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Joan Tusabe,1 Herbert Muyinda,2 Joanita Nangendo,3 Doris Kwesiga,4 Sherifah Nabikande,4 Michael Muhoozi,1 Winnie Agwang,4 Tom Okello,3 Elizeus Rutebemberwa4 1Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda; 2Child Health and Development Center, School of Medicine Makerere University, Kampala, Uganda; 3Clinical epidemiology Unit, School of Medicine, Makerere University, Kampala, Uganda; 4Department of Health Policy, Planning and Management, School of public health, Makerere University, Kampala, UgandaCorrespondence: Joan Tusabe, Email jtusab@gmail.comIntroduction: We asseSssed factors influencing the uptake of voluntary medical male circumcision (VMMC) among boda-boda riders aged 18– 49 years in Hoima, western Uganda. Despite high levels of awareness about availability and benefits of VMMC, uptake was still low.Methods: We employed the convergent parallel mixed methods design among boda-boda riders in Hoima district between August and September 2020. We administered a structured questionnaire to 316 boda-boda riders to determine factors associated with uptake of VMMC. We also conducted eight focus group discussions (FGDs) and six key informant interviews (KIIs) to explore perceptions of VMMC. To determine factors associated with VMMC, we conducted modified Poisson regression analysis at 5% level of significance. We identified sociocultural barriers and facilitators for VMMC using thematic content analysis.Results: Uptake of VMMC was at 33.9% (95% CI 28.6– 39.1) and was associated with higher level of education, adjusted prevalence ratio (APR) 1.63, (95% CI 1.12– 2.40); concern about being away from work, APR 0.66 (95% CI 0.49– 0.88); and the belief that VMMC does not diminish sexual performance, APR 1.78 (95% CI 1.08– 2.9). Facilitators of uptake of VMMC were health education and awareness creation, improved penile hygiene, and perceived sexual functioning; and reduced chances of HIV and sexually transmitted infections (STIs). On the other hand, the barriers to uptake were fear of pain and compulsory HIV testing, healing duration, financial loss during the healing period, fear of sexual misbehavior after circumcision, interruption of God’s creation, and fear of loss of male fertility.Conclusion: Although VMMC is largely perceived as protective against HIV and other STIs, deliberate measures using multiple strategies should be put in place to address the barriers to its uptake among this key population.Keywords: voluntary medical male circumcision, men aged 18– 49 years, Western Uganda

Conrad Musinguzi,1 Leticia Namale,1 Elizeus Rutebemberwa,2 Aruna Dahal,1 Patricia Nahirya-Ntege,1 Adeodata Kekitiinwa1 1Directorate of Health Systems Strengthening, Baylor College of Medicine Children’s Foundation, Kampala, Uganda; 2Department of Health Policy, Planning and Management, School of Public Health Uganda, College of Health Sciences, Makerere University, Kampala, Uganda Background: Leadership is key to strengthening performance of Health Systems. Leadership styles are important organizational antecedents, especially in influencing employee’s motivation, job satisfaction, and teamwork. There is limited research exploring this relationship among health workers in resource-limited settings such as Uganda. The aim of this study was to examine the relationship between transformational, transactional, and laissez-faire leadership styles and motivation, job satisfaction, and teamwork of health workers in Uganda. Method: We conducted a cross-sectional study in 3 geographic regions of Uganda in November 2015, using self-administered questionnaires with 564 health workers from 228 health facilities. Data were collected on health workers’ perception of leadership styles displayed by their facility leaders, their level of motivation, job satisfaction, and team work. Using Pearson correlation, relationships among variables were identified and associations of the components of leadership styles with motivation, job satisfaction, and teamwork was found using multivariable logistic regression. Results: Health workers in Uganda preferred leaders who were transformational (62%) compared with being transactional (42%) or laissez-faire (14%). Transformational leadership was positively correlated with motivation (r=0.32), job satisfaction (r=0.38), and team work (r=0.48), while transactional leadership was positively correlated with job satisfaction (r=0.21) and teamwork (r=0.18). Motivation was positively associated with leaders who displayed idealized influence-behavior (odds ratio [OR]=3.7; 95% CI, 1.33–10.48) and intellectual stimulation (OR=2.4; 95% CI, 1.13–5.15) but negatively associated with management by exception (OR=0.4; 95% CI, 0.19–0.82). Job satisfaction was positively associated with intellectual stimulation (OR=5.7; 95% CI, 1.83–17.79). Teamwork was positively associated with idealized influence-behavior (OR=1.07–8.57), idealized influence-attributed (OR=3.9; 95% CI, 1.24–12.36), and contingent reward (OR=5.6; 95% CI, 1.87–17.01). Conclusion: Transformational styles had a positive impact on stimulating motivation, assuring job satisfaction, and consolidating teamwork among health workers compared with those who demonstrated transactional skills or laissez-faire styles. Recommendation: Supporting transformational leadership skills development in health facility leaders could encourage health worker motivation, strengthen job satisfaction, and maintain cohesion among health workers for better service delivery. Keywords: transformational leadership, transactional leadership, laissez-faire leadership, motivation, job satisfaction, teamwork

Angela N Kisakye,1 Raymond Tweheyo,1 Freddie Ssengooba,1 George W Pariyo,2 Elizeus Rutebemberwa,1 Suzanne N Kiwanuka1 1Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda; 2Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Background: A systematic review was undertaken to identify regulatory mechanisms aimed at mitigating health care worker absenteeism, to describe where and how they have been implemented as well as their possible effects. The goal was to propose potential policy options for managing the problem of absenteeism among human resources for health in low- and middle-income countries. Mechanisms described in this review are at the local workplace and broader national policy level. Methods: A comprehensive online search was conducted on EMBASE, CINAHL, PubMed, Google Scholar, Google, and Social Science Citation Index using MEDLINE search terms. Retrieved studies were uploaded onto reference manager and screened by two independent reviewers. Only publications in English were included. Data were extracted and synthesized according to the objectives of the review. Results: Twenty six of the 4,975 published articles retrieved were included. All were from high-income countries and covered all cadres of health workers. The regulatory mechanisms and possible effects include 1) organizational-level mechanisms being reported as effective in curbing absenteeism in low- and middle-income countries (LMICs); 2) prohibition of private sector activities in LMICs offering benefits but presenting a challenge for the government to monitor the health workforce; 3) contractual changes from temporary to fixed posts having been associated with no reduction in absenteeism and not being appropriate for LMICs; 4) multifaceted work interventions being implemented in most settings; 5) the possibility of using financial and incentive regulatory mechanisms in LMICs; 6) health intervention mechanisms reducing absenteeism when integrated with exercise programs; and 7) attendance by legislation during emergencies being criticized for violating human rights in the United States and not being effective in curbing absenteeism. Conclusion: Most countries have applied multiple strategies to mitigate health care worker absenteeism. The success of these interventions is heavily influenced by the context within which they are applied. Keywords: absenteeism, health workers, regulatory mechanisms, systematic review

Abstract Background Geographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies. Most public health interventions in Uganda have addressed only selected supply side issues, and universities have focused their efforts on providing maternal services at tertiary hospitals. To demonstrate how reforms at Makerere University College of Health Sciences (MakCHS) can lead to making systemic changes that can improve maternal health services, a demand and supply side strategy was developed by working with local communities and national stakeholders. Methods This quasi-experimental trial is conducted in two districts in Eastern Uganda. The supply side component includes health worker refresher training and additions of minimal drugs and supplies, whereas the demand side component involves vouchers given to pregnant women for motorcycle transport and the payment to service providers for antenatal, delivery, and postnatal care. The trial is ongoing, but early analysis from routine health information systems on the number of services used is presented. Results Motorcyclists in the community organized themselves to accept vouchers in exchange for transport for antenatal care, deliveries and postnatal care, and have become actively involved in ensuring that women obtain care. Increases in antenatal, delivery, and postnatal care were demonstrated, with the number of safe deliveries in the intervention area immediately jumping from Conclusions Transport and service vouchers appear to be a viable strategy for rapidly increasing maternal care. MakCHS can design strategies together with stakeholders using a learning-by-doing approach to take advantage of community resources.

Abstract Background While there are biomedical drugs for managing diabetes mellitus, some patients with diabetes use traditional medicine. The aim of the study was to explore why patients with diabetes use traditional medicine for the treatment of diabetes. Methods The study was conducted in Iganga and Bugiri districts in Eastern Uganda using four focus group discussions (FGDs) with patients with diabetes; two with female patients and two with male patients, thirteen key informant interviews (KIIs); nine with health workers working with patients with diabetes and four with herbalists. FGDs and KIIs focused on what respondents perceived as reasons for patients with diabetes taking traditional medicine. Analysis was done using content analysis. Results Reasons for taking traditional medicine included finding difficulties accessing hospitals, diabetic drugs being out of stock, traditional medicine being acceptable and available within community, as well as being supplied in big quantities. Others were traditional medicine being cheaper than biomedical treatment and payment for it being done in installments. Traditional medicine was also more convenient to take and was marketed aggressively by the herbalists. Influence of family and friends as well as traditional healers contributed to use of traditional medicine. Conclusions Possibilities of putting diabetic drugs at facilities closer to patients need to be considered and health facilities should have a constant supply of diabetic drugs. Community members need to be sensitized on the proper treatment for diabetes mellitus and on the dangers of taking traditional medicine.

Abstract Background Curative interventions delivered by community health workers (CHWs) were introduced to increase access to health services for children less than five years and have previously targeted single illnesses. However, CHWs in the integrated community case management of childhood illnesses strategy adopted in Uganda in 2010 will manage multiple illnesses. There is little documentation about the performance of CHWs in the management of multiple illnesses. This study compared the performance of CHWs managing malaria and pneumonia with performance of CHWs managing malaria alone in eastern Uganda and the factors influencing performance. Methods A mixed methods study was conducted among 125 CHWs providing either dual malaria and pneumonia management or malaria management alone for children aged four to 59 months. Performance was assessed using knowledge tests, case scenarios of sick children, review of CHWs’ registers, and observation of CHWs in the dual management arm assessing respiratory symptoms. Four focus group discussions with CHWs were also conducted. Results CHWs in the dual- and single-illness management arms had similar performance with respect to: overall knowledge of malaria (dual 72%, single 70%); eliciting malaria signs and symptoms (50% in both groups); prescribing anti-malarials based on case scenarios (82% dual, 80% single); and correct prescription of anti-malarials from record reviews (dual 99%, single 100%). In the dual-illness arm, scores for malaria and pneumonia differed on overall knowledge (72% vs 40%, p vs 96%, p Conclusion CHWs providing dual-illness management handled malaria cases as well as CHWs providing single-illness management, and also performed reasonably well in the management of pneumonia. With appropriate training that emphasizes pneumonia assessment, adequate supervision, and provision of drugs and necessary supplies, CHWs can provide integrated treatment for malaria and pneumonia.

Abstract Background The proportion of Ugandan children who are fully vaccinated has varied over the years. Understanding vaccination behaviour is important for the success of the immunisation programme. This study examined influences on immunisation behaviour using the attitude-social influence-self efficacy model. Methods We conducted nine focus group discussions (FGDs) with mothers and fathers. Eight key informant interviews (KIIs) were held with those in charge of community mobilisation for immunisation, fathers and mothers. Data was analysed using content analysis. Results Influences on the mother's immunisation behaviour ranged from the non-supportive role of male partners sometimes resulting into intimate partner violence, lack of presentable clothing which made mothers vulnerable to bullying, inconvenient schedules and time constraints, to suspicion against immunisation such as vaccines cause physical disability and/or death. Conclusions Immunisation programmes should position themselves to address social contexts. A community programme that empowers women economically and helps men recognise the role of women in decision making for child health is needed. Increasing male involvement and knowledge of immunisation concepts among caretakers could improve immunisation.

Abstract Background Community members are stakeholders in hospitals and have a right to participate in the improvement of quality of services rendered to them. Their views are important because they reflect the perspectives of the general public. This study explored how communities that live around hospitals pass on their views to and receive feedback from the hospitals' management and administration. Methods The study was conducted in eight hospitals and the communities around them. Four of the hospitals were from three districts from eastern Uganda and another four from two districts from western Uganda. Eight key informant interviews (KIIs) were conducted with medical superintendents of the hospitals. A member from each of three hospital management boards was also interviewed. Eight focus group discussions (FGDs) were conducted with health workers from the hospitals. Another eight FGDs (four with men and four with women) were conducted with communities within a five km radius around the hospitals. Four of the FGDs (two with men and two with women) were done in western Uganda and the other four in eastern Uganda. The focus of the KIIs and FGDs was exploring how hospitals communicated with the communities around them. Analysis was by manifest content analysis. Results Whereas health unit management committees were supposed to have community representatives, the representatives never received views from the community nor gave them any feed back from the hospitals. Messages through the mass media like radio were seen to be non specific for action. Views sent through suggestion boxes were seen as individual needs rather than community concerns. Some community members perceived they would be harassed if they complained and had reached a state of resignation preferring instead to endure the problems quietly. Conclusion There is still lack of effective communication between the communities and the hospitals that serve them in Uganda. This deprives the communities of the right to participate in the improvement of the services they receive, to assume their position as stakeholders. Various avenues could be instituted including using associations in communities, rapid appraisal methods and community meetings.

Abstract Background Community distribution of anti-malarials and antibiotics has been recommended as a strategy to reduce the under-five mortality due to febrile illnesses in sub-Saharan Africa. However, drugs distributed in these interventions have been considered weak by some caretakers and utilization of community medicine distributors has been low. The aim of the study was to explore caretakers' use of drugs, perceptions of drug efficacy and preferred providers for febrile children in order to make suggestions for community management of pneumonia and malaria. Methods The study was conducted in eastern Uganda using four focus group discussions with fathers and mothers of children under five; and eight key informant interviews with health workers in government and non-governmental organization facilities, community medicine distributors, and attendants in drug shops and private clinics. Caretakers were asked the drugs they use for treatment of fever, why they considered them efficacious, and the providers they go to and why they go there. Health providers were interviewed on their opinions of caretakers' perceptions of drugs and providers. Analysis was done using content analysis. Results Drugs that have been phased out as first-line treatment for malaria, such as chloroquine and sulphadoxine/pyrimethamine, are still perceived as efficacious. Use of drugs depended on perception of the disease, cost and drug availability. There were divergent views about drug efficacy concerning drug combinations, side effects, packaging, or using drugs over time. Bitter taste and high cost signified high efficacy for anti-malarials. Government facilities were preferred for conducting diagnostic investigations and attending to serious illnesses, but often lacked drugs and did not treat people fast. Drug shops were preferred for having a variety of drugs, attending to clients promptly and offering treatment on credit. However, drug shops were considered disadvantageous since they lacked diagnostic capability and had unqualified providers. Conclusion Community views about drug efficacy are divergent and some may divert caretakers from obtaining efficacious drugs for febrile illness. Interventions should address these perceptions, equip community medicine distributors with capacity to do diagnostic investigations and provide a constant supply of drugs. Subsidized efficacious drugs could be made available in the private sector.

Abstract Background Despite investments in providing free government health services in Uganda, many caretakers still seek treatment from the drug shops/private clinics. The study aimed to assess determinants for use of government facilities or drug shops/private clinics for febrile illnesses in children under five. Methods Structured questionnaires were administered to caretakers in 1078 randomly selected households in the Iganga – Mayuge Demographic Surveillance site. Those with children who had had fever in the previous two weeks and who had sought care from outside the home were interviewed on presenting symptoms and why they chose the provider they went to. Symptoms children presented with and reasons for seeking care from government facilities were compared with those of drug shops/private clinics. Results Of those who sought care outside the home, 62.7% (286/456) had first gone to drug shops/private clinics and 33.1% (151/456) first went to government facilities. Predictors of having gone to government facilities with a febrile child were child presenting with vomiting (OR 2.07; 95% CI 1.10 – 3.89) and perceiving that the health providers were qualified (OR 10.32; 95% CI 5.84 – 18.26) or experienced (OR 1.93; 95% CI 1.07 – 3.48). Those who took the febrile child to drug shops/private clinics did so because they were going there to get first aid (OR 0.20; 95% CI 0.08 – 0.52). Conclusion Private providers offer 'first aid' to caretakers with febrile children. Government financial assistance to health care providers should not stop at government facilities. Multi-faceted interventions in the private sector and implementation of community case management of febrile children through community medicine distributors could increase the proportion of children who access quality care promptly.

Abstract Background Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach. Methods The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest. Results The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with. Conclusion Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services.

Background: Lower-level urban private-for-profit health service providers are actively engaged in the delivery of immunization services. However, not much is known about their everyday endeavours to improve data quality and ensure the submitted data meets the quality and timeliness requirements as per established guidelines. The objective of this paper was to examine the coping mechanisms and strategies adopted to improve the quality and timeliness of immunization data among lower-level private-for-profit service providers in Kampala Capital City, Uganda., Methods: A qualitative study design was adopted with in-depth interviews (n = 17) and key informant interviews (n = 8) completed among frontline health workers, district health managers and immunization implementing partners. Analysis followed a thematic approach with coding conducted using Atlas. ti, a qualitative data management software., Results: Overall, coping mechanisms and strategies adopted to improve the data quality among lower-level urban private-for-profit immunization service providers included; Experiential attachment for practical skills acquisition in data management, data quality peer-to-peer learning among private-for-profit immunization service providers, registration using cohort system for easy tracking of records during subsequent visits, separation of visiting service user records from regular attendants, service delivery modifications such as reward for better performance, engagement of Village Health Teams (VHTs) in outreaches and data completion, and data quality checks through review of monitoring charts to identify gaps in data quality., Conclusions: Within the urban context, the delivery of immunization services by lower-level private-for-profit services faces data quality challenges some of which stem from the implementation context. Different coping strategies focusing on frontline health worker skills, enhanced experience sharing through peer-to-peer learning, modifications to registration and routine review of monitoring charts. However, these efforts were often faced with chronic barriers such as the high staff turnover calling for dedicated efforts to optimize the available implementation opportunities like guidelines mandating the public health facilities to supervise the lower-level private immunization service providers within their catchment areas to respond to the identified gaps., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ssegujja et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The German Biosecurity Programme was launched in 2013 with the aim to support partner countries overcome biological threats including natural outbreaks or the intentional misuse of highly pathogenic agents. As part of this programme, this paper describes the development and implementation of a multilateral biosafety and biosecurity training initiative, called 'Global Partnership Initiated Biosecurity Academia for Controlling Health Threats' (GIBACHT). To achieve its objectives, GIBACHT implemented a blended-learning approach with self-directed, distance-based learning phases and three training-of-trainer workshops. The programme follows Kirkpatrick's model of learning to guarantee sustainable effects of improved knowledge and skills. One hundred nine fellows from 26 countries have been trained in seven cohorts. Many GIBACHT alumni have established additional biosafety/biosecurity trainings in their home countries. The knowledge exchange is strengthened by the implementation of a Moodle-based alumni network. GIBACHT has the potential to contribute to strengthening the capacities of partner countries in Africa, the Middle East, and South and Central Asia to respond and build resilience to biological threats., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Mertens, Zimmermann, Dywicki, Lee, Pelikan, Bürkin, Rutebemberwa and Hoffmann.)

Background: Subclinical pulmonary tuberculosis, which presents without recognisable symptoms, is frequently detected in community screening. However, the disease category is poorly clinically defined. We explored the prevalence of subclinical pulmonary tuberculosis according to different case definitions., Methods: We did a one-stage individual participant data meta-analysis of nationally representative surveys that were conducted in countries with high incidence of tuberculosis between 2007 and 2020, that reported the prevalence of pulmonary tuberculosis based on chest x-ray and symptom screening in participants aged 15 years and older. Screening and diagnostic criteria were standardised across the surveys, and tuberculosis was defined by positive Mycobacterium tuberculosis sputum culture. We estimated proportions of subclinical tuberculosis for three case definitions: no persistent cough (ie, duration ≥2 weeks), no cough at all, and no symptoms (ie, absence of cough, fever, chest pain, night sweats, and weight loss), both unadjusted and adjusted for false-negative chest x-rays and uninterpretable culture results., Findings: We identified 34 surveys, of which 31 were eligible. Individual participant data were obtained and included for 12 surveys (620 682 participants) across eight countries in Africa and four in Asia. Data on 602 863 participants were analysed, of whom 1944 had tuberculosis. The unadjusted proportion of subclinical tuberculosis was 59·1% (n=1149/1944; 95% CI 55·8-62·3) for no persistent cough and 39·8% (773/1944; 36·6-43·0) for no cough of any duration. The adjusted proportions were 82·8% (95% CI 78·6-86·6) for no persistent cough and 62·5% (56·6-68·7) for no cough at all. In a subset of four surveys, the proportion of participants with tuberculosis but without any symptoms was 20·3% (n=111/547; 95% CI 15·5-25·1) before adjustment and 27·7% (95% CI 21·0-36·4) after adjustment. Tuberculosis without cough, irrespective of its duration, was more frequent among women (no persistent cough: adjusted odds ratio 0·79, 95% CI 0·63-0·97; no cough: adjusted odds ratio 0·76, 95% CI 0·62-0·93). Among participants with tuberculosis, 29·1% (95% CI 25·2-33·3) of those without persistent cough and 23·1% (18·8-27·4) of those without any cough had positive smear examinations., Interpretation: The majority of people in the community who have pulmonary tuberculosis do not report cough, a quarter report no tuberculosis-suggestive symptoms at all, and a quarter of those not reporting any cough have positive sputum smears, suggesting infectiousness. In high-incidence settings, subclinical tuberculosis could contribute considerably to the tuberculosis burden and to Mycobacterium tuberculosis transmission., Funding: Mr Willem Bakhuys Roozeboom Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 World Health Organization. Published by Elsevier Ltd. All rights reserved. Published by Elsevier Ltd.. All rights reserved.)

In light of the suboptimal noncommunicable disease (NCD) risk factor surveillance efforts, the study's main objectives were to: (i) characterize the epidemiological profile of NCD risk factors; (ii) estimate the prevalence of hypertension; and (iii) identify factors associated with hypertension in a peri-urban and rural Ugandan population. A population-based cross-sectional survey of adults was conducted at the Iganga-Mayuge Health and Demographic Surveillance System site in eastern Uganda. After describing sociodemographic characteristics, the prevalence of NCD risk factors and hypertension was reported. Prevalence ratios for NCD risk factors were calculated using weighted Poisson regression to identify factors associated with hypertension. Among 3220 surveyed respondents (mean age: 35.3 years (standard error: 0.1), 49.4% males), 4.4% were current tobacco users, 7.7% were current drinkers, 98.5% had low fruit and vegetable consumption, 26.9% were overweight, and 9.3% were obese. There was a high prevalence of hypertension and prehypertension, at 17.1% and 48.8%, respectively. Among hypertensive people, most had uncontrolled hypertension, at 97.4%. When we examined associated factors, older age (adjusted prevalence ratio (APR): 3.1, 95% CI: 2.2-4.4, APR: 5.2, 95% CI: 3.7-7.3, APR: 8.9, 95% CI: 6.4-12.5 among 30-44, 45-59, and 60+-year-old people than 18-29-year-olds), alcohol drinking (APR: 1.6, 95% CI: 1.3-2.0, ref: no), always adding salt during eating (APR: 1.6, 95% CI: 1.1-2.2, ref: no), poor physical activity (APR: 1.3, 95% CI: 1.1-1.6, ref: no), overweight (APR: 1.3, 95% CI: 1.1-1.5, ref: normal weight), and obesity (APR: 2.0, 95% CI: 1.6-2.4, ref: normal weight) had higher prevalence of hypertension than their counterparts. The high prevalence of NCD risk factors highlights the immediate need to implement and scale-up population-level strategies to increase awareness about leading NCD risk factors in Uganda. These strategies should be accompanied by concomitant investment in building health systems capacity to manage and control NCDs., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gibson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The prevalence of non-communicable diseases (NCDs) is increasing in many low- and middle-income countries (LMICs). This study examined differences in the burden of NCDs and their risk factors according to geographic, sex, and sociodemographic characteristics in a rural and peri-urban community in Eastern Uganda. We compared the prevalence by sex, location, wealth, and education. Unadjusted and adjusted prevalence ratios (PR) were reported. Indicators related to tobacco use, alcohol use, salt consumption, fruit/vegetable consumption, physical activity, body weight, and blood pressure were assessed. Among 3220 people (53.3% males, mean age: 35.3 years), the prevalence of NCD burden differed by sex. Men had significantly higher tobacco (e.g., current smoking: 7.6% vs. 0.7%, adjusted PR (APR): 12.8, 95% CI: 7.4-22.3), alcohol use (e.g., current drinker: 11.1% vs. 4.6%, APR: 13.4, 95% CI: 7.9-22.7), and eat processed food high in salt (13.4% vs. 7.1, APR: 1.8, 95% CI: 1.8, 95% CI: 1.4-2.4) than women; however, the prevalence of overweight (23.1% vs 30.7%, APR: 0.7, 95% CI: 0.6-0.9) and obesity (4.1% vs 14.7%, APR: 0.3, 95% CI: 0.2-0.3) was lower among men than women. Comparing locations, peri-urban residents had a higher prevalence of current alcohol drinking, heavy episodic drinking, always/often adding salt while cooking, always eating processed foods high in salt, poor physical activity, obesity, prehypertension, and hypertension than rural residents (p<0.5). When comparing respondents by wealth and education, we found people who have higher wealth or education had a higher prevalence of always/often adding salt while cooking, poor physical activity, and obesity. Although the findings were inconsistent, we observed significant sociodemographic and socioeconomic differences in the burden of many NCDs, including differences in the distributions of behavioral risk factors. Considering the high burden of many risk factors, we recommend appropriate prevention programs and policies to reduce these risk factors' burden and future negative consequences., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Kibria et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs)., Objectives: The primary objective was to explore IRs' beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda.Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored., Materials and Methods: In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF., Results: Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated.Identified factors within skills domain involved IRs' clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs' understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited., Conclusion: Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others., Competing Interests: All authors declared no conflicts of interest, (© 2024 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Tuberculosis (TB) and non-communicable diseases (NCD) share predisposing risk factors. TB-associated NCD might cluster within households affected with TB requiring shared prevention and care strategies. We conducted an individual participant data meta-analysis of national TB prevalence surveys to determine whether NCD cluster in members of households with TB. We identified eligible surveys that reported at least one NCD or NCD risk factor through the archive maintained by the World Health Organization and searching in Medline and Embase from 1 January 2000 to 10 August 2021, which was updated on 23 March 2023. We compared the prevalence of NCD and their risk factors between people who do not have TB living in households with at least one person with TB (members of households with TB), and members of households without TB. We included 16 surveys (n = 740,815) from Asia and Africa. In a multivariable model adjusted for age and gender, the odds of smoking was higher among members of households with TB (adjusted odds ratio (aOR) 1.23; 95% CI: 1.11-1.38), compared with members of households without TB. The analysis did not find a significant difference in the prevalence of alcohol drinking, diabetes, hypertension, or BMI between members of households with and without TB. Studies evaluating household-wide interventions for smoking to reduce its dual impact on TB and NCD may be warranted. Systematically screening for NCD using objective diagnostic methods is needed to understand the actual burden of NCD and inform comprehensive interventions., Competing Interests: TSo declares a receipt of funding from the Global Fund for conducting the TB prevalence survey in Mongolia. All other authors declare no competing interests., (Copyright: © 2024 Hamada et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: This Delphi study intended to develop competencies for transformational leadership in public health, including behavioral descriptions (descriptors) tailored to individuals and their contexts. Methods: The study involved five rounds, including online "e-Delphi" consultations and real-time online workshops with experts from diverse sectors. Relevant competencies were identified through a literature review, and experts rated, ranked, rephrased, and proposed descriptors. The study followed the Guidance on Conducting and REporting DElphi Studies (CREDES) and the COmpeteNcy FramEwoRk Development in Health Professions (CONFERD-HP) reporting guidelines. Results: Our framework comprises ten competencies for transformational public health leadership (each with its descriptors) within four categories, and also describes a four-stage model for developing relevant competencies tailored to different contexts. Conclusion: Educators responsible for curriculum design, particularly those aiming to align curricula with local goals, making leadership education context-specific and -sensitive, may benefit from the proposed framework. Additionally, it can help strengthen links between education and workforce sectors, address competency gaps, and potentially reduce the out-migration of graduates in the health professions., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2024 Bürkin, Czabanowska, Babich, Casamitjana, Vicente-Crespo, De Souza, Ehrenberg, Hoffmann, Kamath, Matthiä, Okumu, Rutebemberwa, Waser, Kuenzli and Bohlius.)

Objective: To assess the uptake of services provided by community health workers who were trained as community health entrepreneurs (CHEs) for febrile illness and diarrhoea., Design: A cross-sectional survey among households combined with mapping of all providers of basic medicine and primary health services in the study area., Participants: 1265 randomly selected households in 15 rural villages with active CHEs., Setting: Bunyangabu district, Uganda., Outcome Measures: We describe the occurrence and care sought for fever and diarrhoea in the last 3 months by age group in the households. Care provider options included: CHE, health centre or clinic (public or private), pharmacy, drug shop and other. Geographic Information Ssystem (GIS)-based geographical measures were used to map all care providers around the active CHEs., Results: Fever and diarrhoea in the last 3 months occurred most frequently in children under 5; 68% and 41.9%, respectively. For those who sought care, CHE services were used for fever among children under 5, children 5-17 and adults over 18 years of age in 34.7%, 29.9% and 25.1%, respectively. For diarrhoea among children under 5, children 5-17 and adults over 18 years of age, CHE services were used in 22.1%, 19.5% and 7.0%, respectively. For those who did not seek care from a CHE (only), drug shops were most frequently used services for both fever and diarrhoea, followed by health centres or private clinics. Many households used a combination of services, which was possible given the high density and diversity of providers found in the study area., Conclusions: CHEs play a considerable role in providing care in rural areas where they are active. The high density of informal drug shops and private clinics highlights the need for clarity on the de facto roles played by different providers in both the public and private sector to improve primary healthcare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Nicotine replacement therapy (NRT) and short messaging service (SMS)-based tobacco cessation interventions have demonstrated effectiveness in reducing tobacco use in many populations, but evidence is needed on which tailored treatments are most efficacious in meeting the complex medical and psychosocial factors confronting people living with HIV (PLWH) in sub-Saharan Africa (SSA). This paper describes the protocol of a study to test the efficacy of both NRT and a tailored SMS-based tobacco use cessation intervention among PLWH in Uganda and Zambia., Methods: In a randomized controlled trial, 800 adult PLWH who use tobacco will be recruited by health care professionals at HIV treatment centers where they are receiving care. Participants will be randomized to one of the four study arms: (1) standard of care [SOC; brief clinician advice to quit combined with HIV education and information aimed at encouraging HIV treatment adherence (with no mention of tobacco) delivered via text messages]; (2) SOC + 12 weeks of NRT; (3) SOC + 6 weeks of SMS text messages to support quitting tobacco use (SMS); or (4) SOC + NRT + SMS. Participants will receive a cell phone and solar panel with power bank for charging the phone. The main outcome is cessation of tobacco use by study participants verified by urinary cotinine (< 15 ng/mL) at 6 months post-enrollment. As a secondary tobacco use outcome, we will measure 7-day point-prevalence abstinence (7 consecutive days of no tobacco use) measured by self-report and biochemically-verified at 4 weeks, 8 weeks, and 3 months post enrollment., Discussion: Our study will provide insight into the efficacy, feasibility and applicability of delivering tobacco cessation interventions through health care professionals combined with tailored tobacco cessation SMS text messaging in two countries with different tobacco use patterns, policy environments, and health care resources and provide needed information to providers and policymakers looking for cost-effective tobacco cessation interventions. The previously tested SMS-platform to be used in our study is uniquely positioned to be scaled in low- and middle-income countries worldwide, in which case evidence of even modest success in reducing the prevalence of tobacco consumption among PLWH could confer enormous health and economic benefits., Trial Registration: ClinicalTrials.gov Identifier NCT05487807. Registered August 4, 2022, https://clinicaltrials.gov/ct2/show/record/NCT05487807., (© 2024. The Author(s).)

Background: Few low- or middle-income countries (LMICs) have prioritized the expansion of rehabilitation services. Existing scholarship has identified that problem definition, governance, and structural factors are influential in the prioritization of rehabilitation. The objective of this study was to identify the factors influencing the prioritization and implementation of rehabilitation services in Uganda., Methods: A case study design was utilized. The Prioritization of Rehabilitation in National Health Systems framework guided the study. Data sources included 33 key informant interviews (KIIs) with governmental and non-governmental stakeholders and peer-reviewed and grey literature on rehabilitation in Uganda. A thematic content analysis and concept map were conducted to analyze the data., Results: Rehabilitation is an unfunded priority in Uganda, garnering political attention but failing to receive adequate financial or human resource allocation. The national legacy of rehabilitation as a social program, instead of a health program, has influenced its present-day prioritization trajectory. These include a fragmented governance system, a weak advocacy coalition without a unified objective or champion, and a lack of integration into existing health systems structures that makes it challenging to scale-up service provision. Our findings highlight the interactive influences of structural, governance, and framing factors on prioritization and the importance of historical context in understanding both prioritization and implementation., Conclusion: Our findings demonstrate challenges in prioritizing emerging, multi-sectoral health areas like rehabilitation. Strategic considerations for elevating rehabilitation on Uganda's policy agenda include generating credible indicators to quantify the nature and extent of the population's need and uniting governmental and non-governmental actors around a common vision for rehabilitation's expansion. We present opportunities for strengthening rehabilitation, both in Uganda and in similar contexts grappling with many health sector priorities and limited resources., (© 2024 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Medical internship is a key period for doctors' individual career planning and also a transition period for the broader labour market., Objectives: We aimed to understand the complex set of factors influencing the career intentions and decisions of junior doctors, post-internship in Kenya and Uganda., Methods: We conducted semi-structured interviews with 54 junior medical officers and 14 consultants to understand doctors' internship experiences and subsequent employment experiences. We analysed the data using a mix of a direct content approach, informed by an internship experience and career intentions framework developed primarily from high-income country literature, alongside a more inductive thematic analysis., Results: Echoing the internship experience and career intentions framework, we found that clinical exposure during internship, work-life balance, aspects of workplace culture such as relationships with consultants and other team members, and concerns over future job security and professional development all influenced Kenyan and Ugandan doctors' career preferences. Additionally, we added a new category to the framework to reflect our finding that interns might want to 'fill a health system gap' when they choose their future careers, based on what they witness as interns. However, often career intentions did not match career and employment decisions due to specific contextual factors, most importantly a shortage of job opportunities., Conclusion: We have shown how internship experiences shape medical doctors' career intentions in Kenya and Uganda and highlighted the importance of job availability and context in influencing doctors' career choices.

Background: Non-communicable diseases (NCDs) and NCD risk factors, such as smoking, increase the risk for tuberculosis (TB). Data are scarce on the risk of prevalent TB associated with these factors in the context of population-wide systematic screening and on the association between NCDs and NCD risk factors with different manifestations of TB, where ∼50% being asymptomatic but bacteriologically positive (subclinical). We did an individual participant data (IPD) meta-analysis of national and sub-national TB prevalence surveys to synthesise the evidence on the risk of symptomatic and subclinical TB in people with NCDs or risk factors, which could help countries to plan screening activities., Methods: In this systematic review and IPD meta-analysis, we identified eligible prevalence surveys in low-income and middle-income countries that reported at least one NCD (e.g., diabetes) or NCD risk factor (e.g., smoking, alcohol use) through the archive maintained by the World Health Organization and by searching in Medline and Embase from January 1, 2000 to August 10, 2021. The search was updated on March 23, 2023. We performed a one-stage meta-analysis using multivariable multinomial models. We estimated the proportion of and the odds ratio for subclinical and symptomatic TB compared to people without TB for current smoking, alcohol use, and self-reported diabetes, adjusted for age and gender. Subclinical TB was defined as microbiologically confirmed TB without symptoms of current cough, fever, night sweats, or weight loss and symptomatic TB with at least one of these symptoms. We assessed heterogeneity using forest plots and I 2 statistic. Missing variables were imputed through multi-level multiple imputation. This study is registered with PROSPERO (CRD42021272679)., Findings: We obtained IPD from 16 national surveys out of 21 national and five sub-national surveys identified (five in Asia and 11 in Africa, N = 740,815). Across surveys, 15.1%-56.7% of TB were subclinical (median: 38.1%). In the multivariable model, current smoking was associated with both subclinical (OR 1.67, 95% CI 1.27-2.40) and symptomatic TB (OR 1.49, 95% CI 1.34-1.66). Self-reported diabetes was associated with symptomatic TB (OR 1.67, 95% CI 1.17-2.40) but not with subclinical TB (OR 0.92, 95% CI 0.55-1.55). For alcohol drinking ≥ twice per week vs no alcohol drinking, the estimates were imprecise (OR 1.59, 95% CI 0.70-3.62) for subclinical TB and OR 1.43, 95% CI 0.59-3.46 for symptomatic TB). For the association between current smoking and symptomatic TB, I 2 was high (76.5% (95% CI 62.0-85.4), while the direction of the point estimates was consistent except for three surveys with wide CIs., Interpretation: Our findings suggest that current smokers are more likely to have both symptomatic and subclinical TB. These individuals can, therefore, be prioritised for intensified screening, such as the use of chest X-ray in the context of community-based screening. People with self-reported diabetes are also more likely to have symptomatic TB, but the association is unclear for subclinical TB., Funding: None., Competing Interests: TSo declares a receipt of funding from the Global Fund for conducting the TB prevalence survey in Mongolia. All other authors declare no competing interests., (© 2023 The Authors.)

Competing Interests: Potential conflicts of interest . All authors are employees of FIND, employees of the University of Oxford, or are members of the ADIP study group. P. H. reports research funding from FIND and an honoraria payment from Oxford International Biomedical Centre (OIBC). H. H. reports being employed by the London School of Hygiene & Tropical Medicine and receiving separate financial support from the study sponsors for some work on the project reported in this supplement and salary support from the UK Foreign Commonwealth and Development Office. H. H. also report royalties from UpToDate, a clinical decision support tool from Wolters Kluwer, for authorizing and maintaining the chapter on “Laboratory tools for diagnosis of Malaria.” H. H. also report receiving honoraria for lecturing for the University of Virginia and for a doctoral thesis review for the University of Otago in New Zealand. H. H. also report holding index-linked mutual funds and retirement account investments. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Background: Antibiotic prescribing practices are 1 of the contributing causes of antimicrobial resistance (AMR). The study explored the key drivers and barriers to adherence to prescribing instructions among healthcare workers and outpatient attendees with the aim of developing a training and communication intervention to improve adherence to prescription., Methods: Prior to randomized trials at 3 health centers in Uganda (Aduku, Kihihi, and Nagongera), a pre-intervention qualitative assessment was conducted to explore behavioral drivers for adherence to prescriptions and the communication of adherence messages. Based on the findings, a training and communication package was developed for healthcare workers and patients at Day 0 of the trial. During the trial's Day 7 patient follow-up, in-depth interviews were conducted to further investigate adherence behaviors., Results: Five main themes were identified that acted as drivers or barriers to prescription adherence. Key drivers included: drug availability at health facility, health worker knowledge, and communication to patients. Barriers included: care-seeker use of treatment resorts and an inability by care-seeker to buy drugs., Conclusions: The T&C appeared to influence both health workers' and patients' behavior and improve adherence to prescription.The adapted T&C should be considered a toolkit to improve antibiotic use across health facilities accompanied with appropriate guidelines to mitigate AMR., Competing Interests: Potential conflicts of interest. P. H. reports research funding from FIND and an honoraria payment from Oxford International Biomedical Centre (OIBC). H. H. reports being employed by the London School of Hygiene & Tropical Medicine and receiving separate financial support from the study sponsors for some work on the project reported in this supplement and salary support from the UK Foreign Commonwealth and Development Office. They also report royalties from UpToDate, a clinical decision support tool from Wolters Kluwer, for authorizing and maintaining the chapter on “Laboratory tools for diagnosis of Malaria.” They also report receiving honoraria for lecturing for the University of Virginia and for a doctoral thesis review for the University of Otago in New Zealand. They also report holding index-linked mutual fund and retirement account investments. J. N. reports research support and consulting fees from FIND. O. S. reports being an employee of FIND- from 2019 to 2021. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Increasing trends of antimicrobial resistance are observed around the world, driven in part by excessive use of antimicrobials. Limited access to diagnostics, particularly in low- and middle-income countries, contributes to diagnostic uncertainty, which may promote unnecessary antibiotic use. We investigated whether introducing a package of diagnostic tools, clinical algorithm, and training-and-communication messages could safely reduce antibiotic prescribing compared with current standard-of-care for febrile patients presenting to outpatient clinics in Uganda., Methods: This was an open-label, multicenter, 2-arm randomized controlled trial conducted at 3 public health facilities (Aduku, Nagongera, and Kihihi health center IVs) comparing the proportions of antibiotic prescriptions and clinical outcomes for febrile outpatients aged ≥1 year. The intervention arm included a package of point-of-care tests, a diagnostic and treatment algorithm, and training-and-communication messages. Standard-of-care was provided to patients in the control arm., Results: A total of 2400 patients were enrolled, with 49.5% in the intervention arm. Overall, there was no significant difference in antibiotic prescriptions between the study arms (relative risk [RR]: 1.03; 95% CI: .96-1.11). In the intervention arm, patients with positive malaria test results (313/500 [62.6%] vs 170/473 [35.9%]) had a higher RR of being prescribed antibiotics (1.74; 1.52-2.00), while those with negative malaria results (348/688 [50.6%] vs 376/508 [74.0%]) had a lower RR (.68; .63-.75). There was no significant difference in clinical outcomes., Conclusions: This study found that a diagnostic intervention for management of febrile outpatients did not achieve the desired impact on antibiotic prescribing at 3 diverse and representative health facility sites in Uganda., Competing Interests: Potential conflicts of interest. S. D., O. S., P. O., and J. N. were employees of FIND. P. H. reports research funding from FIND and an honoraria payment from Oxford International Biomedical Centre (OIBC). H. H. is a salaried employee of the London School of Hygiene and Tropical Medicine and received separate financial support from the study sponsors for some work on the project reported in this supplement. They receive salary support from the UK Foreign Commonwealth and Development Office. They receive royalties from UpToDate, a clinical decision support tool from Wolters Kluwer for authoring and maintaining the chapter on “Laboratory tools for diagnosis of malaria.” During the study period, they received honoraria for lecturing for the University of Virginia and for a doctoral thesis review for the University of Otago in New Zealand. They also hold index-linked mutual fund and retirement account investments. S. W. reports grant funding from FIND for statistical analysis and services from Agentur für Computeranwendungen in der Medizin (ACOMED). T. K. reports statistical design and analysis grant funding and consultation fees from FIND. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Introduction: Uganda's community health worker (CHW), or village health team (VHT), program faces significant challenges with poor retention and insufficient financial and program investment. Adequate compensation comprising financial and non-financial components is critical to retaining any workforce, including CHWs. This study evaluates the impact of a recognition-based non-financial incentives package on the motivation, performance, and retention of VHTs, as well as on the utilization of health services by the community. The incentive package and intervention were developed in collaboration with the district-level leadership and award VHTs who have met predetermined performance thresholds with a certificate and a government-branded jacket in a public ceremony., Methods: A two-armed cluster randomized controlled trial (RCT), conducted at the parish level in Uganda's Masindi District, will evaluate the effects of the 12-month intervention. The cluster-RCT will use a mixed-methods approach, which includes a baseline/endline VHT survey to assess the impact of the intervention on key outcomes, with an expected sample of 240 VHTs per study arm; our primary outcome is the total number of household visits per VHT and our multiple secondary outcomes include other performance indicators, motivation, and retention; VHT performance and retention data will be validated using monthly phone surveys tracking key performance indicators and through abstraction of VHT-submitted health facility reports; and focus group discussions will be conducted with VHTs and community members to understand how the intervention was received. Data collection activities will be administered in local languages. To assess the impact of the intervention, the study will conduct a regression analysis using Generalized Estimating Equations adjusting for cluster effect. Further, a difference-in-differences analysis will be conducted., Discussion: This study utilized a cluster-RCT design to assess the impact of a recognition-based incentives intervention on the motivation, performance, and retention of VHTs in Uganda's Masindi District. Utilizing a mixed-methods approach, the study will provide insights on the effectiveness and limitations of the intervention, VHT perspectives on perceived value, and critical insights on how non-financial incentives might support the strengthening of the community health workforce., Trial Registration: ClinicalTrials.gov NCT05176106. Retrospectively registered on 4 January 2022., (© 2023. The Author(s).)

Introduction: Hypertension is a growing burden in Uganda and other low- and middle-income countries. Appropriate diagnosis services are needed at primary care health facilities to identify, initiate treatment for, and manage hypertension. This study assessed service availability and readiness as well as facilitators and barriers in primary health care facilities for hypertension diagnosis services in Wakiso District, Uganda., Methods: In July and August 2019, we conducted structured interviews at 77 randomly selected primary care health facilities in Wakiso District. We used an interviewer-administered health facility checklist modified from the World Health Organization's service availability and readiness assessment tool. We also conducted 13 key informant interviews with health workers and district-level managers. Readiness was measured by availability of functional diagnostic equipment, related supplies and tools, and health provider attributes. Service availability was measured by assessing hypertension diagnosis services., Results: Most (86%; 66 of 77) health facilities offered hypertension diagnosis services and 84% (65 of 77) had digital blood pressure measuring devices; only 69% (53 of 77) had functional blood pressure measuring devices. Lower-level facilities lacked appropriate blood pressure cuffs for use across age groups: 92% (71 of 77) lacked pediatric cuffs and 52% (40 of 77) lacked alternative adult cuffs. Facilitators for diagnosing hypertension included partners that built health facility staff capacity and funds for purchasing hypertension diagnostic supplies; common barriers were nonfunctional equipment, delays in receiving training, and inadequate staffing., Conclusion: The results highlight the need for an adequate supply of devices, routine replacements or repairs, and frequent refresher training for health workers.

Background: At the onset of the COVID-19 pandemic, a local consortium in Uganda set up a telehealth approach that aimed to educate 3,500 Community Health Workers (CHW) in rural areas about COVID-19, help them identify, refer and care for potential COVID-19 cases, and support them in continuing their regular community health work. The aim of this study was to assess the functioning of the telehealth approach that was set up to support CHWs during the COVID-19 pandemic., Methods: For this mixed-method study, we combined analysis of routine consultation data from the call-center, 24 interviews with key-informants and two surveys of 150 CHWs. Data were analyzed using constant comparative method of analysis., Results: Between March 2020 and June 2021, a total of 35,553 consultations took place via the call center. While the CHWs made extensive use of the call center, they rarely asked for support for potential Covid-19 cases. According to the CHWs, there were no signs that people in their communities were suffering from severe health problems due to COVID-19. People compared the lack of visible symptoms to diseases such as Ebola and were skeptical about the danger of COVID-19. At the same time, people in rural areas were afraid to report relevant symptoms and get tested for fear of being quarantined and stigmatized. The telehealth approach did prove useful for other purposes, such as supporting CHWs with their regular tasks and coordinating the supply of essential products. The health professionals at the call center supported CHWs in diagnosing, referring and treating patients and adhering to infection prevention and control practices. The CHWs felt more informed and less isolated, saying the support from the call center helped them to provide better care and improved the supply of medicine and other essential health products., Conclusions: The telehealth approach, launched at the start of the COVID-19 pandemic, provided useful support to thousands of CHWs in rural communities in Uganda. The telehealth approach could be quickly set up and scaled up and offers a low cost strategy for providing useful and flexible support to CHWs in rural communities., (© 2023. The Author(s).)

Introduction: Automated mobile phone surveys (MPS) can be used to collect public health data of various types to inform health policy and programs globally. One challenge in administering MPS is identification of an appropriate and effective participant consent process. This study investigated the impact of different survey consent approaches on participant disposition (response characteristics and understanding of the purpose of the survey) within the context of an MPS that measured noncommunicable disease (NCD) risk factors across Colombia and Uganda., Methods: Participants were randomized to one of five consent approaches, with consent modules varying by the consent disclosure and mode of authorization. The control arm consisted of a standard consent disclosure and a combined opt-in/opt-out mode of authorization. The other four arms consist of a modified consent disclosure and one of four different forms of authorization (i.e., opt-in, opt-out, combined opt-in/opt-out, or implied). Data related to respondent disposition and respondent understanding of the survey purpose were analyzed., Results: Among 1889 completed surveys in Colombia, differences in contact, response, refusal, and cooperation rates by study arms were found. About 68% of respondents correctly identified the survey purpose, with no significant difference by study arm. Participants reporting higher levels of education and urban residency were more likely to identify the purpose correctly. Participants were also more likely to accurately identify the survey purpose after completing several survey modules, compared to immediately following the consent disclosure (78.8% vs 54.2% correct, p<0.001). In Uganda, 1890 completed surveys were collected. Though there were differences in contact, refusal, and cooperation rates by study arm, response rates were similar across arms. About 37% of respondents identified the survey purpose correctly, with no difference by arm. Those with higher levels of education and who completed the survey in English were able to more accurately identify the survey purpose. Again, participants were more likely to accurately identify the purpose of the survey after completing several NCD modules, compared to immediately following the consent module (42.0% vs 32.2% correct, p = 0.013)., Conclusion: This study contributes to the limited available evidence regarding consent procedures for automated MPS. Future studies should develop and trial additional interventions to enhance consent for automated public health surveys, and measure other dimensions of participant engagement and understanding., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Ali et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background and Aim: Growing evidence indicates that increasing physical activity may aid in regulating altered glycaemic control, thereby mitigating the risk of diabetes. However, the evidence summarising the efficacy of physical activity on glycaemic control among African adults remains unconsolidated. Our objective was to provide an amalgamated summary of the empirical evidence that explored the effectiveness of physical activity interventions on glycaemic control among African adults., Methods: A systematic search of six journal databases for the studies exploring the efficacy of physical activity on glycaemic control among African adults until March 21, 2022, was administered. Two independent reviewers screened the citations based on a priori set eligibility criteria. Data were analysed using inverse variance method and a summary of findings was synthesised using the Grading of Recommendations, Assessment, Development and Evaluations approach., Results: Of the 14,624 citations retrieved, 26 articles with 1474 participants were included for final analysis. Most of the included trials had a high risk of bias (N = 20; 76.92%). Our review found a significant reduction in fasting blood glucose (FBG, -2.18 [ 95% CI -3.18, -1.18] mmol/L), insulin (-0.99 [-2.71, 0.74] μU/L), Glycosylated haemoglobin (HbA1C) (-0.53% [-0.88, -0.19]), Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) (-0.74% [-1.10, -0.38]) and insulin sensitivity (-0.90 μU/l/min [-1.75, -0.06]) following physical activity interventions. The review reports low certainty of evidence across all outcome measures., Discussion and Conclusion: Physical activity interventions were found to improve glycaemic control among African adults. However, the optimal physical activity dose for demonstrating meaningful benefits on glucose tolerance still remains unclear due to the limited number of primary studies available., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Research Trust of DiabetesIndia (DiabetesIndia) and National Diabetes Obesity and Cholesterol Foundation (N-DOC). Published by Elsevier Ltd. All rights reserved.)

Background: Integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhoea is an equity focused strategy, to increase access to care for febrile illness in children under-5 years of age, in rural communities. Lay community members are trained to diagnose and treat malaria, pneumonia and diarrhoea in children, and to identify and refer very ill children. Today, many low-income countries including Uganda, have a policy for iCCM which is being rolled out through public sector community health workers (CHWs). Ten years after the introduction of the iCCM strategy in Uganda, it is important to take stock and understand the barriers and facilitators affecting implementation of the iCCM policy., Methods: We conducted an iCCM policy analysis in order to identify the challenges, enablers and priorities for scale-up of the iCCM strategy in Uganda. This was a qualitative case study research which included a document review (n=52) and key informant interviews (n=15) with Ugandan stakeholders. Interviews were conducted in 2017 and the desk review included literature up to 2019., Results: This paper highlights the iCCM policy trajectory since 2010 in Uganda and includes a policy timeline. The iCCM policy process was mainly led by international agencies from inception, with little ownership of the government. Many implementation challenges including low government funding, weak coordination and contradicting policies were identified, which could contribute to the slow scale up of the iCCM program. Despite the challenges, many enablers and opportunities also exist within the health system, which should be further harnessed to scale up iCCM in Uganda. These enabling factors include strong community commitment, existing policy instruments and the potential of utilizing also the private sector for iCCM implementation., Conclusion: The iCCM program in Uganda needs to be strengthen through increased domestic funding, strong coordination and a focus on monitoring, evaluation and operational research., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Increased mobile phone penetration allows the interviewing of respondents using interactive voice response surveys in low- and middle-income countries. However, there has been little investigation of the best type of incentive to obtain data from a representative sample in these countries., Objective: We assessed the effect of different airtime incentives options on cooperation and response rates of an interactive voice response survey in Bangladesh and Uganda., Methods: The open-label randomized controlled trial had three arms: (1) no incentive (control), (2) promised airtime incentive of 50 Bangladeshi Taka (US $0.60; 1 BDT is approximately equivalent to US $0.012) or 5000 Ugandan Shilling (US $1.35; 1 UGX is approximately equivalent to US $0.00028), and (3) lottery incentive (500 BDT and 100,000 UGX), in which the odds of winning were 1:20. Fully automated random-digit dialing was used to sample eligible participants aged ≥18 years. The risk ratios (RRs) with 95% confidence intervals for primary outcomes of response and cooperation rates were obtained using log-binomial regression., Results: Between June 14 and July 14, 2017, a total of 546,746 phone calls were made in Bangladesh, with 1165 complete interviews being conducted. Between March 26 and April 22, 2017, a total of 178,572 phone calls were made in Uganda, with 1248 complete interviews being conducted. Cooperation rates were significantly higher for the promised incentive (Bangladesh: 39.3%; RR 1.38, 95% CI 1.24-1.55, P<.001; Uganda: 59.9%; RR 1.47, 95% CI 1.33-1.62, P<.001) and the lottery incentive arms (Bangladesh: 36.6%; RR 1.28, 95% CI 1.15-1.45, P<.001; Uganda: 54.6%; RR 1.34, 95% CI 1.21-1.48, P<.001) than those for the control arm (Bangladesh: 28.4%; Uganda: 40.9%). Similarly, response rates were significantly higher for the promised incentive (Bangladesh: 26.5%%; RR 1.26, 95% CI 1.14-1.39, P<.001; Uganda: 41.2%; RR 1.27, 95% CI 1.16-1.39, P<.001) and lottery incentive arms (Bangladesh: 24.5%%; RR 1.17, 95% CI 1.06-1.29, P=.002; Uganda: 37.9%%; RR 1.17, 95% CI 1.06-1.29, P=.001) than those for the control arm (Bangladesh: 21.0%; Uganda: 32.4%)., Conclusions: Promised or lottery airtime incentives improved survey participation and facilitated a large sample within a short period in 2 countries., Trial Registration: ClinicalTrials.gov NCT03773146; http://clinicaltrials.gov/ct2/show/NCT03773146., (©Dustin Garrett Gibson, Gulam Muhammed Al Kibria, George William Pariyo, Saifuddin Ahmed, Joseph Ali, Alain Bernard Labrique, Iqbal Ansary Khan, Elizeus Rutebemberwa, Meerjady Sabrina Flora, Adnan Ali Hyder. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.05.2022.)

Background: Tobacco use is associated with exacerbation of tuberculosis (TB) and poor TB treatment outcomes. Integrating tobacco use cessation within TB treatment could improve healing among TB patients. The aim was to explore perceptions of health workers on where and how to integrate tobacco use cessation services into TB treatment programs in Uganda., Methods: Between March and April 2019, nine focus group discussions (FGDs) and eight key informant interviews were conducted among health workers attending to patients with tuberculosis on a routine basis in nine facilities from the central, eastern, northern and western parts of Uganda. These facilities were high volume health centres, general hospitals and referral hospitals. The FGD sessions and interviews were tape recorded, transcribed verbatim and analysed using content analysis and the Chronic Care Model as a framework., Results: Respondents highlighted that just like TB prevention starts in the community and TB treatment goes beyond health facility stay, integration of tobacco cessation should be started when people are still healthy and extended to those who have been healed as they go back to communities. There was need to coordinate with different organizations like peers, the media and TB treatment supporters. TB patients needed regular follow up and self-management support for both TB and tobacco cessation. Patients needed to be empowered to know their condition and their caretakers needed to be involved. Effective referral between primary health facilities and specialist facilities was needed. Clinical information systems should identify relevant people for proactive care and follow up. In order to achieve effective integration, the health system needed to be strengthened especially health worker training and provision of more space in some of the facilities., Conclusions: Tobacco cessation activities should be provided in a continuum starting in the community before the TB patients get to hospital, during the patients' interface with hospital treatment and be given in the community after TB patients have been discharged. This requires collaboration between those who carry out health education in communities, the TB treatment supporters and the health workers who treat patients in health facilities., (© 2021. The Author(s).)

Background: This is the first study to examine the costs of conducting a mobile phone survey (MPS) through interactive voice response (IVR) to collect information on risk factors for noncommunicable diseases (NCD) in three low- and middle-income countries (LMIC); Bangladesh, Colombia, and Uganda., Methods: This is a micro-costing study conducted from the perspective of the payer/funder with a 1-year horizon. The study evaluates the fixed costs and variable costs of implementing one nationally representative MPS for NCD risk factors of the adult population. In this costing study, we estimated the sample size of calls required to achieve a population-representative survey and associated incentives. Cost inputs were obtained from direct economic costs incurred by a central study team, from country-specific collaborators, and from platform developers who participated in the deployment of these MPS during 2017. Costs were reported in US dollars (USD). A sensitivity analysis was conducted assessing different scenarios of pricing and incentive strategies. Also, costs were calculated for a survey deployed targeting only adults younger than 45 years., Results: We estimated the fixed costs ranging between $47,000 USD and $74,000 USD. Variable costs were found to be between $32,000 USD and $129,000 USD per nationally representative survey. The main cost driver was the number of calls required to meet the sample size, and its variability largely depends on the extent of mobile phone coverage and access in the country. Therefore, a larger number of calls were estimated to survey specific harder-to-reach sub-populations., Conclusion: Mobile phone surveys have the potential to be a relatively less expensive and timely method of collecting survey information than face-to-face surveys, allowing decision-makers to deploy survey-based monitoring or evaluation programs more frequently than it would be possible having only face-to-face contact. The main driver of variable costs is survey time, and most of the variability across countries is attributable to the sampling differences associated to reaching out to population subgroups with low mobile phone ownership or access.

Objective: To characterise developmental milestones among young children living in rural communities in Uganda., Design: Cross-sectional study., Setting: Iganga-Mayuge Health and Demographic Surveillance Site in rural eastern Uganda., Participants: A total of 720 caregivers of children aged 3-4 years old from a health and demographic surveillance site in rural eastern Uganda were recruited into this study. Caregivers reported on their child's developmental skills and behaviours using the 10-item Early Childhood Development Index (ECDI) developed by UNICEF. Childhood development was characterised based on the ECDI's four domains: literacy-numeracy, learning/cognition, physical and socioemotional development. As an exploratory analysis, we implemented a hierarchical agglomerative cluster analysis to identify homogenous subgroups of children based on the features assessed. The cluster analysis was performed to identify potential subgroups of children who may be at risk of developmental problems., Results: Between November 2017 and June 2018, 720 caregivers of children aged 3-4 years completed the ECDI. The proportions of children at risk of delay in each domain were as follows: literacy-numeracy: 75% (n=538); socioemotional development: 22% (n=157); physical: 3% (n=22); and cognitive: 4% (n=32). The cluster analysis revealed a three-cluster solution that included 93% of children assigned to a low-risk group, 4% assigned to a moderate-risk group and 3% assigned to a high-risk group characterised by low scores in almost all domains., Conclusion: The findings suggest that a high proportion of children in rural eastern Uganda demonstrate poor literacy-numeracy skills. These results underscore the need to improve population-based screening and intervention efforts to improve early childhood developmental outcomes, particularly in literacy and socioemotional domains, in low-income and middle-income countries such as Uganda., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© Meghani et al.)

Background: There is international consensus on the need for countries to work towards achieving universal health coverage (UHC) whereby the population is given access to all appropriate promotive, preventive, curative and rehabilitative services at affordable cost. The World Health Organisation (2013) urges all countries to undertake research to customise UHC within national development agendas., Objective: To describe the process used to prioritise UHC within the health systems research and development agenda in Uganda., Methods: Two national consultative workshops were convened in May and August 2015 to develop a UHC research agenda in Uganda. The participants included multisector representatives from local, national, and international organisations. A participatory approach with structured deliberations and multi-voting techniques was used. Stakeholders' views were analysed thematically according to health systems building blocks, and multi-voting was used to assign priorities across themes and sub-themes. The priorities were further validated and disseminated at national health sector meetings., Results: Of the 80 invited stakeholders, 57 (71.3%) attended. The expressed priorities were: 1) health workforce; 2) governance; 3) financing; 4) service delivery, and 5) community health. The participants also recommended crosscutting research themes to address the social determinants of health, multisectoral collaboration, and health system resilience to protect against external shocks and disease epidemics., Conclusion: Discussions that capture the diverse perspectives of stakeholders provide a way of exploring UHC within health policy and systems development. In Uganda, attention should be paid to the principal challenges of mobilising financial and technical capabilities for research and strengthening the link between evidence generation and policy actions to achieve UHC.

Background: With the growing burden of noncommunicable diseases in low- and middle- income countries, the World Health Organization recommended a stepwise approach of surveillance for noncommunicable diseases. This is expensive to conduct on a frequent basis and using interactive voice response mobile phone surveys has been put forth as an alternative. However, there is limited evidence on how to design and deliver interactive voice response calls that are robust and acceptable to respondents., Objective: This study aimed to explore user perceptions and experiences of receiving and responding to an interactive voice response call in Uganda in order to adapt and refine the instrument prior to national deployment., Methods: A qualitative study design was used and comprised a locally translated audiorecorded interactive voice response survey delivered in 4 languages to 59 purposively selected participants' mobile phones in 5 survey rounds guided by data saturation. The interactive voice response survey had modules on sociodemographic characteristics, physical activity, fruit and vegetable consumption, diabetes, and hypertension. After the interactive voice response survey, study staff called participants back and used a semistructured interview to collect information on the participant's perceptions of interactive voice response call audibility, instruction clarity, interview pace, language courtesy and appropriateness, the validity of questions, and the lottery incentive. Descriptive statistics were used for the interactive voice response survey, while a framework analysis was used to analyze qualitative data., Results: Key findings that favored interactive voice response survey participation or completion included preference for brief surveys of 10 minutes or shorter, preference for evening calls between 6 PM and 10 PM, preference for courteous language, and favorable perceptions of the lottery-type incentive. While key findings curtailing participation were suspicion about the caller's identity, unclear voice, confusing skip patterns, difficulty with the phone interface such as for selecting inappropriate digits for both ordinary and smartphones, and poor network connectivity for remote and rural participants., Conclusions: Interactive voice response surveys should be as brief as possible and considerate of local preferences to increase completion rates. Caller credibility needs to be enhanced through either masking the caller or prior community mobilization. There is need to evaluate the preferred timing of interactive voice response calls, as the finding of evening call preference is inconclusive and might be contextual., (©Raymond Tweheyo, Hannah Selig, Dustin G Gibson, George William Pariyo, Elizeus Rutebemberwa. Originally published in JMIR Formative Research (http://formative.jmir.org), 03.12.2020.)

Introduction: the Global-Partnership-Initiated-Biosecurity-Academia for Controlling Health Threats (GIBACHT) consortium conducts a biosafety and biosecurity training for fellows from Africa, the Middle East and Asia. To achieve a multiplier effect, fellows conduct trainings in their own organizations. It was during such trainings that training needs assessments were done assessing reasons for and barriers to biosafety and biosecurity training., Methods: this was a cross sectional assessment. Trainings were conducted from April to July 2018 and April to June 2019. In 2018, training needs were explored using a structured tool. Responses were coded using manifest content analysis and key issues identified. In 2019, respondents quantified the identified key issues using a Likert scale. Proportions of those who strongly agreed, agreed, neither agreed nor disagreed, disagreed or strongly disagreed were calculated and results presented in tables and charts., Results: in 2018 and 2019, there were 183 and 191 respondents respectively. About 96% of respondents in 2018 supported training in biosafety and biosecurity citing individual, community and global benefits. Barriers highlighted included governance, financial, human resource, information and infrastructure challenges. In 2019, majority of respondents indicated inadequate guidelines dissemination, lack of financial resources, inadequate personnel, lack of equipped laboratories and lack of instructional materials among major barriers., Conclusion: support for biosafety and biosecurity training was high though systemic barriers exist. Improving human resource capacity and provision of instructional materials can be achieved through training programs. However, systemic assessments need to be done before each training as different organizations have different barriers., Competing Interests: The authors declare no competing interests., (Copyright: Elizeus Rutebemberwa et al.)