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Photovoice methodology centralizes the voices of marginalised populations within health systems using photography and critical dialogue to record, reflect and communicate community health issues. This paper presents findings from applying photovoice to explore and document the lived experiences of groups of marginalised populations in six low- and middle-income countries: Cambodia, Ghana, Nepal, Sierra Leone, Uganda and Zambia. The strengths of using photovoice included: creating safe spaces for communication; community solidarity and stakeholder engagement; community ownership of actions and advocacy; developing new soft skills and confidence; capturing hidden community challenges; and taking collective action. Suggestions for use in future photovoice studies include: providing space for the exploration of contextual factors before implementation; developing a capacity strengthening plan to ensure participants have the competencies required to effectively take part in research and dissemination; considering the use of non-visual methods alongside photovoice when needed; and having in place partnership structures between researchers and participants that facilitate power sharing, agency, empowerment and joint decision making. Lastly, we present recommendations that have the potential to strengthen the value and use of photovoice as more than a participatory method but also a vehicle for individual, relational and health systems improvements.

Background Pesticide use for fruits and vegetable production in Uganda may result in presence of residues on produce which may pose health risks to consumers. Uganda does not have an established system for monitoring pesticide residues in fruits and vegetables and assessing potential health risks. This research aimed to conduct a health risk assessment of presence of pesticide residues in fruits and vegetables in the Kampala Metropolitan Area in Uganda. Method Pesticides were measured in 160 fruits and vegetables samples collected at farms, markets, street vendors, restaurants and homes; and analysed using liquid chromatography-tandem mass spectrometry and gas chromatography-mass spectrometry. Fruit and vegetable consumption information was collected from 2177 people. Pesticide concentrations were compared with European Union maximum residual limits (MRLs). Mean values of pesticide concentration residues found in the sample of fruits and vegetables; and fruits and vegetables intake and body weight were used to calculate the estimated daily intake (EDI) of pesticide residues. EDI values were compared with acceptable daily intakes (ADI) to calculate the hazard quotient by age group, and stage at which consumption happens along the chain. Results Overall, 57 pesticides were detected in fruits and vegetables from farm to fork. Of the 57, 39 pesticides were detected in all the fruits and vegetables studied. Concentrations of fonofos, fenitrothion and fenhexamid were above the European Union MRLs in some samples. Hazard quotients based on dietary ingestion scenarios for 18 pesticides, including dichlorvos (444) alanycarb (314), fonofos (68), fenitrothion (62), dioxacarb (55) and benfuracarb (24) and others, were above 1, indicating the possibility of chronic health risk to consumers. Chronic health risk decreased with age but was stable for stage at which consumption happens along the food chain. The number of pesticides with EDI greater than the ADI decreased with increase in age; with 18, 13, 9, 11, 8, 9, and 9 pesticides for age groups Conclusion Chronic dietary pesticide exposures to Ugandans are likely common, and for some pesticides result in exposure exceeding health-based benchmarks. Risks were highest for younger participants. There is an urgent need to increase monitoring and regulation of pesticides in fruits and vegetables in order to protect consumers, especially the children who are vulnerable to the adverse effects of pesticides.

Despite the fact that several cases of unsafe pesticide use among farmers in different parts of Africa have been documented, there is limited evidence regarding which specific interventions are effective in reducing pesticide exposure and associated risks to human health and ecology. The overall goal of the African Pesticide Intervention Project (APsent) study is to better understand ongoing research and public health activities related to interventions in Africa through the implementation of suitable target-specific situations or use contexts. A systematic review of the scientific literature on pesticide intervention studies with a focus on Africa was conducted. This was followed by a qualitative survey among stakeholders involved in pesticide research or management in the African region to learn about barriers to and promoters of successful interventions. The project was concluded with an international workshop in November 2021, where a broad range of topics relevant to occupational and environmental health risks were discussed such as acute poisoning, street pesticides, switching to alternatives, or disposal of empty pesticide containers. Key areas of improvement identified were training on pesticide usage techniques, research on the effectiveness of interventions targeted at exposure reduction and/or behavioral changes, awareness raising, implementation of adequate policies, and enforcement of regulations and processes.

Background Health service delivery should ensure ethical principles are observed at all levels of healthcare. Working towards this goal requires understanding the ethics-related priorities and concerns in the day-to-day activities among different health practitioners. These practitioners include community health workers (CHWs) who are involved in healthcare delivery in communities in many low-and middle-income countries such as Uganda. In this study, we used photovoice, an innovative community based participatory research method that uses photography, to examine CHWs' perspectives on ethical concerns in their work. Methods We explored perspectives of 10 CHWs (5 females and 5 males) on ethical dimensions of their work for 5 months using photovoice in a rural community in Wakiso district, Uganda. As part of the study, we: 1. Oriented CHWs on photovoice research and ethics; 2. Asked CHWs to take photographs of key ethical dimensions of their work; 3. Held monthly meetings to discuss and reflect on the photos; and 4. Disseminated the findings. The discussions from the monthly meetings were audio recorded, transcribed, and emerging data analysed using conventional content analysis with the help of Atlas ti version 6.0.15. Results CHWs were aware of and highly concerned about the need to observe ethical principles while carrying out their roles. The ethical principles CHWs were aware of and endeavoured to observe during their work were: maintaining professional integrity and abiding by ethical principles of practice; ethical responsibility in patient care; maintaining confidentiality while handling clients; respect for persons and communities; and enhancing their knowledge and skills for better practice. However, CHWs also identified challenges concerning their observance of ethical principles including: low commitment to their work due to other obligations; availability of some reference materials and guidelines in English yet majority could only read in the local language; and minimal avenues for knowledge enhancement such as trainings. Conclusions CHWs were aware of and keen to discuss ethical issues in their work. However, there is need to address the challenges they face so as to facilitate observing ethical principles during the course of their work in communities.

Background. Only a third of the total waste generated in slum communities in Kampala is collected and disposed of to the landfill every month. This study assessed the status of household solid waste management and associated factors in a slum community in Kampala, Uganda. Methods. We conducted a community-based cross-sectional study involving 395 households using a semistructured questionnaire and an observational checklist. Proper solid waste management was determined based on possession of waste collection and storage receptacle; collection receptacle ability to minimise nuisances (covered); segregation of waste; presence of flies and other vectors; and collection receptacle fill status. Prevalence rate ratios and their 95% confidence intervals were used as a measure of association. Results. Only, 41.3% (163/395) of the households exhibited proper waste management practices. The majority of the households 85.8% (339/395) owned solid waste storage receptacles, most of which were sacs 61.7% (209/339) and would minimise nuisances 72.9% (245/339). The main type of waste collected was biodegradable materials 56.7% (224/395). The majority of the households 78.7% (311/395) did not segregate their waste. Solid waste was mainly transported to the collection point by pulling the collecting sac 54.4% (215/395). The city authority 73.9% (292/395) and private companies 12.9% (51/395) were the major entities collecting waste. Factors associated with proper waste management were collecting waste in plastic containers (adjusted PR = 1.27, 95% CI (1.04–1.55)), polythene bags (adjusted PR = 0.26, 95% CI (0.14–0.47)), and paper bags or metallic bins (adjusted PR = 0.13, 95% CI (0.03–0.44)) as well as awareness of solid waste management laws (adjusted PR = 1.49, 95% CI (1.20–1.85)) and the dangers of improper solid waste management (adjusted PR = 2.15, 95% CI (1.51–3.06)). Conclusion. Solid waste management was generally poor. As such, a cascade of interventions that address knowledge, physical, and behavioural aspects of solid waste management is required to improve its management in slum communities.

We explored the facilitators and barriers to uptake of water, sanitation and hygiene (WASH) interventions among slum dwellers in Kampala, Uganda using a socio-ecological perspective. This qualitative exploration used focus group discussions with community members and key informant interviews with community leaders and technocrats to collect data. Among facilitators to uptake of WASH interventions were susceptibility to WASH-related diseases and low WASH knowledge levels at individual level, peer practices at household level, and promotion of WASH at organizational level. At community and public policy levels, community engagement and empowerment, and formation and enforcement of ordinances and bye-laws, respectively, motivated slums dwellers to adopt WASH interventions. Conversely, individual knowledge, beliefs, language, and financial status inhibited individuals from taking up WASH interventions. Negative peer practices and upbringing at peer level; unsupportive environments, and engagement of communities at organizational level; cultural beliefs and lack of space at community level; and unexamplary leaders and political interference barred slum dwellers in Kampala from embracing the WASH interventions. Uptake of WASH interventions in the slum community is influenced by a cascade of facilitators and barriers across the socio-ecological realm. Hence, a multi-faceted approach targeting all stakeholders is required in planning and implementation of WASH interventions.

Background This study assessed characteristics of sanitation and hygiene facilities in a slum community in Kampala, Uganda. Methods We conducted a household-based cross-sectional study among 395 households in Kasubi slum using a semi-structured questionnaire and observational checklist to collect data. Results Almost 98.0% (387/395) of households owned a sanitation facility and 77.0% (298/387) shared it with other households. The most common type of sanitation facility was a pit latrine with slab (66.9% [259/387]). Most (90.5% [305/337]) latrines had a door or shutter, a roof (92.9% [313/337]) and a depth >1.5 m (68.2% [229/337]). Overall, 21.3% (84/395) and 65.6% (259/395) of households had improved and functional sanitation facilities, respectively. Only 16.5% (65/395) of the households had a hand-washing facility. Student-led (adjusted prevalence rate [PR] 2.67 [95% confidence interval [CI] 1.83–3.94]) and households that owned their house (adjusted PR 2.17 [95% CI 1.33–3.53]) were 2.67 and 2.17 times more likely to have improved sanitation facilities, respectively. Households that owned their house (adjusted PR 1.90 [95% CI 1.18–3.05]) were 1.9 times more likely to possess a hand-washing facility. Conclusions The coverage of improved sanitation and hygiene facilities was low. The majority of households were using a shared pit latrine with a slab that had no hand-washing facility. Sanitation and hygiene interventions should prioritize improving sanitation and hygiene facilities.

Objective The objective of the project was to strengthen the community health worker (CHW) programme in Ssisa sub-county, Wakiso district, Uganda by providing a coherent, structured and standardized training, supervision and motivation package so as to enhance their performance. Results The project trained all 301 CHWs who received non-financial incentives of t-shirts, gumboots and umbrellas, and 75 of them received solar equipment to support lighting their houses and charging phones. Twenty-four of the CHWs who had coordination roles received additional training. Three motorcycles were also provided to enhance transportation of CHW coordinators during their work including supervision. By end of the project, the CHWs had conducted 40,213 household visits, carried out health education sessions with 127,011 community members, and treated 19,387 children under 5 years of age. From the project evaluation, which used both quantitative and qualitative methods, 98% of the CHWs reported having improved competence in performance of their roles. In addition, the CHWs were highly motivated to do their work. The motorcycles were instrumental in supporting the work of CHW coordinators including monthly collection of reports and distribution of medicines. The project demonstrated that by improving training, supervision and motivation, performance of CHW programmes can be enhanced.

This mixed methods study used laboratory measurements of pesticide residues in produce, semi-structured questionnaires, and in-depth interview data to describe trends in pesticide residue in produce and handling and processing practices for fruits (watermelon and passion fruit) and vegetables (tomato, cabbage, and eggplant) along the farm to fork chain. Of the 50 farmers visited, 34 (68.0%) sold their fruits and vegetables to transporters, 11 (22.0%) to market vendors, and 4 (8.0%) directly to homes and restaurants. The majority 42 (93.3%) of the consumers (home/restaurant) purchased their fruits and vegetables from market vendors and transporters. Washing with water or vinegar, wiping with a cloth, peeling the outer layer, and blending and cooking were the most common post-harvesting processing methods used by stakeholders along the supply chain. Some farmers and market vendors reported spraying fruits and vegetables with pesticides either prior- or post-harvest to increase shelf life. Statistically significant decreasing pesticide residue trends along the farm to fork chain were observed for dioxacarb, likely due to degradation or washing, peeling, cooking, blending, or wiping by consumers. Increasing trends were observed for methidathion and quinalphos possibly due to pesticide applications. There is a need in Uganda to promote practices that minimize pesticide use and exposure through diet, while maintaining food integrity.

The public health context is becoming increasingly more complex requiring highly trained professionals equipped with knowledge, competencies and tools to address or transform current and future challenges. Doctoral degree training offers an opportunity to build the capacity to detect and respond to such dynamic health challenges. In this paper, we discuss how Africa’s public health doctoral students can be better positioned for the different career pathways to provide leadership on complex health and development challenges. Public health PhD graduates can take up careers in academia, civil service, private sector and civil society, among others. To thrive in these pathways, PhD training should equip them with knowledge, skills and competencies in leadership, creativity and social competence among others. To produce career-ready PhD graduates, there is need to rethink training curricula to build critical skills for diverse career pathways, introduce students to entrepreneurship, and enhance linkages between universities and industry. Experiential learning, exposure to networks and partnerships, postdoctoral programmes and mentorship and exchange programmes can further equip PhD students with key knowledge, skills and competencies. For students to position themselves for the different careers, they ought to plan their careers early, albeit with flexibility. Students should build their soft skills and embrace technology among other transferable competencies. By identifying potential career pathways and being positioned for these early, Africa can produce transformative PhD students on a path for success not just for themselves but for society at large, including in new environments such as that created by COVID-19.

Background More than half of the disease burden in Uganda can be prevented through improving water, sanitation, and hygiene (WASH). In slum communities, water supply is insufficient but also highly contaminated; therefore, ensuring that the safe water chain is maintained by households is paramount to preventing water-related diseases. This study aimed at assessing knowledge and practices of households on safe water chain maintenance in slum communities in Kampala City, Uganda. Methods This was a community-based cross-sectional study carried out among 395 households in slum communities in Kampala, Uganda. Data were collected using a semi-structured questionnaire. Prevalence ratios (PRs) and their 95% confidence intervals were used as a measure of association between safe water chain management and associated knowledge and practice factors. The PRs were obtained using a multivariable modified Poisson regression with logarithm as the link function, with robust standard errors. Results Majority (76.7%, 303/395) of the households collected their water from a piped water system and paid for the water (72.9%, 288/395). Almost all (97.2%, 384/395) of the participants said that they knew the dangers associated with drinking unsafe water, boiled their drinking water (95.4%, 377/395), and used storage containers that minimize contamination (97.0%, 383/395). However, only (32.4%, 128/395) of the households satisfactorily maintained the safe water chain. Female- (adjusted PR = 1.82, 95% CI (1.19–2.78)) and student-led households (adjusted PR = 1.58, 95% CI (1.03–2.41)) and those whose heads had attained post-primary education (adjusted PR = 1.48, 95% CI (1.02–2.17)) were more likely to satisfactorily maintain the safe water chain. This was similar among members who thought most contamination occurs during storage (adjusted PR = 1.47, 95% CI (1.10–1.97)). Conclusion Only a third of the households maintained the safe water chain satisfactory. Female-led, student-led, and post-primary educated-led household and household that thought most contamination occurs during storage were more likely to maintain the safe water chain. There is a need to improve the level of awareness about the importance of the safe water chain among slum dwellers.

Background: Community health workers (CHWs) continue to play a crucial role in supporting health service delivery globally. Several CHW programmes around the world face vast challenges which affect their performance. Objectives: This study assessed the performance of CHWs and associated factors in a rural community in Wakiso district, Uganda. Methods: This was a cross-sectional study that employed a structured questionnaire to collect quantitative data from 201 CHWs in Wakiso district. The main study variable was CHW performance based on various roles carried out by CHWs. Multivariable logistic regression in STATA was used to establish the predictors of CHW performance. Results: Only 40 (19.9%) of the CHWs had a high performance which was associated with having attended additional / refresher trainings [AOR=12.79 (95% CI: 1.02-159.26)], and having attained secondary level education and above [AOR=3.93 (95% CI: 1.17-13.24)]. CHWs who were married [AOR=0.29 (95% CI: 0.09-0.94)] were less likely to perform highly. Among CHWs who had received essential medicines for treatment of childhood illnesses, the majority 90.3% (112/124) had experienced stock-outs in the 6 months preceding the study. Despite the majority of CHWs, 198 (98.5%), stating that being motivated was very important in their work, only 91 (45%) said that they were motivated. Conclusion: Additional / refresher trainings are necessary to enhance performance of CHWs. In addition, level of education should be considered while selecting CHWs. The health system challenges of low motivation of CHWs as well as stock-out of medicines need to be addressed to support their work. Keywords: Community health workers, performance, motivation, satisfaction, stock-outs, village health teams, Uganda.

Statement of purpose Globally, thousands of children lose their lives to unintentional injuries every year. Injuries occurring at home to under 5s (burns, falls, poisoning) can be prevented through providing safety equipment e.g. barriers and childproof containers. Although a number of studies have shown significant reductions in child injuries most have been conducted in high-income countries. This research aims to reduce unintentional home injuries among under 5s in Jinja, Uganda through the provision of a toolkit. Methods/Approach This study is guided by a community-based participatory research approach utilizing mixed methods. A quantitative retrospective review of hospital data was combined with a community- based household survey and risk assessment tool to provide incidence and risk factor data. An exploration of perceptions of injuries, risky behaviours and practices in the home was provided through focus-group discussions and Photovoice. Results Preliminary analysis of ongoing data collection has been done. Hospital record review of 225 cases revealed that 34% of injuries were due to burns, 45% were seen in outpatients and 39% admitted to the wards. The survey of 615 households indicated that there had been 879 injury events amongst under 5s in the preceding 12 months. The majority occurred within the compound of the home (57% fall-related ; 23% burn injuries). From the qualitative exploration, falling in pits, open fireplaces and off beds were the major causes of injuries. Conclusion This formative research contextualises the problem and looks to propose an intervention toolkit including educational material, parent training workshops, awareness campaigns, home visits and environmental modifications. The findings will inform the development of a culturally appropriate/affordable set of interventions and provide accurate incidence rates for a future intervention trial. Significance The results will have significant implications for low-income countries in terms of research methodology and effective information in mitigating injuries among under 5s.

Background Globally, nearly 650,000 children lose their lives to injuries every year. Injuries occurring in and around the home to children under 5 years (burns, falls, drowning, poisoning) can be prevented through providing safety equipment e.g. barriers, childproof containers. A number of studies have shown significant reductions in child injuries following this approach but all studies have thus far been conducted in high-income countries. Our research aims to reduce unintentional home injuries among under 5’s in Jinja, Uganda through the provision of a child safety kit and parental education. Methods This study is guided by a community-based participatory research (CBPR) approach utilizing mixed methods. A quantitative retrospective review of hospital data is combined with a community-based household survey and risk assessment checklist tool to provide incidence and risk factor data. A deeper exploration of attitudes and perceptions of injuries in the home along with participatory workshops is provided through focus-group discussions and Photovoice. Results Data collection is currently underway and will be analysed between March-June 2020. Conclusion This formative research will contextualize the problem and develop an intervention package including the child safety kit, educational material, parent training workshops and an awareness campaign. The findings will inform the development of a culturally appropriate/affordable safety kit and provide accurate incidence rates on which to base sample size calculations for an intervention trial to measure behaviour change and reductions in injuries. Learning Outcomes The results will have significant implications for other low-income countries both in terms of research methodology and effectiveness information.

Background Community health workers (CHWs) are an important cadre of the global health workforce as they are involved in providing health services at the community level. However, evidence on the role of CHWs in delivering interventions for non-communicable diseases (NCDs) in Uganda is limited. This study, therefore, assessed the involvement of CHWs in the prevention and control of NCDs in Wakiso District, Uganda with a focus on their knowledge, attitudes and practices, as well as community perceptions. Methods A cross-sectional study using mixed methods was conducted which involved a structured questionnaire among 485 CHWs, and 6 focus group discussions (FGDs) among community members. The study assessed knowledge, perceptions including the importance of the various risk factors, and the current involvement of CHWs in NCDs, including the challenges they faced. Quantitative data were analysed in STATA version 13.0 while thematic analysis was used for the qualitative data. Results The majority of CHWs (75.3%) correctly defined what NCDs are. Among CHWs who knew examples of NCDs (87.4%), the majority mentioned high blood pressure (77.1%), diabetes (73.4%) and cancer (63.0%). Many CHWs said that healthy diet (86.2%), physical activity (77.7%), avoiding smoking/tobacco use (70.9%), and limiting alcohol consumption (63.7%) were very important to prevent NCDs. Although more than half of the CHWs (63.1%) reported being involved in NCDs activities, only 20.9 and 20.6% had participated in community mobilisation and referral of patients respectively. The majority of CHWs (80.1%) who were involved in NCDs prevention and control reported challenges including inadequate knowledge (58.4%), lack of training (37.6%), and negative community perception towards NCDs (35.1%). From the FGDs, community members were concerned that CHWs did not have enough training on NCDs hence lacked enough information. Therefore, the community did not have much confidence in them regarding NCDs, hence rarely consulted them concerning these diseases. Conclusions Despite CHWs having some knowledge on NCDs and their risk factors, their involvement in the prevention and control of the diseases was low. Through enhanced training and community engagement, CHWs can contribute to the prevention and control of NCDs, including health education and community mobilisation.

Understanding the experiences of community health workers (CHWs) through the use of participatory visual methods (PVMs) has been relatively underexplored. One such PVM is photovoice, which involves the capture of photographic images related to issues of social importance. In this study, we explore challenges faced by eight CHWs in Mukono District, Uganda through the use of photovoice. Over a six-week period, CHWs captured 62 relevant photographs. Subsequent individual interviews and group discussions were held with the CHWs regarding the content of the photographs. Using traditional content analysis, a range of themes related to perceived challenges faced by the CHWs were highlighted, including poor infrastructure, insufficient on-going training and supervision, relationships with other health professionals and equipment supplies. Suggestions were raised as to why such challenges existed and how they could be addressed; mainly through increased roles of the government and supporting NGOs. Overall, photovoice was generally a feasible method to highlight the challenges faced by CHWs, however community acceptability regarding image capture and consent taking may prove challenging, given past historical experiences. The use of photovoice in this study highlighted the need to address the multiple and complex challenges faced by CHWs in order to help them fulfil their roles.

To respond to the growing burden of noncommunicable diseases (NCDs) in Uganda, technical, managerial, and financial resources must be increased in the Ministry of Health as well as in primary and secondary health care facilities. This investment would help further Uganda's efforts to achieve sustainable development goals and build the government's capacity to meet the increasing needs for NCD services., Key Findings Inadequate government funding for noncommunicable diseases (NCDs) has elevated the role of external partners in shaping the development and implementation of NCD policies and programs in Uganda. Limited recruitment of technical experts and managers for NCDs in the Ministry of Health (MOH) has been a barrier to the effective coordination and communication across multiple government and nongovernmental actors in the NCD space. Financial, technical, and managerial constraints have contributed to external actors spearheading several NCD program activities with the MOH playing a more supportive role. Key Implications Policy makers and public health practitioners should prioritize building the MOH's financial, managerial, and technical capacity to oversee and lead the development and implementation of NCD programs and policies. Government leadership is critical in developing and executing a comprehensive strategic plan for NCDs that all actors can agree upon and adopt as the guiding framework for action., Background: Uganda faces a complex policy landscape as it simultaneously addresses infectious diseases and noncommunicable diseases (NCDs). The health system has been overwhelmed by the growing burden of NCDs across all socioeconomic strata. In this study, we sought to understand the policy context around NCDs in Uganda, the roles of actors both within and external to the government, and the factors shaping the development and implementation of NCD policies and programs in Uganda. Methods: We conducted in-depth interviews with 30 policy actors from the Ugandan Ministry of Health (MOH), nongovernmental organizations, and academia to understand the roles of different actors in the Ugandan NCD space, the programs and policy measures in discussion, and how to bridge any identified gaps. A thematic data analysis was conducted. Results: All national actors viewed funding constraints as a critical barrier to developing and executing an NCD strategic plan and as a barrier to leading and coordinating NCD prevention and control efforts in Uganda. The crowding of nongovernment actors was found to fragment NCD efforts, particularly due to the weak implementation of a framework for action among NCD actors. Relatedly, limited recruitment of technical experts on NCDs within the MOH was viewed to further diminish the government's role in leading policy and program formulation and implementation. Though recent MOH efforts have aimed at addressing these concerns, some skepticism remains about the government's commitment to increase budgetary allocations for NCDs and to address the technical and human resources gaps needed to achieve NCD policy aims in Uganda. Conclusions: This study highlights the immediate need to mobilize more resources, reduce fragmented efforts in the NCD space, and prioritize investment in NCD prevention and management in Uganda.

Background Pesticides are responsible for a significant percentage of deaths globally with majority occurring in sub-Saharan Africa. Deaths due to pesticide poisoning can be reduced if poisoning cases are managed optimally. However, the quality of care given to pesticide poisoning patients is still insufficient especially in sub-Saharan Africa. This study was aimed at exploring doctors’ experiences on quality of care for pesticide poisoning cases in hospitals in Kampala, Uganda. Methods Fifteen (15) in-depth interviews were conducted with doctors who were directly involved in management of pesticide poisoning patients in the accident and emergency, Medicine, Pediatrics and Intensive Care Unit wards in 5 hospitals in Kampala, Uganda. All interviews were transcribed and subjected to directed content analysis with the guidance of the Donabedian model of quality of care which emphasizes structure, process and outcome measures as pertinent to ensuring quality of care. Results Doctors reported structural, process and outcome facets that support diagnosis and treatment of pesticide poisoning cases that improved the quality of care they provided. Among the structures includes hospital units such as Intensive Care Unit (ICU), pediatrics and internal medicine; equipment and clinical guidelines such as airway, breathing and consciousness (ABC) protocol; and doctors’ knowledge and experiences. Doctors relied on history, and signs and symptoms to establish the cause and severity of pesticide poisoning. However, some patients and caretakers provided inaccurate pesticide poisoning history. Due to its availability in hospitals, doctors largely relied on atropine to manage pesticide poisoning cases whether or not relevant to treat the actual pesticide active ingredient responsible for the poisoning. Although majority of the cases treated recovered, those due to suicide were further referred to the hospital psychiatrist. Sharing experiences of managing pesticide poisoning patients among health workers and engaging in sensitization outreaches against pesticide poisoning were reported as potential activities to improve quality of care for pesticide poisoning patients. Conclusion Doctors reflected on the structure, process and outcome measures of quality of care given to pesticide poisoning patients. The implications of hospital structures and clinical process to the quality of the outcomes of care demonstrates their importance in improving management of pesticide poisoning cases in hospitals in Kampala, Uganda.

This study assessed concentrations of pesticide residues in fruits and vegetables from farm-to-fork in Kampala Metropolitan Area, Uganda. A total of 160 samples of fruit and vegetables collected from farms, markets, streets, restaurants and homes were analysed using liquid chromatography–tandem mass spectrometry; and Gas Chromatograph–Mass Spectrometer for dithiocarbamates. Multiple pesticide residues were detected in majority of the samples (95.6%). The proportions of the most frequently detected pesticides residue classes were organophosphates (91.3%), carbamates (67.5%), pyrethroids (60.0%) dithiocarbamates (48.1%) and neonicotinoids (42.5%). Among organophosphates, propotamophos, acephate, fonofos, monocrotophos and dichlorvos were the most detected active ingredients; aminocarb, methomyl and pirimicarb were the commonly detected carbamates; while imidacloprid, a neonicotinoid and lambda-cyhalothrin, pyrethroid were also highly detected. Twenty-seven pesticide were tested at all stages, of which the concentrations either decreased or increased along the chain. Multiple pesticide residues occurred in commonly consumed fruit and vegetables with decreasing or increasing concentrations from farm-to-fork.

Background There is need for more timely data to inform interventions that address the growing noncommunicable disease (NCD) epidemic. With a global increase in mobile phone ownership, mobile phone surveys can bridge this gap. Objective This study aimed to explore the acceptability and use of interactive voice response (IVR) surveys for surveillance of NCD behavioral risk factors in rural Uganda. Methods This qualitative study employed user group testing (UGT) with community members. The study was conducted at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Eastern Uganda. We conducted four UGTs which consisted of different categories of HDSS members: females living in urban areas, males living in urban areas, females living in rural areas, and males living in rural areas. Participants were individually sent an IVR survey, then were brought in for a group discussion using a semistructured guide. Data were analyzed thematically using directed content analysis. Results Participants perceived that IVR surveys may be useful in promoting confidentiality, saving costs, and raising awareness on NCD behavioral risk factors. Due to the clarity and delivery of questions in the local language, the IVR survey was perceived as easy to use. Community members suggested scheduling surveys on specific days and sending reminders as ways to improve their use for surveillance. Social issues such as domestic violence and perceptions toward unknown calls, technological factors including poor network connections and inability to use phones, and personal issues such as lack of access to phones and use of multiple networks were identified as barriers to the acceptability and use of mobile phone surveys. However, incentives were reported to motivate people to complete the survey. Conclusions Community members reflected on contextual and sociological implications of using mobile phones for surveillance of NCD behavioral risk factors. The opportunities and challenges that affect acceptability and use of IVR surveys should be considered in designing and implementing surveillance programs for NCD risk factors.

Background Community health workers (CHWs) are an important human resource in Uganda as they are the first contact of the population with the health system. Understanding gendered roles of CHWs is important in establishing how they influence their performance and relationships in communities. This paper explores the differential roles of male and female CHWs in rural Wakiso district, Uganda, using photovoice, an innovative community-based participatory research approach. Methods We trained ten CHWs (five males and five females) on key concepts about gender and photovoice. The CHWs took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis in Atlas ti version 6.0.15. Results Although responsibilities were the same for both male and female CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male CHWs were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female CHWs more available to address local problems. Conclusions CHWs reflected both strategic and conformist gendered implications of their community work. The differing roles and perspectives about the nature of male and female CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.

Given that little is known about the epidemiology of unintentional injuries in children in low-income countries, this study sought to determine the incidence and characteristics of unintentional injuries among children aged ≤18 years in a slum community in Uganda. From a household survey, the incidence and odds ratios for factors associated with unintentional injury characteristics were calculated. Of 1583 children, 706 had suffered 787 unintentional injuries yielding an annual incidence rate of 497 injuries per 1000 children. Commonest injuries were cuts, bites or open wounds (30.6%) and bruises or superficial injuries (28.6%) with majority (75.5%) occurring at home. Boys were more likely to be injured at school (AOR 4.34; 95% CI 1.22-15.54) and to be injured from falls (AOR 1.41; 95% CI 1.01-1.96). Older children (12-18 years) were more likely to suffer from fractures (AOR 2.37; 95% CI 1.26-4.43), concussions and organ system injuries (AOR 3.58; 95% CI 1.03-12.39) and cuts, bites or open wounds (AOR 2.05; 95% CI 1.21-3.48). Older children were less likely to suffer burns or scalds as compared to the young children (AOR: 0.23; 95% CI 0.11-0.50). Unintentional injury incidence rate was high among children with most occurring in the homes.

BACKGROUND There is need for more timely data to inform interventions that address the growing noncommunicable disease (NCD) epidemic. With a global increase in mobile phone ownership, mobile phone surveys can bridge this gap. OBJECTIVE This study aimed to explore the acceptability and use of interactive voice response (IVR) surveys for surveillance of NCD behavioral risk factors in rural Uganda. METHODS This qualitative study employed user group testing (UGT) with community members. The study was conducted at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Eastern Uganda. We conducted four UGTs which consisted of different categories of HDSS members: females living in urban areas, males living in urban areas, females living in rural areas, and males living in rural areas. Participants were individually sent an IVR survey, then were brought in for a group discussion using a semistructured guide. Data were analyzed thematically using directed content analysis. RESULTS Participants perceived that IVR surveys may be useful in promoting confidentiality, saving costs, and raising awareness on NCD behavioral risk factors. Due to the clarity and delivery of questions in the local language, the IVR survey was perceived as easy to use. Community members suggested scheduling surveys on specific days and sending reminders as ways to improve their use for surveillance. Social issues such as domestic violence and perceptions toward unknown calls, technological factors including poor network connections and inability to use phones, and personal issues such as lack of access to phones and use of multiple networks were identified as barriers to the acceptability and use of mobile phone surveys. However, incentives were reported to motivate people to complete the survey. CONCLUSIONS Community members reflected on contextual and sociological implications of using mobile phones for surveillance of NCD behavioral risk factors. The opportunities and challenges that affect acceptability and use of IVR surveys should be considered in designing and implementing surveillance programs for NCD risk factors.

Background Many patients with epilepsy in sub-Saharan Africa do not receive adequate treatment. The purpose of the study was to identify the health care providers where patients with epilepsy sought care and what treatment they received. Methods A cross sectional study was conducted across 87 out of 312 villages in Masindi district. A total of 305 households having patients with epilepsy were surveyed using an interviewer administered questionnaire. Data was entered and analysed in Epi-info ver 7 for univariate and bivariate analysis, and in Stata SE ver 15.0 for multivariable analysis. Sequences of health providers consulted in care seeking, rationale and drugs used, and factors associated with choice of provider were assessed. Results A total of 139 out of 305 (45.6%) households offered some treatment regimen at home when patients got symptoms of epilepsy with 44.6% (62/139) giving herbs and 18.0% (25/139) offering prayers. Eight different types of providers were consulted as first contact providers for treatment of epilepsy. Health centres received the highest percentage 35.4% (108/305) followed by hospitals 20.9% (64/305). A total of 192 of 305 (63.0%) households received anti-epileptic drugs, 13.1% (40/305) received prayers and 21.6% (66/305) received herbs at the first contact care seeking. Compared to a health centre as the first choice provider, other facilities more significantly visited were; hospitals if they were perceived as nearer (adj. Coeff 2.16, 95%CI 0.74, 3.59, p = 0.003), churches / mosques if cure for epilepsy was expected (adj. Coeff 1.91, 95%CI 0.38, 3.48, p = 0.014), and traditional healer for those aged ≥46 years (adj. Coeff 5.83, 95%CI 0.67, 10.99, p = 0.027), and friends/neighbour for traders (adj. Coeff 2.87, 95%CI 0.71, 5.04, p = 0.009). Conclusion Patients with epilepsy seek treatment from multiple providers with the public sector attending to the biggest proportion of patients. Engaging the private sector and community health workers, conducting community outreaches and community sensitization with messages tailored for audiences including the young, older epileptics, traditional healers as stakeholders, and traders could increase access to appropriate treatment for epilepsy.

This article explores the history and evolution of Environmental Health in Uganda under four key themes: training and practice; research; governance, policy and regulatory framework; and challenges. The article also describes the future of the profession. Through a review of documents and key informant interviews, it is noted that Environmental Health in Uganda dates back to colonial times when the country was affected by diseases including plague, trypanosomiasis and small pox. Concerted efforts were advanced to train cadres that would improve the sanitation status and address the prevailing disease burden. Over several decades, the Environmental Health profession has evolved in many areas of training, practice, research and governance, policy and legal framework amidst several challenges. The future of Environmental Health in Uganda will require more advanced training and research, broadened practice, and streamlined governance.

Background Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. Methods The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. Results Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. Conclusion The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

Due to increasing urbanization, many people find themselves living in slums that expose them to several health risks. We explored urban health risks that fall short of the planetary boundaries in an urban slum in Kampala, Uganda using photovoice. We selected, trained, and assigned ten youth (five females and five males) to take photos on urban health risks. The photographs were discussed, and transcripts were analyzed based on the doughnut economics model using content analysis in NVivo 12. Environments and actions of slum dwellers expose them to health risks, and cause them to live at the edge of planetary boundaries. Environmental sanitation challenges, including solid and liquid waste management, excreta management, and food hygiene and safety expose slum dwellers to risks at the edge of the lower boundary of the planet. Urban conditions expose slum dwellers to poor physical infrastructure, undesirable work conditions, pollution, and health and safety challenges. Crime, violence, and substance use were also viewed as vices that make slum environments dangerous habitats. On the other hand, practices like inhabiting wetlands and using biomass fuels in addition to traffic fumes expose slum dwellers to effects associated with living above the planetary boundaries. Urban youth reflected on health risks that have immediate effects on their health and day-to-day living. Urbanization, especially in low resource settings, needs to be cognizant of the ensuing risks to health and thus ensure sustainable growth.

It was otherwise an unremarkable November bus ride from Antwerp to Montreux; cold, but in the rather warm company of early career researchers who were to soon become the first cohort of Emerging Voices for Global Health (EV4GH; http://www.ev4gh.net). On that ride, 52 early career health system researchers from 30 countries began a journey. Little did they know it would continue for over a decade, gathering in its wake, 208 more early career researchers from 60 countries, overwhelmingly from the global south. The EV4GH programme has come a long way, from the first meeting at the 2010 annual colloquium of Institute of Tropical Medicine, Antwerp, Belgium, and the subsequent road trip from Antwerp to the first Global Symposium on Health Systems Research at Montreux, Switzerland. EV4GH began as a leadership and capacity-building programme incubated within the Institute of Tropical Medicine, Antwerp (ITM-A) by a team led by Professor Wim Van Damme. With an explicit commitment to switching the poles (between the global north to the global south), the team at ITM-A sought to design a unique programme to provide early career researchers with communication skills to critically examine global health agendas and events, and more importantly to not become passive consumers of evidence in global health events (such as the one that was, at the time, coming up in Montreux). This was a disruptive idea. Early career researchers typically enter global events in awe of the authoritative and prominent names featured in keynotes and panels. Indeed, the first EV4GH programme began by acknowledging the elderly white male high-income country dominance of the global health agenda. The programme wanted to do something about it, beginning at that first symposium in Montreux. This year, 2020, marks the 10th year of this programme and offers an opportunity to look back and look within. …

Unintentional injuries cause deaths, disabilities, productivity and financial losses and disproportionately affect children in low-income settings yet their cost remains under studied. This study determined the household out-of-pocket expenditure and missed school attendance due to unintentional childhood injuries in a Ugandan slum. We used a cross-sectional household survey design. Data were collected on occurrence and associated costs of unintentional injuries during a one-year period from July 2014 to June 2015. A total of 706 (44.7%) children who had suffered from injuries were reported in the one year period. More male children (N = 415, 58.7%) suffered injuries than females (N = 291, 41.2%). The average out-of-pocket expenditure on treating an injury was US $24.1 [standard deviation (SD) = ±$62.8] and mean school days lost were 25 days (SD = ±51.8). Road traffic injuries (RTIs) resulted in higher costs [mean difference was US $51.1 (95% CI: $11.4-$90.8)] compared to injuries that, for example, occurred at school. In a Ugandan slum community, unintentional childhood injuries resulted in high out-of-pocket expenditures and missed school attendance. The costs varied widely depending on external causes of the injury. These findings highlight the need to invest in population level injury prevention interventions to reduce injury costs by households.

Introduction Unintentional injuries burden communities’ worldwide causing deaths, disability, productivity and financial losses and disproportionately affect children in low-income settings but their cost on communities remains under studied. This study aimed to determine direct and indirect costs of unintentional childhood injuries in a resource deprived community. Methods We used a cross-sectional household survey design in Kasubi, a Kampala city slum. We collected data on occurrence and associated costs for a one-year period from July 2014 to June 2015. Data was entered in Epidata 3.02 and analyzed in Stata 13.0 statistical software. Descriptive and bivariate analysis were conducted to identify risk factors for injury, cost-estimates of injuries by severity, cause and nature. Results A total of 706 (44.7%) children who had suffered from injuries were reported in the one year period. More male children, (n=415, 58.7%) suffered injuries than females (n=291, 41.2%). The average out-of-pocket expenditure on treating an injury was US $24.1 (standard deviation [SD]=±$62.8) and mean school days lost was 25.1 days (SD=±51.8). Road traffic injuries (RTIs) resulted in higher costs (mean difference was US $51.1 (95% CI: $11.4 to $90.8) compared to injuries that occurred at school. Also, road traffic related injuries (mean difference=39.4; 95% CI: 13.1 to 65.7) resulted in significantly more school days lost compared to falls. Conclusion In a slum community within Uganda, unintentional childhood injuries resulted in high out-of-pocket expenditures and missed school attendance and the cost varied widely amongst the cases. These findings highlight the need to invest in population level injury prevention interventions to reduce household expenditure by poor households on injury treatment.

Introduction Childhood unintentional injuries remain understudied. This assessed the incidence and characteristics of all unintentional injuries among children aged 18 years and below in a slum community in Uganda. Methods A cross-sectional survey was conducted among households in a slum community using a semi-structured interviewer-administered questionnaire. Incidence of unintentional injuries in children Results Out of 1583 children in the 422 surveyed households, 44.6% (706/1583) had suffered from at least one unintentional injury yielding an annual incidence rate of 446 per 1000 children. Cuts, animal bites or open wounds 30.6% (185/608), and bruises or superficial injuries 28.6% (174/608) were the commonest injuries. Majority of injuries occurred at home, 75.5% (459/608). Falls 56.7% (345/608) and playing or recreation 83.6% (508/608) were the leading cause and activity at time of injury respectively. Boys were significantly more likely to be injured at school (AOR 4.34; 95% CI 1.22–15.54) and to be injured from falls (AOR 1.41; 95% CI 1.01–1.96), as compared to girls. Older children (12–18 years) were more likely to suffer from fractures (AOR 2.37; 95% CI 1.26–4.43) concussions and organ system injuries (AOR 3.58; 95% CI 1.–3 – 12.39) and cuts, bites or open wounds (AOR 2.05; 95% CI 1.21–3.48) as compared to younger children. Older children were less likely to have burns or scalds as compared to the youngest children (AOR: 0.23; 95% CI 0.11 to 0.50). Conclusions Unintentional injury incidence rate was high among children with most occurring in the homes. Injury prevention interventions should aim at creating safe playing spaces for children and developing awareness programs about injury prevention.

This study was aimed at assessing prevalence, circumstance, and management of acute pesticide poisoning in hospitals in Kampala. It was a retrospective cross-sectional study that involved reviewing of 739 poisoning patient records from 5 hospitals in Kampala. Of the 739 patients, 212 were due to pesticide poisoning resulting in a prevalence of 28.8%. About 91.4% (191/210) of the cases were due to organophosphate poisoning, 63.3% (133/210) were intentional, and 98.1% (206/210) were exposed through ingestion. Diagnosis was majorly based on poisoning history 91.2% (187/205), and clinical features such as airways, breathing, and circulation examination 48.0% (95/198); nausea and vomiting 42.9% (91/212); muscle weakness 29.7% (63/212); excessive salivation 23.1% (49/212); and confusion 20.3% (43/212). More than half of the patients admitted were treated using atropine 52.3% (113/212). The prevalence of acute pesticide poisoning was high with most managed based on physical and clinical examination.

Pesticide poisoning is a significant burden on health care systems in many low-income countries. This study evaluates cases of registered pesticide poisonings treated in selected rural (N = 101) and urban (N = 212) health facilities in Uganda from January 2010 to August 2016. In the urban setting, pesticides were the most prevalent single poison responsible for intoxications (N = 212 [28.8%]). Self-harm constituted a significantly higher proportion of the total number of poisonings in urban (63.3%) compared with rural areas (25.6%) where unintentional poisonings prevailed. Men were older than women and represented a majority of around 60% of the cases in both the urban and rural settings. Unintentional cases were almost the only ones seen below the age of 10, whereas self-harm dominated among adolescents and young persons from 10 to 29 years of age. Organophosphorus insecticides accounted for 73.0% of the poisonings. Urban hospitals provided a more intensive treatment and had registered fever complications than rural health care settings. To minimize self-harm with pesticides, a restriction of pesticide availability as shown to be effective in other low-income countries is recommended. Training of health care workers in proper diagnosis and treatment of poisonings and improved equipment in the health care settings should be strengthened.

Introduction: tungiasis is an endemic but neglected health problem in Uganda especially in resource poor communities. It is largely affecting rural communities in the Eastern, West Nile and Central regions. This study assessed prevalence and risk factors associated with tungiasis in Mayuge district, Eastern Uganda. Methods: this was a cross sectional study that used a semi-structured questionnaire and observational checklist to collect quantitative data from 422 households in 12 villages. Prevalence of tungiasis was defined as presence of Tunga penetrans in the skin of any household member at the time of data collection. Results: the prevalence of tungiasis was 22.5%. However, a big percentage 41.5% of households were reported to have had T. penetrans in the previous month while 49.5% had T. penetrans for more than one month. Majority (90.5%)of the participants used a pin, needle, or thorn to remove sand flea from infected body parts. Having dirty feet (AOR 3.86, CI (1.76-8.34)), dirty clothes (AOR 3.46, CI (2.00-5.97)), cracked house floor (AOR =6.28, CI (3.28-12.03)),dirty floor (AOR 3.21, CI (1.38-7.46)), littered compounds (AOR= 2.95, CI (1.66-5.26)) and rearing cattle (AOR 2.38, CI (1.28-4.45)) were associated with tungiasis. However, practicing preventive measures (AOR 0.51, CI (0.29-0.90)) was found protective for disease. Conclusion: tungiasis is still a prevalent health problem in rural communities in Eastern Uganda due to a number of individual (host) and environmental factors. There is need to increase awareness regarding improvement in sanitation and hygiene to enable communities' implements interventions for prevention of T. penetrans.The Pan African Medical Journal 2016;24

Objective. To assess the bacteriological and physical quality of locally packaged drinking water sold for public consumption.Methods. This was cross-sectional study where a total of 60 samples of bottled water from 10 brands and 30 samples of sachet water from 15 brands purchased randomly were analyzed for bacteriological contamination (total coliform and faecal coliform per 100 mL) using membrane filtrate method and reported in terms of cfu/100 mL.Results. Both bottled water and sachet water were not contaminated with faecal coliform. Majority (70%, 21/30) of the sachet water analyzed exceeded acceptable limits of 0 total coliforms per 100 mL set by WHO and the national drinking water standards. The physical quality (turbidity and pH) of all the packaged water brands analyzed was within the acceptable limits. There was statistically significant difference between the median count of total coliform in both sachet water and bottled water brands (U(24)=37.0,p=0.027).Conclusion. Both bottled water and sachet water were not contaminated with faecal coliforms; majority of sachet water was contaminated with total coliform above acceptable limits. Government and other stakeholders should consider intensifying surveillance activities and enforcing strict hygienic measures in this rapidly expanding industry to improve packaged water quality.