Lived experiences and drivers of induced abortion among women in central Uganda.

Although unsafe abortions are preventable, they are one of the leading causes of maternal mortality and morbidity. Despite the serious potential health consequences, there is limited published information about drivers and challenges of obtaining abortions in restrictive settings such as Uganda. This limits efforts to improve programing for preventing unsafe abortion and providing comprehensive post abortion care. This study sought to understand the drivers and explain the lived abortion experiences among women from central Uganda, in an effort to promote greater access to safe reproductive healthcare services, and reduce unsafe abortions. This qualitative study included 40 purposely selected women who self-reported an abortion, living in Kampala and greater Rakai district, Uganda. They were part of a larger survey using respondent driven sampling, where seed participants were recruited from selected facilities offering post-abortion care, or through social referrals. Data were collected from May to September 2021 through in-depth interviews. Audio data were transcribed, managed using Atlas.ti 9, and analyzed thematically. The findings show that the underlying drivers stemmed from partners who were unsupportive, denied responsibility, or had raped/defiled women. Career and education decisions, stigma and fear to disappoint family also contributed. Women had feelings of confusion, neglect, betrayal, or shame after conception. Abortion and post-abortion experiences were mixed with physical and emotional pain including stigma, even when the conditions for safe abortion in the guidelines were satisfied. Although most women sought care from health facilities judged to provide safe and quality care, there was barely any counselling in these venues. Confidantes and health providers informed the choice of abortion methods, although the cost ultimately mattered most. The mental health of women whose partners are unsupportive or who conceive unintendedly need consideration. Abortion provided psychological relief from more complicated consequences of having an unplanned birth for women.

Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys.

Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.

Uvula infections and traditional uvulectomy: Beliefs and practices in Luwero district, central Uganda.

Uvulitis is the inflammation and swelling of the uvula, usually associated with infection of nearby structures. Uvulitis can be treated symptomatically, using medication or in some cases with uvulectomy, the uvula surgical removal or shortening. Traditional uvulectomy by traditional practitioners has been practiced in Africa for ages, associated with adverse outcomes. Although there is no empirical evidence for the association between adverse outcomes and traditional uvulectomy in Uganda, anecdotal findings showed incidents of uvula infections following uvulectomy in central Uganda. While these findings also indicate that traditional uvulectomy is common, the community understanding of uvulitis, the beliefs and practices are not well understood. This qualitative study sought to understand beliefs and practices using interviews with community health workers, traditional uvulectomy clients, and traditional surgeons, and focus group discussions with community members. Transcribed data were analysed in Atlas.ti 9 using thematic analysis steps. The findings show that uvula infection, locally known as "Akamiro" and the associated traditional uvulectomy are common in Luwero and beyond. "Akamiro" was described as larger than the normal, the size of a chicken heart or a big pimple, visible when a child cries, with unknown causes. Symptoms included persistent cough, diarrhoea, vomiting, loss of appetite, inability to swallow and ultimately weight loss, swollen stomach, saliva overflow, fever, breathing and speech difficulty. Diagnosis was confirmed after seeking care from health workers or in consultation with significant others and finally the traditional surgeon; in a hierarchical pattern. Uvulectomy was conducted by traditional surgeons, with surgery lasting a few minutes, in the morning or after sun-set. Tools used were razor blades, reeds, strings, wires, sickle knives and spoons. Payment was flexible; cash or in-kind. Surgeons had immense community trust, including community health workers. Interventions to support persons with uvula infections need to address the health system weaknesses, and health education.

Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda.

BACKGROUND: Transwomen (also known as transgender women) are disproportionately affected by all forms of gender-based violence (GBV). The high prevalence of physical, sexual and emotional violence not only predisposes transwomen to HIV infection but also limits the uptake/access to HIV prevention, care, and treatment services. Despite the high prevalence of HIV infection and GBV among transwomen, there is limited evidence on how GBV affects the uptake and utilisation of HIV prevention, care, and treatment services. Therefore, this qualitative study explored how GBV affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area (GKMA), Uganda. METHODS: This participatory qualitative study was conducted among transwomen in the GKMA. A total of 20 in-depth interviews, 6 focus group discussions, and 10 key informant interviews were conducted to explore how GBV affects the uptake and utilisation of HIV prevention, treatment, and care services among transwomen. Data were analysed using a thematic content analysis framework. Data were transcribed verbatim, and NVivo version 12 was used for coding. RESULTS: At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy (ART). Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level led to fear among transwomen traveling to healthcare facilities. Emotional violence suffered by transwomen in healthcare settings led to the limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. The fear of emotional violence also made it difficult for transwomen to approach healthcare providers. Fear of physical violence such as being beaten while in healthcare settings made transwomen shun healthcare facilities. CONCLUSION: The effects of GBV on the uptake and utilisation of HIV prevention, care, and treatment services were observed in individual, community, and healthcare settings. Across all levels, physical, emotional, and sexual violence suffered by transwomen led to the shunning of healthcare facilities, denial of healthcare services, delays in receiving appropriate care, and the low utilisation of post-exposure prophylaxis, and HIV testing services. Given its effects on HIV transmission, there is a need to develop and implement strategies/ interventions targeting a reduction in GBV. Interventions should include strategies to sensitize communities to accept transwomen. Healthcare settings should provide an enabling environment for transwomen to approach any healthcare provider of their choice without fear of experiencing GBV.

Prevalence and correlates of reproductive coercion across ten sites: commonalities and divergence.

BACKGROUND: Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. Recent research emphasizes that RC experiences may differ within and across low- and middle-income countries (LMICs), as compared to higher income contexts, given social pressures surrounding childbearing. To date, nationally representative surveys have lacked comprehensive measures for RC, leading to gaps in understanding its prevalence and risk factors. Across eight LMICs (10 sites), we aimed to (1) validate the RC Scale; (2) calculate prevalence of RC and specific behaviors; and (3) assess correlates of RC. METHODS: This analysis leverages cross-sectional Performance Monitoring for Action (PMA) data collected from November 2020 to May 2022. Analyses were limited to women in need of contraception (Burkina Faso n = 2767; Côte d'Ivoire n = 1561; Kongo Central, Democratic Republic of Congo (DRC) n = 830; Kinshasa, DRC n = 846; Kenya n = 4588; Kano, Nigeria n = 535; Lagos, Nigeria n = 612; Niger n = 1525; Rajasthan, India n = 3017; Uganda n = 2020). Past-year RC was assessed via five items adapted from the original RC Scale and previously tested in LMICs. Confirmatory factor analysis examined fit statistics by site. Per-item and overall prevalence were calculated. Site-specific bivariate and multivariable logistic regression examined RC correlates across the socioecological framework. RESULTS: Confirmatory factor analysis confirmed goodness of fit across all sites, with moderate internal consistency (alpha range: 0.66 Cote d'Ivoire-0.89 Kinshasa, DRC/Lagos, Nigeria). Past-year reported prevalence of RC was highest in Kongo Central, DRC (20.3%) and lowest in Niger (3.1%). Prevalence of individual items varied substantially by geography. Polygyny was the most common RC risk factor across six sites (adjusted odds ratio (aOR) range: 1.59-10.76). Increased partner education levels were protective in Kenya and Kano, Nigeria (aOR range: 0.23-0.67). Other assessed correlates differed by site. CONCLUSIONS: Understanding RC prevalence and behaviors is central to providing woman-centered reproductive care. RC was most strongly correlated with factors at the partner dyad level; future research is needed to unpack the relative contributions of relationship power dynamics versus cultural norms surrounding childbearing. Family planning services must recognize and respond to women's immediate needs to ensure RC does not alter reproductive trajectories, including vulnerability to unintended pregnancy.

Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. While RC was conceptualized in the United States, recent research highlights that it may be prominent in other geographies, including sub-Saharan Africa. Existing national surveillance programs, including the Demographic and Health Surveys, have included a single item on RC beginning in 2018. Given the phased approach to Demographic and Health Survey roll-out, no studies have examined this single item across diverse contexts. Further, this single item may miss the range of abusive experiences women face when seeking to manage their fertility. Using annual national cross-sections in 10 diverse contexts (eight countries), we sought to: (1) validate a comprehensive RC measure; (2) calculate prevalence of RC and specific behaviors; (3) understand risk factors for RC across contexts. We found that the comprehensive RC measure performed well across sites. Prevalence of past-year RC was highest in the Kongo Central region of the Democratic Republic of Congo (20.3%) and lowest in Niger (3.1%). Polygynous marriage was associated with increased risk of RC across six sites, whereas increased partner education levels were protective against RC in two sites. Understanding the prevalence of RC within a given context and range of specific abusive behaviors, as well as risk profiles, can help alert local service providers to women's needs. A thorough understanding of commonalities and divergence of RC experiences and drivers across sites can help inform prevention and response programming to address RC and its health effects.

Help-seeking and challenges faced by transwomen following exposure to gender-based violence; a qualitative study in the Greater Kampala Metropolitan Area, Uganda.

BACKGROUND: The high prevalence of gender-based violence (GBV) among transwomen is a human rights and public health challenge. Nonetheless, there is limited evidence of sources of GBV support services and the challenges faced by transwomen while help-seeking, especially in transphobic settings like Uganda. This study explored the sources of GBV support services and the challenges faced by transwomen in the Greater Kampala Metropolitan Area during help-seeking. METHODS: A qualitative study design involving 60 transwomen and 10 key informants was conducted. Respondents were recruited using snowball sampling. An in-depth interview (IDI), and a focus group discussion guide were used to collect data from 20 IDI respondents and six focus group discussants. Each focus group discussion averaged six participants. A key informant interview guide was used for key informant interviews. Data were transcribed verbatim and analysed following a thematic framework, informed by the socio-ecological model. Data were organised into themes and subthemes using NVivo 12.0. RESULTS: The sources of support following exposure to GBV included key population-friendly healthcare facilities and civil society organisations (CSOs), and friends and family. Friends and family provided emotional support while key population-friendly healthcare facilities offered medical services including HIV post-exposure prophylaxis. Key population CSOs provided shelter, nutritional support, and legal advice to GBV victims. Lack of recognition of transgender identity; long distances to healthcare facilities; discrimination by healthcare providers and CSO staff, inappropriate questioning of the trans-gender identity by police officers and healthcare providers, and the lack of trans-competent healthcare providers and legal personnel hindered help-seeking following exposure to GBV. CONCLUSION: The immediate sources of GBV support services included key population-friendly healthcare facilities and CSOs, police, and friends and family. However, a significant number of transwomen did not report incidences of GBV. Transwomen were discriminated against at some key population healthcare facilities and CSOs, and police, which hindered help-seeking following exposure to GBV. This study highlights the need to tackle internalized stigma and discrimination against transwomen at the existing sources of GBV support. There is also a need to train law enforcers and legal personnel on the right to access healthcare among transwomen in Uganda.

Prevalence and characteristics of covert contraceptive use in the Performance Monitoring for Action multi-country study.

Objectives: A more nuanced understanding of contributors to covert contraceptive use remains critical to protecting covert users and reducing its necessity. This study aimed to examine the overall prevalence of covert use, and sociodemographic characteristics associated with covert vs overt use across multiple geographies in sub-Saharan Africa and Asia. Study Design: Performance Monitoring for Action (PMA) is one of the few nationally representative surveys that measures covert use across socially diverse contexts via a direct question. Utilizing PMA 2019-2020 phase 1 data from Burkina Faso, Côte D'Ivoire, Kenya, Democratic Republic of Congo (DRC; Kinshasa and Kongo Central regions), Uganda, Nigeria (Kano and Lagos), Niger, and Rajasthan, we estimated overall prevalence of covert use. We conducted bivariate analyses and multivariate logistic regressions for 6 sites, comparing the odds of covert use with overt use among users of contraception by sociodemographic characteristics. Results: Covert use ranged from 1% in Rajasthan to 16% in Burkina Faso. Marital status was the only sociodemographic characteristic consistently associated with type of use across sites. Specifically, polygynous marriage (compared to monogamous) increased odds of using covertly, ranging from adjusted odds ratio (aOR) of 1.8 [95% confidence interval (CI) 1.2-2.7] in Burkina Faso to 6.2 [95% CI 2.9-13.3] in Kinshasa. Unmarried women with partners or boyfriends were also more likely to be using covertly compared with their monogamously married counterparts in all sites (aORs ranged from 2.2 [95% CI 1.0-4.7] in Uganda to 4.4 [95% CI 1.7-11.0] in Kinshasa). Conclusion: Understanding factors associated with covert use has programmatic and policy implications for women's reproductive autonomy. Implications: Covert use is a common phenomenon across most sites, representing a small but programmatically important contingent of users. Family planning providers and programs must protect access to and maintain privacy of reproductive services to this population, but should also focus on creating interventions and environments that support overt use.

Total Demand, Use and Unmet Need for Modern Contraceptives Among Women Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda. Implications for Urban Health.

Background: Update and utilization of modern contraceptives has public health benefits including reduction of unintended pregnancies, unsafe abortions, and related maternal mortality. However, paucity of evidence on key indicators of family planning in the informal settlements abounds. Data are usually collapsed within the larger urban communities that tend to mask peculiarities of informal settlements. This study determined the proportion of women using modern contraceptives, the unmet need for modern contraceptives and the total demand in informal settlements of an urban municipality. Methods: A cross-sectional study conducted among 626 women in the reproductive age (15-49 years) in the informal settlements of Kira municipality (part of metropolitan Kampala). Multi-stage sampling was applied in the selection of the respondents. Descriptive and log-binomial regression analysis were conducted to determine percentage of women using modern contraceptives, unmet need, and total demand with their associated factors. All analyses were conducted using STATA version 15.0. Results: The total demand for modern contraceptives was 84.9%, modern contraceptive prevalence was 47.4% nearly meeting the national target of 50%, however the unmet need was 37.3%, which much higher than the national target of 10%. Lower total demand for contraceptives was associated with higher women's education status and preference to have another child, while higher total demand was associated with having at least one living child. Higher modern contraceptives use was associated with older age, having at least one living child and high decision-making power, while lower modern contraceptives use was associated with higher education and undetermined fertility preference. Lower unmet need for modern contraceptives was associated with older age (PR 0.68, 95% CI: 0.48-0.97) and high decision-making power (PR 0.64, 95% CI: 0.50-0.81), while higher unmet need was found among those who having at least one living child (PR 1.40, 95% CI: 1.01-1.93) and undetermined fertility preference (PR 1.70, 95% CI: 1.24-2.34). Conclusions: Total demand and contraceptive use were found to be higher in the informal settlements of Kira municipality, however, the unmet need was much higher among this population as compared to the national urban estimates. This indicates a much higher demand for contraceptives and the need to consider the diverse socio-demographic characteristics of urban spaces. Development of Interventions need to critically consider the diverse urban space, associated explanatory variables and a collaborative systems lens to achieve sustained improvements.

A Panel Study of Fertility Preferences and Contraceptive Dynamics in the Presence of Competing Pregnancy Risks in Uganda.

Although many studies have examined the influence of women's fertility preferences on subsequent fertility behavior and the role of contraceptive use intentions on unmet need, very few have explored their concurrent effects on contraceptive use dynamics. This study examines the independent concurrent effects of women's fertility preferences and contraceptive intentions on subsequent adoption and discontinuation, treating pregnancy as a competing risk factor that may alter contraceptive need. The data are derived from a 2018 follow-up survey of a 2014 national sample of 3,800 Ugandan female respondents of childbearing age. The survey included a contraceptive calendar that recorded pregnancy, birth, and contraceptive event episodes, including reasons for discontinuation. We use competing risk regression to estimate the effect of fertility preferences and contraceptive intentions on the cumulative incidence function of contraceptive behaviors, accounting for intervening pregnancy, female background covariates, loss to follow-up, and complex survey design. We find that women's contraceptive intentions significantly increase the rate of contraceptive adoption. After having adopted, women's contraceptive intentions have been realized and do not prolong use. The risk of discontinuation among women who adopted after baseline was significantly higher than for those using at baseline, irrespective of their initial intentions. The effectiveness of the type of contraceptive method chosen significantly lowered discontinuation risk. Fertility preferences were not significantly associated with either time to adoption or discontinuation. The pace of the fertility transition in this sub-Saharan African setting is likely being shaped by reproductive regulation through the intentional use of contraception that enables spacing births.

A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa.

Volitional sex is central to the sexual health and well-being of women and girls globally. To date, few studies have examined women's empowerment and its application to sexual health outcomes, including volitional sex. The aim of this study was to explore the relevance of a sexual and reproductive empowerment framework to volitional sex across four geographically and culturally diverse contexts in sub-Saharan Africa. Qualitative data were collected between July and August 2017 in four sites: Ethiopia, Nigeria (Anambra and Kano states) and Uganda. A total of 352 women aged 15-49 and 88 men aged 18 and older were interviewed through 120 in-depth interviews and 38 focus group discussions (n = 440 total participants). Results describe the substantial barriers restraining women's sexual choices, particularly norms that stigmatise women's requests for sex, even within marriage. Results further highlight women's internal sexual motivations, particularly related to the enjoyment of sex and the role of sex in strengthening partner relationships. Future empowerment research and measurement should focus not only on sexual constraints, but also integrate internal motivations, in order to fully understand the factors that shape women's sexual health outcomes.

Reconceptualizing Women's and Girls' Empowerment: A Cross-Cultural Index for Measuring Progress Toward Improved Sexual and Reproductive Health.

CONTEXT: Improving women's empowerment is pivotal to public health and development programs; however, inconsistent definitions and lack of cross-cultural measures compromise monitoring efforts. METHODS: Data collected in 2017-2018 in Ethiopia, Uganda and two sites in Nigeria were used to develop a cross-cultural index of women's and girls' empowerment in sexual and reproductive health (WGE-SRH). Item development was grounded in qualitative interviews, and informed by a conceptual framework that included domains of existence of choice and exercise of choice related to sex, contraceptive use and pregnancy. Items were pilot tested among 1,229 women aged 15-49 across sites. Psychometric properties were explored to identify crosssite constructs, and logistic regression was used to assess the construct validity of each dimension. RESULTS: Analyses identified subscales for sexual existence of choice (Cronbach's alphas, 0.71-0.79) and contraceptive existence of choice (0.56-0.78). A pregnancy existence of choice subscale emerged for only two sites (0.61-0.80). Internal reliability of the exercise of choice subscales varied. Construct validity analyses found that for some sites, high scores on the sexual and contraceptive existence of choice subscales were associated with elevated odds of volitional sex and contraceptive use, respectively. Combining the existence of choice and exercise of choice summary scores for sex strengthened associations with volitional sex. CONCLUSIONS: The cross-cultural WGE-SRH index can be used to assess existence of choice related to contraception and volitional sex. Further work is needed to improve measures of SRH exercise of choice, and investigate the index's multidimensionality and associations with SRH outcomes.

RESUMEN Contexto: Mejorar el empoderamiento de las mujeres es fundamental para los programas de salud pública y de desarrollo; sin embargo, la existencia de definiciones inconsistentes y la falta de medidas interculturales dificultan los esfuerzos de monitoreo. Métodos: Utilizamos datos recolectados entre 2017 y 2018 en Etiopía, Uganda y dos sitios en Nigeria para desarrollar un índice intercultural del empoderamiento de mujeres y niñas en materia de salud sexual y reproductiva (EMN-SSR). El desarrollo de sus componentes se basó en entrevistas cualitativas y se sustentó en un marco conceptual que incluyó dominios de existencia de opciones y ejercicio del poder de decisión en relación con las relaciones sexuales, el uso de anticonceptivos y el embarazo. Los componentes del índice se sujetaron a pruebas piloto en 1,229 mujeres en edades de 15 a 49 años en todos los sitios. Se exploraron las propiedades psicométricas para identificar constructos intersitios y regresión logística para evaluar la validez de los constructos de cada dimensión. Resultados: Los análisis identificaron subescalas para la existencia de opciones sexuales (Cronbach's alphas, 0.71­0.79) y la existencia de opciones anticonceptivas (0.56­0.78). Una subescala de existencia de opciones de embarazo surgió para solo dos sitios (0.61­0.80). La confiabilidad interna de las subescalas del ejercicio del poder de decisión varió. El análisis de validez de constructos encontró que, para algunos sitios, los puntajes altos en las subescalas de existencia de opciones sexuales y anticonceptivas estuvieron asociados con altas probabilidades de relaciones sexuales voluntarias y uso de anticonceptivos, respectivamente. La combinación de los puntajes resumidos de la existencia de opciones y el ejercicio del poder de decisión para las relaciones sexuales fortaleció las asociaciones con las relaciones sexuales voluntarias. Conclusiónes: El índice intercultural EMN-SSR puede usarse para valorar la existencia de opciones relacionadas con la anticoncepción y las relaciones sexuales voluntarias. Se necesita trabajo adicional para mejorar las medidas del ejercicio del poder de decisión y para investigar la multidimensionalidad y las asociaciones del índice con los resultados de SSR.

RÉSUMÉ Contexte: Les programmes de santé publique et de développement dépendent fondamentalement d'une meilleure auto-nomisation des femmes. Le manque de cohérence dans les définitions et l'absence de mesures transculturelles limitent cependant les efforts de suivi. Méthodes: Des données collectées en 2017­2018 en Éthiopie, en Ouganda et sur deux sites nigérians ont servi à l'élaboration d'un indice transculturel de l'autonomisation des femmes et des filles sur le plan de la santé sexuelle et reproductive (l'indice WGE-SRH). Des entretiens qualitatifs ont servi de base à l'élaboration des questions, avec l'aide d'une cadre conceptuel comprenant les domaines d'existence du choix et d'exercice du choix en matière de rapports sexuels, de pratique contraceptive et de grossesse. Les questions ont été testées parmi 1 229 femmes âgées de 15 à 49 ans sur l'ensemble des sites. Les propriétés psychométriques ont été examinées pour identifier les facteurs inter-sites et la validité conceptuelle de chaque dimension a été évaluée par régression logistique. Résultats: Les analyses ont identifié des sous-échelles pour l'existence du choix sur le plan sexuel (alpha de Cronbach, 0,71­0,79) et sur celui de la contraception (0,56­0,78). Concernant la grossesse, une sous-échelle d'existence du choix n'est apparue que pour deux sites (0,61­0,80). La fiabilité interne des sous-échelles d'exercice du choix s'est révélée variable. Les analyses de validité conceptuelle ont indiqué que, pour certains sites, les hautes cotes sur les sous-échelles d'existence du choix sur les plans sexuel et contraceptif étaient associées à des probabilités élevées de rapports sexuels volontaires et de pratique contraceptive, respectivement. La combinaison des cotes sommaires d'existence du choix et d'exercice du choix concernant les rapports sexuels renforçait les associations avec les rapports volontaires. Conclusions: L'indice transculturel WGE-SRH peut servir à évaluer l'existence du choix concernant la contraception et les rapports sexuels volontaires. Il faut toutefois améliorer les mesures d'exercice du choix en matière de santé sexuelle et reproductive et étudier plus avant la multidimensionnalité de l'indice et les associations avec les résultats de santé sexuelle et reproductive.

'I am the master key that opens and locks': Presentation and application of a conceptual framework for women's and girls' empowerment in reproductive health.

RATIONALE: A renewed focus on women's and girls' empowerment in the era of Sustainable Development Goals reflects the belief that empowerment is central to health and development. Sexual and reproductive health (SRH) outcomes, including pregnancy and contraceptive use, may contribute to and result from empowerment. However, enhanced understanding of how women become empowered for SRH requires clear conceptualization of empowerment. OBJECTIVE: We aimed to assess the applicability of a proposed framework for women's and girls' SRH empowerment (WGE-SRH) in sub-Saharan Africa. We sought to understand what shapes and motivates preferences for childbearing and contraception, exploring how women and girls navigate external pressures or rewards to exercise and achieve their reproductive goals. METHODS: Grounded in the WGE-SRH framework, we conducted a qualitative study in four distinct contexts (Ethiopia, Kano and Anambra States in Nigeria, and Uganda). We implemented and analyzed 120 in-depth interviews and 38 focus group discussions with 440 women and men and translated results to refine the WGE-SRH framework. RESULTS: Findings demonstrate the salience of women's internal motivations, including the social value and joys of motherhood, in shaping existence of reproductive choices. However, existence of choice was limited by couples' economic situations, pressures from providers, partners, and family members, and women's fears of contraceptive side effects or relationship dissolution. Despite these constraints, many found ways to exercise their reproductive choices through negotiation with partners, third party involvement in reproductive discussions, non-verbal communication, and covert use of contraception. CONCLUSIONS: The WGE-SRH framework is useful for exploring SRH empowerment, embracing the multilevel, dynamic nature of empowerment, as a process transitioning from existence of choice (autonomy) to exercise of choice (self-efficacy, decision-making, negotiation), and, ultimately, to achievement of choice. Future research and programs related to SRH empowerment should distinguish between existence and exercise of choices to promote the health and well-being of women and girls.

Modern contraceptive use among postpartum women living with HIV attending mother baby care points in Kabarole District, Uganda.

BACKGROUND: Preventing unintended pregnancies among women living with HIV is important for improving maternal and child health outcomes. Despite multiple contacts between postpartum women and healthcare providers at health facilities, modern contraceptive use during postpartum period remains low even among women with intentions to limit or delay childbearing. We estimated postpartum modern contraceptive use, unmet need and factors associated with modern contraceptive use among HIV positive women attending mother-baby HIV care points. METHODS: We conducted a cross-sectional study, between April and May 2016, among HIV positive women attending postpartum care at six health facilities in Kabarole district, Uganda. Health facilities were stratified by level prior to selecting participants using systematic sampling. We administered structured questionnaires to women who had delivered within the last two to 18 months. Women who reported current use of a modern method were categorized as modern contraceptive users. Women not using but wanted to stop childbearing or space childbirth by at least 2 years were considered to have unmet need for modern contraception. We estimated a modified Poisson regression model to examine variations in the use of modern methods by various characteristics of participants. RESULTS: We interviewed 369 women. Forty percent of them were using a modern method, with injectables being the most widely used. A third (33%) of the women had unmet need for modern methods, with unmet need for spacing (24%) being higher than for limiting births (9%). Modern contraceptive use was significantly higher among women who had delivered seven or more months earlier (Adj.PR = 2.02; CI: 1.49, 2.74); women who were counseled on family planning during antenatal care (Adj.PR = 1.53; CI: 1.07, 2.18); those who obtained methods through the care points (Adj.PR =2.27; CI: 1.32, 3.90); and those who jointly made decisions regarding childbearing with their partners (Adj.PR = 1.49; CI: 1.02, 2.17). CONCLUSION: Use of modern contraceptives was low while unmet need was high among postpartum women living with HIV. The findings suggest that there are gaps which indicate the need to strengthen contraceptive service delivery at these care-points. Providing family planning counseling early would improve uptake of contraception upon resumption of menses and sexual activity.

Investigating the early impact of the Trump Administration's Global Gag Rule on sexual and reproductive health service delivery in Uganda.

BACKGROUND: The Global Gag Rule (GGR), reinstated by President Trump in January 2017, makes non-U.S. non-governmental organizations ineligible for U.S. foreign assistance if they provide access to or information about abortion. While evidence suggests previous iterations of the GGR negatively impacted sexual and reproductive health outcomes, no studies have quantitatively assessed the impacts of the Trump administration's GGR. METHODS: We constructed a panel dataset of facilities (76% public) using 2017/2018 Performance Monitoring and Accountability 2020 service delivery point (SDP) surveys in Uganda. Based on information from stakeholder meetings, we classified districts as more or less exposed to the GGR; 45% (N = 34) of study districts were classified as "more exposed", which corresponded to 145 "more exposed" and 142 "less exposed" health facilities in our sample. We assessed changes in provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, engagement with community health workers (CHWs), service integration, and quality of care from 2017 (pre-GGR) to 2018 (post-GGR). Multivariable regression models were estimated, and difference-in-differences impact estimators were determined by calculating predicted probabilities from interaction terms for exposure and survey round. FINDINGS: We observed no immediate impact of the GGR on the provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, service integration, or quality of care. We did observe a significant impact of the policy on the average number of CHWs, with "more exposed" facilities engaging 3.8 fewer CHWs post-GGR (95% CI:-7.31,-0.32). CONCLUSIONS: The reduction in CHWs could reduce contraceptive use and increase unintended pregnancies in Uganda. The lack of other significant findings may not be surprising given the short post-GGR observation window. Rapid organizational responses and stopgap funding from foreign governments may have mitigated any immediate impacts on service delivery in the short term. The true impact may not be felt for many years, as stopgap funding potentially ebbs and service providers adapt to new funding environments.

Schistosomiasis infection in pre-school aged children in Uganda: a qualitative descriptive study to identify routes of exposure.

BACKGROUND: Prevalence of schistosomiasis is high among children under five years in Uganda. Schistosomiasis control efforts over time have included periodic mass treatments in endemic areas for adults and school going children aged 5 years and above. This study explores behaviour practices of children age 2-4 years that increase the risk of schistosomiasis infection in this age group. METHODS: A qualitative descriptive study was conducted using in-depth interviews with 30 caregivers of children aged 2-4 years who tested positive for schistosomiasis in a national prevalence survey in 2017. Observations were done at water bodies where young children go with caretakers or other older children. The study was conducted in three Ugandan sub-regions of West Nile and East-central, and South-western with high, and low prevalence of schistosomiasis, respectively. Data were thematically analysed. Anonymised supporting photos from observations are also presented. RESULTS: Knowledge about schistosomiasis transmission was poor among caregivers, who concurrently had mixed right and wrong information. Reported avenues for contracting schistosomiasis included both correct: contact activities with infested water, and incorrect modes: contact with dirty water, sharing bathrooms, witchcraft, polluted air and contaminated food. The children in this study could have contracted schistosomiasis through the contact with infested water during activities such as bathing and playing, while their caregivers washed clothes, collected snail shells for poultry feeds, fetched water at the water bodies. These activities were reported by caregivers and observed in all study areas. Evidence of open defecation and urination in and near water bodies by adults and children was also observed. CONCLUSIONS: Pre-school children age 2-4 years are at a high risk of exposure to schistosomiasis while caretakers conduct activities in infested water bodies. There is need for prevention interventions to target children in their early stages of life to control schistosomiasis in this vulnerable population.

Measuring family planning quality and its link with contraceptive use in public facilities in Burkina Faso, Ethiopia, Kenya and Uganda.

The individual impacts of several components of family planning service quality on contraceptive use have been studied, but the influence of a composite measure synthesizing these components has not been often investigated. We (1) develop a composite score for family planning service quality based on health facility data from Burkina Faso, Ethiopia, Kenya and Uganda and (2) examine the influence of structural quality on contraceptive practice in these four countries. We used nationally representative cross-sectional survey data of health facilities and women of reproductive age. First, we constructed quality scores for facilities using principal component analysis to integrate 18 variables. Second, we linked women to their closest facility using geo-coordinates. Third, we estimated multivariable logistic regression models to calculate women's odds ratios for modern contraceptive use adjusting for facilities' quality and other factors. In Burkina Faso, Ethiopia and Uganda, the odds of using a modern method of contraception was greater if the nearest facility provided high- or medium-quality services compared with low quality in the univariable model. After controlling for possible confounders, the adjusted odds ratios were significant for high quality (aOR: 3.12, P value: 0.005) and medium quality (aOR: 2.57, P value: 0.009) in Ethiopia and in the hypothesized direction but not statistically significant in Uganda or Burkina Faso, and in the opposite direction in Kenya. A process quality measure-having been visited by a community health worker-was statistically significantly associated with modern contraceptive use in three of the four countries (Burkina Faso aOR: 2.18, P value: 0.000; Ethiopia aOR: 1.78, P value: 0.000; Uganda aOR: 1.96, P value: 0.012). These results suggest that service quality in public facilities may be less relevant to contraceptive use in environments where the universe and reach of providers changes actively. Programs promoting contraception therefore need to consider quality within facility types and their service environments.

"Now that you are circumcised, you cannot have first sex with your wife": post circumcision sexual behaviours and beliefs among men in Wakiso district, Uganda.

INTRODUCTION: Safe male circumcision is an important biomedical intervention in the comprehensive HIV prevention programmes implemented in 14 sub-Saharan African countries with high HIV prevalence. To sustain its partial protective benefit, it is important that perceived reduced HIV risk does not lead to behavioural risk compensation among circumcised men and their sexual partners. This study explored beliefs that may influence post circumcision sexual behaviours among circumcised men in a programme setting. METHODS: Forty-eight in-depth interviews were conducted with newly circumcised men in Wakiso district, central Uganda. Twenty-five men seeking circumcision services at public health facilities in the district were recruited from May to June 2015 and, interviewed at baseline and after 6 months. Participants' beliefs and sexual behaviours were compared just after circumcision and at follow up to explore changes. Data were managed using atlas.ti7 and analysed following a thematic network analysis framework. RESULTS: Four themes following safe male circumcision emerged from this study. Beliefs related to: (1) sexual cleansing, (2) healing, (3) post SMC sexual capabilities and (4) continued HIV transmission risk. Most men maintained or adopted safer sexual behaviour; being faithful to their partner after circumcision or using condoms with extramarital partners following the knowledge that there was continued HIV risk post circumcision. The most prevalent risky belief was regarding sexual cleansing post circumcision, and as a result of this belief, some men had one off condom-less sexual intercourse with a casual partner. Some resumed sex before the recommended period due to misunderstanding of what comprised healing. CONCLUSIONS: Although most men maintained or adopted safer sexual behaviour, there were instances of risky sexual behaviour resulting from beliefs regarding the first sexual intercourse after circumcision or misunderstandings of what comprised wound healing. If not addressed, these may attenuate the safe male circumcision benefits of risk reduction for HIV.

Health facilities' readiness to provide friendly reproductive health services to young people aged 10-24 years in Wakiso district, Uganda.

BACKGROUND: While adolescents aged 10-19 years make up to 23.3% of Uganda's population, health facilities offering adolescent sexual and reproductive health services are few and do not fully address young people's needs. There is a paucity of evidence on the extent to which Ugandan health facilities in rural and peri-urban settings offer these services. This study assessed the readiness of health facilities to provide friendly reproductive health services to young people in rural and peri-urban contexts in Uganda. METHODS: The data for this paper come from a cross-sectional study that used quantitative and qualitative approaches to capture information. The study was conducted in 2012 in 32 health facilities in Wakiso district. It involved reviewing health facility records to assess client load for reproductive health services in the three months preceding data collection as well as key informant interviews with health managers and providers to identify gaps in service provision for young people. Quantitative data were entered into Epi-data and analysed using STATA10, while qualitative data were analysed using content analysis. FINDINGS: Among the 32 facilities visited; 41% (13/32) young people had to walk a distance of more than 5kms to access them, only one health centre had a separate space for providing services for adolescent clients and all facilities visited lacked a waiting room exclusive for young people. On the other hand, only 29% (9/32) and 22% (7/32) of the health facilities reported sufficient supplies and equipment respectively that are necessary for providing services that meet the needs of young people. Deliveries within the facilities were very low representing just 23% (1843/7975) of the number of young people who sought antenatal care services. Moreover 19% (6/32) of the facilities were not routinely screening for STIs yet in facilities where screening was being done, individuals younger than 15 years were being diagnosed with STIs. In addition, most facilities 86% (27/32) provided restricted family planning services to young people. No facility reported providing services responding to gender based violence while most facilities indicated verbal referrals for these services. CONCLUSION: The findings of this paper suggest the need for training and equipping health care workers in order to improve the provision of reproductive health services to young people.

Prototype Positive Control Wells for Malaria Rapid Diagnostic Tests: Prospective Evaluation of Implementation Among Health Workers in Lao People's Democratic Republic and Uganda.

Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis, but lack of quality control at point of care restricts trust in test results. Prototype positive control wells (PCW) containing recombinant malaria antigens have been developed to identify poor-quality RDT lots. This study assessed community and facility health workers' (HW) ability to use PCWs to detect degraded RDTs, the impact of PCW availability on RDT use and prescribing, and preferred strategies for implementation in Lao People's Democratic Republic (Laos) and Uganda. A total of 557 HWs participated in Laos (267) and Uganda (290). After training, most (88% to ≥ 99%) participants correctly performed the six key individual PCW steps; performance was generally maintained during the 6-month study period. Nearly all (97%) reported a correct action based on PCW use at routine work sites. In Uganda, where data for 127,775 individual patients were available, PCW introduction in health facilities was followed by a decrease in antimalarial prescribing for RDT-negative patients ≥ 5 years of age (4.7-1.9%); among community-based HWs, the decrease was 12.2% (P < 0.05) for all patients. Qualitative data revealed PCWs as a way to confirm RDT quality and restore confidence in RDT results. HWs in malaria-endemic areas are able to use prototype PCWs for quality control of malaria RDTs. PCW availability can improve HWs' confidence in RDT results, and benefit malaria diagnostic programs. Lessons learned from this study may be valuable for introduction of other point-of-care diagnostic and quality-control tools. Future work should evaluate longer term impacts of PCWs on patient management.