Practices and attitudes of herbalists regarding informed consent in Uganda: A qualitative study.

Background: Informed consent (IC) is a fundamental principle in medical ethics that upholds respect for patient autonomy. Although widely applied in healthcare, its feasibility and implementation in herbal medicine have been underexplored. This study therefore aimed to explore the practices and attitudes of herbalists regarding informed consent. Methods: To achieve these objectives, a qualitative cross-sectional study was conducted from June to December 2020. Twenty-one in-depth interviews with herbalists and four key informant interviews with leaders of the different traditional medicine organizations were also conducted. The data were analyzed thematically using NVivo version 12 software. Results: Sixteen of the twenty-one participants acquired oral herbal medicine knowledge from their relatives. Although a positive inclination toward obtaining IC was evident, the focus was on disclosing basic information. Discussions of alternative treatments and herbal specifics less frequent. Disease management decisions often involve shared responsibility within families or societies. Documented IC procedures are rare among herbalists, who deem consent forms unnecessary, although they recognize the potential benefits of IC in fostering trust and professionalism. Challenges hindering IC implementation included regulatory gaps, inadequate skills, and the absence of mechanisms to protect the intellectual property rights of herbal medicine. Conclusion: This study illuminates how educational, cultural, familial, and regulatory factors influence herbalists' practices and attitudes toward informed consent.

Acceptability of hair harvest as a method of tuberculosis therapeutic drug monitoring among adult pulmonary TB patients: a qualitative study

Background: The current six months regimen for drug-susceptible tuberculosis (TB) is long, complex, and requires adherence monitoring. TB hair drug level assay is one innovative approach to monitor TB treatment adherence however, its acceptability in the context of African multi-cultural settings is not known. Objective: To determine the acceptability of hair harvest and testing as a TB therapeutic drug monitoring method. Methods: The study explored perceptions, and lived experiences among TB patients with regard to using hair harvest and testing as a method of tuberculosis therapeutic drug monitoring in the context of their cultural beliefs, and faith. We used a descriptive phenomenological approach. Results: Four main themes emerged namely: participants' perceptions about the cultural meaning of their body parts; perceptions about hair having any medical value or meaning; perceptions about hospitals starting to use hair harvest and testing for routine hospital TB treatment adherence monitoring; and perceived advantages and disadvantages of using hair for treatment adherence monitoring. Overall, we found that using hair to monitor adherence was acceptable to TB patients provided the hair was harvested and tested by a medical worker. Conclusion: Hair harvest for medical testing is acceptable to TB patients on the condition that it is conducted by a medical worker

Preferred techniques of hair harvest for medical testing among adult pulmonary TB patients

Background: Antiretroviral hair drug levels are currently being used to monitor adherence to HIV treatment. There is currently a dearth of literature on the preferred technique(s) of hair harvest for medical testing in the context of African multicultural settings. Objective: To explore the preferred techniques(s) of hair harvest for medical testing among TB patients. Methods: We used a descriptive phenomenological approach to conduct interviews for 15 TB patients from the 06th through the 24th of June 2022. Data was organized by N-VIVO version 10 and analysed step by step using a thematic analytical approach. Results: Participants aged <30 years were more knowledgeable, positively perceived, and experienced about the salon-based hair cutting technique compared to those aged≥30 years old. Participants aged ≥30 had experience, flexibility to use, and were knowledgeable in all three techniques, Overall, for all age categories (<30,30-40 and >40 years), majority of the respondents were knowledgeable, flexible and experienced in using all the three techniques. Conclusion: The majority of TB patients were knowledgeable, experienced and flexible about the hair cutting techniques however, efforts are needed to educate the youth that hair for medical testing can be cut by any of the three techniques without changing their cosmetic look.

Acceptability of hair harvest as a method of tuberculosis therapeutic drug monitoring among adult pulmonary TB patients: a qualitative study.

Background: The current six months regimen for drug-susceptible tuberculosis (TB) is long, complex, and requires adherence monitoring. TB hair drug level assay is one innovative approach to monitor TB treatment adherence however, its acceptability in the context of African multi-cultural settings is not known. Objective: To determine the acceptability of hair harvest and testing as a TB therapeutic drug monitoring method. Methods: The study explored perceptions, and lived experiences among TB patients with regard to using hair harvest and testing as a method of tuberculosis therapeutic drug monitoring in the context of their cultural beliefs, and faith. We used a descriptive phenomenological approach. Results: Four main themes emerged namely: participants' perceptions about the cultural meaning of their body parts; perceptions about hair having any medical value or meaning; perceptions about hospitals starting to use hair harvest and testing for routine hospital TB treatment adherence monitoring; and perceived advantages and disadvantages of using hair for treatment adherence monitoring. Overall, we found that using hair to monitor adherence was acceptable to TB patients provided the hair was harvested and tested by a medical worker. Conclusion: Hair harvest for medical testing is acceptable to TB patients on the condition that it is conducted by a medical worker.

Preferred techniques of hair harvest for medical testing among adult pulmonary TB patients.

Background: Antiretroviral hair drug levels are currently being used to monitor adherence to HIV treatment. There is currently a dearth of literature on the preferred technique(s) of hair harvest for medical testing in the context of African multicultural settings. Objective: To explore the preferred techniques(s) of hair harvest for medical testing among TB patients. Methods: We used a descriptive phenomenological approach to conduct interviews for 15 TB patients from the 06th through the 24th of June 2022. Data was organized by N-VIVO version 10 and analysed step by step using a thematic analytical approach. Results: Participants aged <30 years were more knowledgeable, positively perceived, and experienced about the salon-based hair cutting technique compared to those aged≥30 years old. Participants aged ≥30 had experience, flexibility to use, and were knowledgeable in all three techniques, Overall, for all age categories (<30,30-40 and >40 years), majority of the respondents were knowledgeable, flexible and experienced in using all the three techniques. Conclusion: The majority of TB patients were knowledgeable, experienced and flexible about the hair cutting techniques however, efforts are needed to educate the youth that hair for medical testing can be cut by any of the three techniques without changing their cosmetic look.

HIV counseling and testing practices among clients presenting at a market HIV clinic in Kampala, Uganda: a cross-sectional study.

BACKGROUND: Uptake of HIV counseling and testing (HCT) among informal sector workers is not well documented. OBJECTIVE: To assess HCT practices among clients presenting for HIV services at a market HIV clinic in Kampala, Uganda. METHODS: Between August 1 and September 15, 2009, clients presenting for HIV services at a market HIV clinic were invited to participate in the study. Socio-demographic and HCT data were collected from consenting adults aged 16+ years. Descriptive statistics were performed using STATA version 14.1. RESULTS: Of 224 individuals who consented to the interview, n=139 62 % were market vendors while n=85 38 % were engaged in other market-related activities. Majority of the respondents, n=165, 73.7 %, had ever tested for HIV; of these, n=148,89.7 % had ever tested for 2+ times. The main reasons for repeat testing were the need to confirm previous HIV test results, n=126, 85.1% and the belief that the previous HIV test results were false, n=35, 23.6 %. Uptake of couples' HCT was low, n=63, 38.2 %, despite the fact that n=200, 89 % had ever heard of couples' HCT. CONCLUSION: These findings indicate high rates of repeat testing but low rates of couples' HCT uptake in this population.

Hazardous alcohol consumption is not associated with CD4+ T-cell count decline among PLHIV in Kampala Uganda: A prospective cohort study.

INTRODUCTION: There is limited data on the effects of alcohol on immunological response among persons living with HIV (PLHIV) in sub-Saharan Africa. We assessed the relationship between hazardous alcohol use and CD4+ T-cell count, among PLHIV in Uganda. METHODS: PLHIV aged ≥ 18 years were enrolled in a cohort study at the Infectious diseases clinic Kampala, Uganda. Alcohol consumption was assessed at enrolment (baseline) and 6 monthly thereafter using the alcohol use disorders identification test (AUDIT). The CD4+ T-cell counts, assessed at baseline and over the next 12 months were compared between alcohol use strata, using linear mixed effects regression. Using longitudinal mediation analysis methods, we estimated the effect of alcohol induced ART non-adherence on CD4+ T-cell count. RESULTS: Of the 1566 participants enrolled, 863(44.1%) were non-alcohol users (AUDIT score = 0), 433(27.7%) were non-hazardous (AUDIT score 1-7) alcohol users while 270 (17.2%) were hazardous (AUDIT score ≥ 8) alcohol users. The overall median (IQR) baseline CD4+ T-cell count was 356 (243-516) cells/µl. There were no differences in the median baseline CD4+ T-cell count between hazardous and non-hazardous alcohol users compared to non-alcohol users in both the non-ART (p = 0.43) and ART group (p = 0.77). The mean CD4+ T-cell count over 12 months was not different between hazardous alcohol users and non-alcohol users (non-ART group p = 0.88 and ART group p = 0.62), nor between non-hazardous alcohol users and non-alcohol users (and non-ART group p = 0.66 and ART group p = 0.20). Alcohol use was not associated with a significant natural direct effect on CD4+ T-cell count (1.37 95%CI [-1.78, 4.52] cells/µl, p = 0.39) but had a statistically significant natural indirect effect on reduction of CD4+ T-cell count (-0.91 cells/µl [-1.36, -0.45], p < 0.001) mediated through ART non-adherence. CONCLUSION: Hazardous alcohol use among PLHIV was not directly associated with lower CD4+ T-cell count but had a significant natural indirect effect on CD4+ T-cell count mediated through ART non-adherence. Among PLHIV with lower than expected CD4+ T-cell count, alcohol consumption should be excluded as an underlying factor for non-adherence to ART and any interventions targeting alcohol use should tackle possible ART non-adherence.

Linking communities to formal health care providers through village health teams in rural Uganda: lessons from linking social capital.

BACKGROUND: Community-based programmes, particularly community health workers (CHWs), have been portrayed as a cost-effective alternative to the shortage of health workers in low-income countries. Usually, literature emphasises how easily CHWs link and connect communities to formal health care services. There is little evidence in Uganda to support or dispute such claims. Drawing from linking social capital framework, this paper examines the claim that village health teams (VHTs), as an example of CHWs, link and connect communities with formal health care services. METHODS: Data were collected through ethnographic fieldwork undertaken as part of a larger research program in Luwero District, Uganda, between 2012 and 2014. The main methods of data collection were participant observation in events organised by VHTs. In addition, a total of 91 in-depth interviews and 42 focus group discussions (FGD) were conducted with adult community members as part of the larger project. After preliminary analysis of the data, we conducted an additional six in-depth interviews and three FGD with VHTs and four FGD with community members on the role of VHTs. Key informant interviews were conducted with local government staff, health workers, local leaders, and NGO staff with health programs in Luwero. Thematic analysis was used during data analysis. RESULTS: The ability of VHTs to link communities with formal health care was affected by the stakeholders' perception of their roles. Community members perceive VHTs as working for and under instructions of "others", which makes them powerless in the formal health care system. One of the challenges associated with VHTs' linking roles is support from the government and formal health care providers. Formal health care providers perceived VHTs as interested in special recognition for their services yet they are not "experts". For some health workers, the introduction of VHTs is seen as a ploy by the government to control people and hide its inability to provide health services. Having received training and initial support from an NGO, VHTs suffered transition failure from NGO to the formal public health care structure. As a result, VHTs are entangled in power relations that affect their role of linking community members with formal health care services. We also found that factors such as lack of money for treatment, poor transport networks, the attitudes of health workers and the existence of multiple health care systems, all factors that hinder access to formal health care, cannot be addressed by the VHTs. CONCLUSIONS: As linking social capital framework shows, for VHTs to effectively act as links between the community and formal health care and harness the resources that exist in institutions beyond the community, it is important to take into account the power relationships embedded in vertical relationships and forge a partnership between public health providers and the communities they serve. This will ensure strengthened partnerships and the improved capacity of local people to leverage resources embedded in vertical power networks.

Undergraduate students' contributions to health service delivery through community-based education: A qualitative study by the MESAU Consortium in Uganda.

BACKGROUND: It has been realised that there is need to have medical training closer to communities where the majority of the population lives in order to orient the trainees' attitudes towards future practice in such communities. Although community based education (CBE) has increasingly been integrated into health professions curricula since the 1990s, the contribution students make to service delivery during CBE remains largely undocumented. In this study, we examined undergraduate health professions students' contribution to primary health care during their CBE placements. METHODS: This was a qualitative study involving the Medical Education for Equitable Services to All Ugandans consortium (MESAU). Overall, we conducted 36 Focus Group Discussions (FGDs): one each with youth, men and women at each of 12 CBE sites. Additionally, we interviewed 64 community key-informants. All data were audio-recorded, transcribed and analysed using qualitative data analysis software Atlas.ti Ver7. RESULTS: Two themes emerged: students' contribution at health facility level and students' contribution at community level. Under theme one, we established that students were not only learning; they also contributed to delivery of health services at the facilities. Their contribution was highly appreciated especially by community members. Students were described as caring and compassionate, available on time and anytime, and as participating in patient care. They were willing to share their knowledge and skills, and stimulated discussion on work ethics. Under the second theme, students were reported to have participated in water, sanitation, and hygiene education in the community. Students contributed to maintenance of safe water sources, educated communities on drinking safe water and on good sanitation practices (hand washing and proper waste disposal). Hygiene promotion was done at household level (food hygiene, hand washing, cleanliness) and to the public. Public health education was extended to institutions. School pupils were sensitised on various health-related issues including sexuality and sexual health. CONCLUSION: Health professions students at the MESAU institutions contribute meaningfully to primary health care delivery. We recommend CBE to all health training programs in sub-Saharan Africa.

Traditional birth attendants (TBAs) as potential agents in promoting male involvement in maternity preparedness: insights from a rural community in Uganda.

BACKGROUND: Since the 1994 International Conference on Population and Development, male involvement in reproductive health issues has been advocated as a means to improve maternal and child health outcomes, but to date, health providers have failed to achieve successful male involvement in pregnancy care especially in rural and remote areas where majority of the underserved populations live. In an effort to enhance community participation in maternity care, TBAs were trained and equipped to ensure better care and quick referral. In 1997, after the advent of the World Health Organization's Safe Motherhood initiative, the enthusiasm turned away from traditional birth attendants (TBAs). However, in many developing countries, and especially in rural areas, TBAs continue to play a significant role. This study explored the interaction between men and TBAs in shaping maternal healthcare in a rural Ugandan context. METHODS: This study employed ethnographic methods including participant observation, which took place in the process of everyday life activities of the respondents within the community; 12 focus group discussions, and 12 in-depth interviews with community members and key informants. Participants in this study were purposively selected to include TBAs, men, opinion leaders like village chairmen, and other key informants who had knowledge about the configuration of maternity services in the community. Data analysis was done inductively through an iterative process in which transcribed data was read to identify themes and codes were assigned to those themes. RESULTS: Contrary to the thinking that TBA services are utilized by women only, we found that men actively seek the services of TBAs and utilize them for their wives' healthcare within the community. TBAs in turn sensitize men using both cultural and biomedical health knowledge, and become allies with women in influencing men to provide resources needed for maternity care. CONCLUSION: In this study area, men trust and have confidence in TBAs; closer collaboration with TBAs may provide a suitable platform through which communities can be sensitized and men actively brought on board in promoting maternal health services for women in rural communities.

Selection and performance of village health teams (VHTs) in Uganda: lessons from the natural helper model of health promotion.

BACKGROUND: Community health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion. METHODS: As part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members. RESULTS: The VHT selection process created distrust, damaging the programme's legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community's members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work. CONCLUSION: As the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.

Level of understanding of co-trimoxazole use among HIV infected, recurrent pulmonary tuberculosis suspects at a national referral tuberculosis clinic in Kampala, Uganda: a qualitative analysis.

BACKGROUND: Co-trimoxazole use is the standard of care for preventing Pneumocystis jirovecii pneumonia in sub-Saharan Africa but implementation remains slow. Co-trimoxazole is self- administered with uncertain adherence. Knowledge of co-trimoxazole use among HIV infected persons is unknown. OBJECTIVES: To assess knowledge, attitudes and practices of co-trimoxazole use among HIV infected adults evaluated for recurrent PTB in Kampala, Uganda. METHODS: A qualitative study utilizing 5 focus group discussions among 30 HIV infected PTB suspects at the national referral tuberculosis treatment centre in Kampala. RESULTS: Males and females had similar median ages. 80% were currently on co-trimoxazole and 50% of participants were on HAART. Majority of participants defined co-trimoxazole as an analgesic. Few noted co-trimoxazole was a drug to treat cough and chest pain. However, few responses revealed that co-trimoxazole prevents opportunistic diseases among PLHIV. Most of participants believed HAART and anti-TB drugs work as co-trimoxazole thus it should not be taken together with them. This belief may lead to increased risk of opportunistic infections, morbidity and mortality. CONCLUSIONS: We revealed gaps in understanding of co-trimoxazole use among study participants. We therefore recommend that more facts about co-trimoxazle as prophylaxis against P. jirovecii, bacterial and diarrheal pathogens should be incorporated in VCT fact sheets.

Medical Education for Equitable Services for All Ugandans (MESAU) consortium: development and achievements.

PURPOSE: In 2011, five medical schools in Uganda formed the Medical Education for Equitable Services for All Ugandans consortium to address the medical education challenges in meeting the nation's health needs. In this paper, the authors document the development and achievements of this unique collaboration to transform medical education in Uganda. METHOD: A longitudinal qualitative study employed anthropological techniques to examine the proposed idea and development of the consortium, the experiences of consortium members, and the successes and challenges encountered during its first three years (2011-2013). RESULTS: The consortium approach to medical education has made important contributions to member institutions despite initial reservations and uncertainties. Acceptance of the consortium emerged because of the added benefits accruing to individual institutions and the network. The consortium has flourished partly because of its organizational structure, the support of its leadership, the ownership and active participation by member institutions, and a strong commitment to its broader goals. However, some challenges in implementation remain, including inadequate capacity, limited grants management experience, and varying degrees of research expertise among the participating institutions. CONCLUSIONS: Despite these challenges, the consortium approach has had a positive impact on medical education by reducing interinstitutional rivalries, promoting strong collaboration, and providing mutual support and the sharing of resources for medical education and research in Uganda.

Aetiology of pulmonary symptoms in HIV-infected smear negative recurrent PTB suspects in Kampala, Uganda: a cross-sectional study.

INTRODUCTION: Previously treated TB patients with pulmonary symptoms are often considered recurrent TB suspects in the resource-limited settings, where investigations are limited to microscopy and chest x-ray. Category II anti-TB drugs may be inappropriate and may expose patients to pill burden, drug toxicities and drug-drug interactions. OBJECTIVE: To determine the causes of pulmonary symptoms in HIV-infected smear negative recurrent pulmonary tuberculosis suspects at Mulago Hospital, Kampala. METHODS: Between March 2008 and December 2011, induced sputum samples of 178 consented HIV-infected smear negative recurrent TB suspects in Kampala were subjected to MGIT and LJ cultures for mycobacteria at TB Reference Laboratory, Kampala. Processed sputum samples were also tested by PCR to detect 18S rRNA gene of P.jirovecii and cultured for other bacteria. RESULTS: Bacteria, M. tuberculosis and Pneumocystis jirovecii were detected in 27%, 18% and 6.7% of patients respectively and 53.4% of the specimens had no microorganisms. S. pneumoniae, M. catarrhalis and H. influenzae were 100% susceptible to chloramphenicol and erythromycin but co-trimoxazole resistant. CONCLUSION: At least 81.5% of participants had no microbiologically-confirmed TB. However our findings call for thorough investigation of HIV-infected smear negative recurrent TB suspects to guide cost effective treatment.

Determinants of clinician knowledge on aging and HIV/AIDS: a survey of practitioners and policy makers in Kampala District, Uganda.

OBJECTIVE: The HIV/AIDS epidemic has evolved with an increasing burden in older adults. We assessed for knowledge about aging and HIV/AIDS, among clinicians in Kampala district, Uganda. METHODS: A cross-sectional survey of 301 clinicians complemented by 9 key-informant interviews between May and October 2011. Data was analyzed by multivariable logistic regression for potential determinants of clinician knowledge about HIV/AIDS in older adults, estimating their adjusted Odds Ratios (aOR) and 95% confidence intervals (95% CI) using Stata 11.2 software. RESULTS: Two-hundred and sixty-two questionnaires (87.7%) were returned. Respondents had a median age of 30 years (IQR 27-34) and 57.8% were general medical doctors. The mean knowledge score was 49% (range 8.8%-79.4%). Questions related to co-morbidities in HIV/AIDS (non-AIDS related cancers and systemic diseases) and chronic antiretroviral treatment toxicities (metabolic disorders) accounted for significantly lower scores (mean, 41.7%, 95% CI: 39.3%-44%) compared to HIV/AIDS epidemiology and prevention (mean, 65.7%, 95% CI: 63.7%-67.7%). Determinants of clinician knowledge in the multivariable analysis included (category, aOR, 95% CI): clinician age (30-39 years; 3.28∶1.65-9.75), number of persons with HIV/AIDS seen in the past year (less than 50; 0.34∶0.14-0.86) and clinical profession (clinical nurse practitioner; 0.31∶0.11-0.83). Having diploma level education had a marginal association with lower knowledge about HIV and aging (p = 0.09). CONCLUSION: Our study identified gaps and determinants of knowledge about HIV/AIDS in older adults among clinicians in Kampala district, Uganda. Clinicians in low and middle income countries could benefit from targeted training in chronic care for older adults with HIV/AIDS and long-term complications of antiretroviral treatment.

Task shifting for tuberculosis control: a qualitative study of community-based directly observed therapy in urban Uganda.

This qualitative study of task shifting examined tuberculosis (TB) therapy under modified community-based directly observed treatment short-course (CB-DOTS) in Kampala, Uganda. New TB patients selected one of two strategies: home-based DOTS and clinic-based DOTS. Relevant socio-economic characteristics, treatment-seeking experiences and outcomes were assessed over eight months of follow-up. Of 107 patients recruited, 89 (83%) selected home-based DOTS. Sixty-two patients (70%) under home-based DOTS and 16 patients (89%) under clinic-based DOTS had successful outcomes following completion of tuberculosis therapy. Treatment supporters' provision of social support beyond observing drug ingestion contributed to successful outcomes under both strategies. Home-based DOTS provides continuity of social support during therapy, strengthening the potential for treatment success. Conventional health facility-based DOTS can be modified in resource-limited urban Africa to offer a viable DOTS strategy that is sensitive to personal preference. Shifting the task of DOTS support away from only qualified health workers to include laypersons in the patients' social-support network may contribute to meeting World Health Organization (WHO) treatment targets. We recommend an intervention evaluating this modified DOTS strategy on a larger scale in TB high-burden, resource-poor urban settings.

Learning health professionalism at Makerere University: an exploratory study amongst undergraduate students.

BACKGROUND: Anecdotal evidence shows that unprofessional conduct is becoming a common occurrence amongst health workers in Uganda. The development of appropriate professional values, attitudes and behaviors is a continuum that starts when a student joins a health professional training institution and as such health professionals in training need to be exposed to the essence of professionalism. We sought to explore undergraduate health professions students' perceptions and experiences of learning professionalism as a preliminary step in addressing the problem of unprofessional conduct amongst health workers in Uganda. METHODS: Eight focus group discussions were conducted with 49 first to fifth year health professions undergraduate students of the 2008/2009 academic year at Makerere University College of Health Sciences. The focus group discussions were recorded and transcribed, and were analyzed using content analysis with emergent coding. RESULTS: The difference in the way first and fifth year students of Makerere University College of Health Sciences conceptualized professionalism was suggestive of the decline in attitude that occurs during medical education. The formal curriculum was described as being inadequate while the hidden and informal curricula were found to play a critical role in learning professionalism. Students identified role models as being essential to the development of professionalism and emphasized the need for appropriate role modeling. In our setting, resource constraints present an important, additional challenge to learning universal standards of health professionalism. Furthermore, students described practices that reflect the cultural concept of communalism, which conflicts with the universally accepted standard of individual medical confidentiality. The students questioned the universal applicability of internationally accepted standards of professionalism. CONCLUSIONS: The findings call for a review of the formal professionalism curriculum at Makerere University College of Health Sciences to make it more comprehensive and to meet the needs expressed by the students. Role models need capacity building in professionalism as health professionals and as educators. In our setting, resource constraints present an additional challenge to learning universal standards of health professionalism. There is need for further research and discourse on education in health professionalism in the Sub-Saharan context of resource constraints and cultural challenges.