. Despite this, HIV and CC screening programs in many developing countries have remained disintegrated. Therefore, the objective of the study was to explore perceptions of healthcare providers (HCP) and policy makers (PM) about integration of HIV and CC screening services in Uganda. Methods: This was a qualitative study conducted among 16 participants comprising of 12 healthcare providers and 4 policy makers in Uganda. Data were collected through individual interviews. Participants were purposively selected from different level of health facilities with clinics for HIV and CC screening services. Content analysis method was used to analyze the data. Results: Three themes emerged from the data, namely appreciating benefits of integration, worrying about the limited health system capacity and potential consequences of integration and feeling optimistic about integration under improved health system conditions. The benefits embraced the women – particularly the HIV-positive women- but also men, healthcare providers and the health system or the government. There were worries that HIV stigma and shortage of healthcare workers would affect the effective delivery of the integrated program. Conclusion: Integration of HIV and CC screening can offer manifold benefits to all stakeholders in the health system, more so to the women. However, its feasibility in developing countries such as Uganda will most likely be hampered by weak and inefficient health systems. Therefore, when considering HIV and CC screening integration, it is important not to only recognize the benefits but also take into account resources requirements for addressing the existing weaknesses and inefficiencies in the health systems such as limited infrastructure, insufficient drugs and supplies, inadequate and poorly motivated healthcare workers.
Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries
(Bull World Health Organ, 2011) LaMontagne, D Scott; Barge, Sandhya; Le, Nga Thi; Mugisha, Emmanuel; Penny, Mary E; Gandhi, Sanjay; Janmohamed, Amynah; Kumakech, Edward; Mosqueira, N Rocio; Nguyen, Nghi Quy; Paul, Proma; Tang, Yuxiao; Minh, Tran Hung; Uttekar, Bella Patel; Jumaan, Aisha O
Objective To assess human papillomavirus (HPV) vaccination coverage after demonstration projects conducted in India, Peru, Uganda and Viet Nam by PATH and national governments and to explore the reasons for vaccine acceptance or refusal. Methods Vaccines were delivered through schools or health centres or in combination with other health interventions, and either monthly or through campaigns at fixed time points. Using a two-stage cluster sample design, the authors selected households in demonstration project areas and interviewed over 7000 parents or guardians of adolescent girls to assess coverage and acceptability. They defined full vaccination as the receipt of all three vaccine doses and used an open-ended question to explore acceptability. Findings Vaccination coverage in school-based programmes was 82.6% (95% confidence interval, CI: 79.3–85.6) in Peru, 88.9% (95% CI: 84.7–92.4) in 2009 in Uganda and 96.1% (95% CI: 93.0–97.8) in 2009 in Viet Nam. In India, a campaign approach achieved 77.2% (95% CI: 72.4–81.6) to 87.8% (95% CI: 84.3–91.3) coverage, whereas monthly delivery achieved 68.4% (95% CI: 63.4–73.4) to 83.3% (95% CI: 79.3–87.3) coverage. More than two thirds of respondents gave as reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g. school absenteeism) than by opposition to the vaccine. Conclusion High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied. Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.
Immunogenicity of bivalent HPV vaccine among partially vaccinatedyoung adolescent girls in Uganda
(Elsevier Ltd., 2014) LaMontagne, D. Scott; Mugisha, Emmanuel; Pan, Yuanji; Kumakech, Edward; Ssemaganda, Aloysius; Kemp, Troy J.; Cover, Jane; Pinto, Ligia A.; Safaeian, Mahboobeh
Background: Investigations of vaccine efficacy and immunogenicity for adult females receiving fewerthan three doses of human papillomavirus (HPV) vaccine have suggested protection against infection andprecancerous lesions. We investigated the immunogenicity of bivalent HPV vaccines among adolescentgirls from Uganda who received one, two, or three vaccine doses.Methods: Young girls vaccinated through a government program in Uganda were invited to participate.HPV16- and HPV18-specific antibodies were measured at ≥24 months after the last vaccine dose usingan enzyme linked immunoassay in girls who received one (n = 36), two (n = 145), or three (n = 195) doses.Results: Nearly all subjects (99%) were HPV16 and HPV18 seropositive at the time of blood-draw.Geometric mean antibody levels (GMTs) were: HPV161-dose= 230 EU/mL, HPV162-dose= 808 EU/mL,and HPV163-dose= 1607 EU/mL; HPV181-dose= 87 EU/mL, HPV182-dose= 270 EU/mL, andHPV183-dose= 296 EU/mL. The GMT ratio for 2:3 doses was 0.50 (HPV16) and 0.68 (HPV18) anddid not meet the non-inferiority criteria (i.e., lower bound of 97.5% confidence interval of the GMT ratiogreater than 0.50). The GMT ratio for 1:3 doses for HPV16 and HPV18 was inferior, but absolute GMTs forone dose were higher than adult women who received one dose (HPV16 = 124 EU/mL, HPV18 = 69 EU/mL)where efficacy has been demonstrated.Conclusions: Even though immunogenicity with less than three doses did not meet a priori non-inferioritythresholds, antibody levels measured ≥24 months after last dose were similar to those of adult womenwho have been followed for more than eight years for efficacy.
Impacts of IRC’s Fifth Child community engagement strategy to increase immunisation in northern Uganda
(2019) Webster, Jayne; Landegger, Justine; Bruce, Jane; Malunda, Dickson; Chantler, Tracey; Kumakech, Edward; Schmucker, Laura; Kiapi, Lilian; Kozuki, Naoko; Olorunsaiye, Comfort; Byrne, Erin
The 2011 Uganda Demographic and Health Survey (UDHS) reported that the national coverage of the third dose of the combined diphtheria, pertussis, tetanus vaccine (DPT3) among children 12-23 months of age was 73%, and only 52% were fully immunized. Intervention overview In search of innovative ways to increase immunization coverage, the IRC, in coordination with the Uganda Ministry of Health, piloted from August 2015-April 2016 an mReach application (mReach) and community engagement strategy (the ‘Fifth Child’ intervention), working with Village Health Teams (VHTs) to identify immunization defaulters and re-enter them into the vaccination schedule. Based on positive results of this pilot, the IRC received funding from 3ie to scale and evaluate the impact of this intervention. The goal of the ‘Fifth Child’ intervention was to increase immunization coverage through defaulter tracing and targeted service delivery, facilitated by the mReach data platform and community engagement strategies. The intervention was implemented from mid-September 2016 to mid-September 2017. The underlying hypothesis of the intervention is that data-driven, targeted community engagement would facilitate more effective defaulter tracing and contribute to increased immunization coverage in hard-to-reach communities. The project has two main components. The first is supporting activities aimed at strengthening the health system (support for outreaches, transport of vaccines and supplies, financial support for VHTs to attend community engagement meetings with health care workers and community leaders, etc.). The second component, mReach with community engagement, included continuous newborn registration, quality VHT home visits for immunization due and defaulter tracking, and community leader involvement and co-management of outreaches based on defaulter data.

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