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Private Health Facilities (PHFs), Uganda's main healthcare providers, are indispensable stakeholders in the national tuberculosis (TB) program's efforts to improve TB case notification and combat the epidemic. However, notification rates remain relatively low in PHFs compared to public providers. In this study, we sought to assess facilitators and barriers to TB case notification among private facilities in Kampala Capital City. We conducted a cross-sectional study utilizing a mixed-methods approach to assess facilitators and barriers to TB notification in Kampala Capital City between March and July 2022. For the quantitative strand of the study, we interviewed the TB focal persons at 224 PHFs using a structured questionnaire and for the qualitative, we conducted 14 key informant and in-depth interviews with Ministry of Health-Uganda staff, and TB focal persons at the Kampala Division administration level and at the PHFs. The quantitative analysis involved Modified Poisson regression and the qualitative analysis was carried out using thematic analysis to identify the facilitators and barriers to TB case notification. Of the 224 PHFs surveyed, the majority, 39.3%(88), were facilities in Nakawa division and 55.4% (124) of the respondents were male, with a mean age of 32.6 years (SD = 8.6). We found that the prevalence of TB case notification was significantly lower for facilities in Kawempe (PR 0.16; 95%CI 0.05,0.47) and Nakawa (PR 0.39, 95%CI 0.21,0.73). Notification was lower among facilities that had no guide for TB screening and diagnosis (PR 0.50; 95%CI 0.25,0.97) and among those facilities where training of other health workers at the facility in TB diagnosis was unknown (PR 0.35; 95%CI 0.13,0.93). Qualitative data showed that the main facilitators of TB case notification were: regular engagements between the NTLP and private health providers and, provision of materials and support to conduct case finding, while the main barriers included TB stigma, lack of resources such as TB diagnostic facilities. PHFs in Kampala Capital City are receptive to programmatic TB case notification. However, they need regular supervision and engagement activities to ensure that they have updated knowledge, equipment and funding support to carry out TB case notification according to policy.

ObjectiveThis paper examines the challenges frontline health workers face, as well as their coping practices following district splitting. It also has ramifications for the need to take into account the nexus between district splitting and subnational health system functioning.DesignA qualitative cross-sectional study employing an exploratory design. Data were collected using an in-depth interview guide for individual interviews. We used a deductive thematic analysis to identify and structure challenges faced and coping mechanisms by health workers in new districts. The data were analysed deductively using Braun and Clarke’s six-step thematic analysis.SettingFrontline health workers from four randomly selected regions with one parent district selected randomly from each region and a respective child district that had been split from it between 2005 and 2015. Interviews were conducted between June and November 2018.ParticipantsIn-depth interviews were conducted with 24 frontline health workers whose age ranged from 33 to 51 years and these had changed locations between districts after district splitting occurred.ResultsThe challenges frontline health workers faced included work-related role changes, social demands, team integration and health system inadequacies. Health workers switched roles across districts, adapting to leadership while balancing clinical and administrative duties. Overall, five themes emerged during analysis. Newly promoted staff faced knowledge gaps in facility management. Social demands included accommodation issues and family/community pressures. Team integration impacted daily work, requiring newcomers to navigate hierarchy and culture. Health system issues, such as understaffing, poor infrastructure, drug shortages and strained work relations, worsened working conditions. Coping practices included induction, leadership training, staff appraisals, duty rosters, supervision, team building, partner support and financial/community planning.ConclusionsDistrict splitting worsens challenges for frontline health workers. While they show resilience through coping strategies, systemic improvements remain essential. Addressing root causes like better resource distribution, expanded training and stronger administrative support is crucial to achieving the district splitting goal of improving healthcare delivery in newly formed districts in Uganda.

Background Lower-level private for-profit health service providers form part of the pluralistic health systems delivering immunization services in urban areas of sub–Saharan Africa. However, their operational context is less documented since the conventional national Expanded Programme on Immunization (EPI) programmes tend to support delivery through public structures. Yet, private providers contribute greatly to immunization service coverage in urban settings. This paper explores the operational level context and stakeholders’ perspectives regarding immunization data among lower-level private for-profit service providers in the city of Kampala, Uganda. The objective of this baseline assessment was to document the current implementation context of immunization data among urban lower-level private for-profit immunization service providers to inform implementation research to improve immunization data in Kampala, Uganda. Methods The study adopted an exploratory qualitative design where key informant interviews and in-depth interviews were conducted. Analysis was guided by the health systems building-block framework, which informed the design of the codebook with coding done in Atlas.ti, a qualitative data management software. Results Overall, private for-profit immunization service providers reflected a context consisting of both barriers and opportunities underlying immunization data management practices. The barriers identified included: high staff turnover; data overload and manipulation tendencies; a transient population that access immunization services from different service providers without data linkage systems; computation of catchment populations, which affects utilization coverage data; financial barriers to the collection of community-level data; and inadequate facilitation leading to lean human resources at EPI departments managing immunization data from private providers. Nonetheless, opportunities to improve immunization data included the ability to widen data coverage through their services, enhanced public–private-partnership through data sharing arrangements, linkage of urban data among providers, improved recording of urban surveillance data, additional human resource to record data, widened scope for capturing adverse events data, improved community data linkages, and transitioning from paper-based to electronic data capture. Conclusions Opportunities to improve urban immunization data management through private for-profit providers exist amidst numerous barriers. This calls for innovative strategies by the programme managers to design interventions with specific emphasis on addressing barriers inherent among urban lower-level private for-profit service providers if immunization data management among these entities is to be improved.

Background Tobacco use is a significant public health problem, especially among People Living with HIV (PLWH) yet evidence on its prevalence and multi-level drivers in Uganda remains limited. This study assessed the prevalence and multilevel drivers of tobacco use among PLWH in two regions in northern Uganda. Methods We conducted a mixed-methods study involving a survey of 439 PLWH randomly sampled from eight health facilities in West Nile and Karamoja regions and Focus Group Discussion (FGDs) of 47 PLWH to understand multi-level drivers of tobacco use. Data was collected from August 15th to December 20th, 2024. Survey data was collected electronically using Open Data Kit (ODK) platform. Tobacco use was biochemically verified using cotinine urine dipsticks. We conducted quantitative analysis to identify factors associated with tobacco use using multinomial regression model using STATA v14. Qualitative data was analyzed using thematic analysis in NVivo V15. Results According to self-reports, Tobacco use was more prevalent in Karamoja than in West Nile, with smokeless tobacco dominating in Karamoja and smoking more common in West Nile. Nicotine dependence was higher among smokers (49.1%) than smokeless users (32.1%). Smoking was associated with being male (RRR = 11.13; 95% CI, 5.08–24.41) and having lower tobacco realted - knowledge (RRR = 0.39; 95% CI, 0.17–0.90). Smokeless tobacco use was associated with district of residence (RRR = 177.57; 95% CI, 29.36–1074.02) and other substance use (RRR = 4.08; 95% CI, 1.06–15.64). FGDs revealed multi-level drivers spanning the intrapersonal level (addiction, HIV-related distress, gender norms, and limited knowledge), interpersonal level (peer and family influence), community level (cultural practices and stigma), organizational level (tobacco affordability and inadequate cessation services), and the policy level, where limited awareness and weak enforcement of existing smokeless tobacco regulations contributed to continued use of tobacco. Conclusion Tobacco cessation strategies should be mode-specific and context-sensitive. In West Nile, where smoking and dual use are common, interventions should target men with low tobacco-related knowledge. In Karamoja, where smokeless tobacco is culturally entrenched and enforcement of existing bans is weak, cessation requires community-based education, facility-based treatment, and post-care support. Addressing multi-level drivers is essential for tobacco use cessation among PLWH in similar settings.

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.

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 < 0.001); and correct doses of medicines from records (100% vs 96%, p < 0.001). According to records, 82% of the children with fast breathing had received an antibiotic. From observations 49% of CHWs counted respiratory rates within five breaths of the physician (gold standard) and 75% correctly classified the children. The factors perceived to influence CHWs’ performance were: community support and confidence, continued training, availability of drugs and other necessary supplies, and cooperation from formal health workers. 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.

Background Despite many improvements in maternal, newborn, sexual, and reproductive health (RMNCAH) in sub-Saharan Africa, the overall progress remains inadequate and uneven. Some of the reasons for this include fragmented healthcare systems, gaps in evidence-based policy, inadequate investment and funding for health, and weaknesses in policy dissemination and implementation. Current stakeholder views on RMNCAH policy formulation and policy implementation in Uganda has not been exhaustively studied to help inform adjustments in policy formulation approaches and implementation strategies. The objective was to conduct a situation analysis to identify gaps in RMNCAH policies and guidelines formulation, dissemination, and implementation in Uganda to be able to recommend strategies to address these gaps, and catalyse policy formulation and implementation. Methods This was an exploratory qualitative study conducted among RMNCAH stakeholders at central level and four district local governments in Uganda. Data were collected through review of RMNCAH policies and guideline documents using a document review guide, two guided small-group discussions (SGDs) with central government stakeholders and partners, four SGDs with district health teams (DHTs), eight key informant interviews (KIIs), and four focus group discussions (FGDs) with women 20–35 years of age. The interviews and group discussions were conducted using pretested interview guides, audio-recorded and transcribed verbatim. The transcripts were analysed by thematic analysis using open code software. Results It was established that the policy and guideline documents addressing most of RMNCAH components existed. However, the indicators have not improved adequately to meet the international targets. The main policy implementation gaps reported revolved around policy leadership and coordination such as weaknesses in district and facility leadership and management, insufficient monitoring and evaluation, inadequate community engagement in policy formulation and implementation, inadequate policy and guidelines dissemination, limited multisectoral approach, and insufficient resource allocation to implement the policies and guidelines. Conclusion Policies and guidelines covering all RMNCAH components are in place, but implementing and translating these into improved indicators has been the major challenge. A strategic framework should be developed to test interventions to address these gaps to catalyse policy implementation in selected districts and later be rolled out to cover the whole country to cause wholesome policy impact.

Staphylococci are a key component of the human microbiota, and they mainly colonize the skin and anterior nares. However, they can cause infection in hospitalized patients and healthy individuals in the community. Although majority of the Staphylococcus aureus strains are coagulase-positive, some do not produce coagulase, and the isolation of coagulase-positive non-S. aureus isolates in humans is increasingly being reported. Therefore, sound knowledge of the species and characteristics of staphylococci in a given setting is important, especially isolates from children and immunocompromised individuals. The spectrum of Staphylococcus species colonizing children in Uganda is poorly understood; here, we aimed to determine the species and characteristics of staphylococci isolated from children in Eastern Uganda. Seven hundred and sixty four healthy children less than 5 years residing in Iganga and Mayuge districts in Eastern Uganda were enrolled. A total of 513 staphylococci belonging to 13 species were isolated from 485 children (63.5%, 485/764), with S. aureus being the dominant species (37.6%, 193/513) followed by S. epidermidis (25.5%, 131/513), S. haemolyticus (2.3%, 12/513), S. hominis (0.8%, 4/513) and S. haemolyticus/lugdunensis (0.58%, 3/513). Twenty four (4.95%, 24/485) children were co-colonized by two or more Staphylococcus species. With the exception of penicillin, antimicrobial resistance (AMR) rates were low; all isolates were susceptible to vancomycin, teicoplanin, linezolid and daptomycin. The prevalence of methicillin resistance was 23.8% (122/513) and it was highest in S. haemolyticus (66.7%, 8/12) followed by S. aureus (28.5%, 55/193) and S. epidermidis (23.7%, 31/131). The prevalence of multidrug resistance was 20.3% (104/513), and 59% (72/122) of methicillin resistant staphylococci were multidrug resistant. Four methicillin susceptible S. aureus isolates and a methicillin resistant S. scuiri isolate were mupirocin resistant (high-level). The most frequent AMR genes were mecA, vanA, ant(4')-Ia, and aac(6')-Ie- aph(2'')-Ia, pointing to presence of AMR drivers in the community.

The increased subscription and ownership of mobile phones have created opportunities to improve health, education, or economic outcomes, including mobile phone surveys (MPS) to collect health data. Most MPS used cross-sectional survey designs. We explored the potential of MPS to collect panel data using anonymous surveys with agreement in age and gender, and participants’ retention across survey waves in three low- and middle-income countries (LMICs): Bangladesh, Colombia, and Uganda. Using random digit dialing, participants were recruited from 6 age-gender strata (i.e., 18-29-, 30-44-, and 45+-year-old males and females). Three interactive voice response survey waves were sent at two-week intervals. In Wave 1, the number of complete interviews in Bangladesh, Colombia, and Uganda was 2693, 5912, and 4813, respectively. In all waves, the proportion of 18-29-year-olds responding to the surveys was higher than that of 30-44- or 50+-year-olds. Bangladesh (83.7% in Wave 1) and Uganda (70.1% in Wave 1) had a higher proportion of males than females, while it was different in Colombia (45.6% in Wave 1). Regarding the reporting of age and gender in survey waves, we observed a high agreement in all three countries; the Kappa statistic was 0.89 (agreement: 93.7%) from Wave 1 to Wave 2 and 0.90 (agreement: 94.5%) from Wave 1 to Wave 3. In Wave 1, the response and refusal rates were, respectively, 0.26% and 0.19% in Bangladesh; 0.65% and 0.89% in Colombia; and 2.63% and 0.71% in Uganda. From Wave 1 to Wave 2, the attrition rate was 37.2% in Bangladesh, 43.7% in Colombia, and 39.2% in Uganda. From Wave 1 to Wave 3, the attrition rate was 64.2%, 62.8%, and 58.4% in Bangladesh, Colombia, and Uganda, respectively. Despite high attrition across survey waves, the agreement about responses was substantial in all countries and MPS has the potential to be implemented in LMICs. More research is required to improve the retention and increase enrollment in some sociodemographic groups (e.g., older people or women). Future studies could also be benefitted from adding validation questions to ensure the participation by the same respondent.

Background Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals. Methods Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another. Results Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals’ diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another. Conclusions Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.