A Ugandan Parenting Programme to Prevent Gender-Based Violence: Description and Formative Evaluation.

Purpose: To develop a culturally-sensitive intervention for the early prevention of gender-based violence (GBV) in Uganda. Methods: Programme design followed the 6SQuID model of intervention development and multi-sectorial advice. A formative evaluation was conducted in two communities with six groups and 138 participants. Findings: Four familial predictors of GBV were identified as potentially malleable: poor parent-child attachment, harsh parenting, inequitable gendered socialization and parental conflict. A community-based parenting programme was developed to address them. Its programme theory incorporates Attachment Theory, the concept that positive behavioural control develops emotional control, and Social Learning Theory. Its rationale, structure and content are presented using the TIDieR checklist. A formative evaluation showed the programme to be widely acceptable, culturally appropriate, and perceived to be effective, but also identified challenges. Conclusion: The careful development of this community-based parenting programme shows promise for the early prevention of GBV.

Community perceptions of paediatric severe anaemia in Uganda.

BACKGROUND: Severe anaemia remains a major cause of morbidity and mortality among children in sub-Saharan Africa. There is limited research on the beliefs and knowledge for paediatric severe anaemia in the region. The effect of these local beliefs and knowledge on the healthcare seeking of paediatric severe anaemia remains unknown. OBJECTIVE: To describe community perceptions of paediatric severe anaemia in Uganda. METHODS: Sixteen in-depth interviews of caregivers of children treated for severe anaemia and six focus group discussions of community members were conducted in three regions of Uganda between October and November 2017. RESULTS: There was no common local name used to describe paediatric severe anaemia, but the disease was understood in context as 'having no blood'. Severe anaemia was identified to be a serious disease and the majority felt blood transfusion was the ideal treatment, but concomitant use of traditional and home remedies was also widespread. Participants articulated signs of severe pediatric anemia, such as palmar, conjunctival, and tongue pallor. Other signs described included jaundice, splenomegaly, difficulty in breathing and poor appetite. Poor feeding, malaria, splenomegaly and evil spirits were perceived to be the common causes of severe anaemia. Other causes included: human immunodeficiency virus (HIV), haemoglobinuria, fever, witchcraft, mosquito bites, and sickle cell. Splenomegaly and jaundice were perceived to be both signs and causes of severe anaemia. Severe anaemia was interpreted to be caused by evil spirits if it was either recurrent, led to sudden death, or manifested with cold extremities. CONCLUSION: The community in Uganda perceived paediatric severe anaemia as a serious disease. Their understanding of the signs and perceived causes of severe anaemia to a large extent aligned with known clinical signs and biological causes. Belief in evil spirits persists and may be one obstacle to seeking timely medical care for paediatric severe anaemia.

Incidence, patterns and risk factors for injuries among Ugandan children.

There is limited epidemiological data on childhood injuries in developing countries. This study assessed the incidence, patterns and risk factors for injuries among children aged 0-5 years in Wakiso District, Uganda. To determine differences, chi-square and Wilcoxon rank sum tests were used. Risk factors were assessed using Poisson regression. Overall, information from 359 children of mean age 32 months (SD: 18.4) was collected. Annual incidence of injuries was 69.8 per 1000 children/year (95% CI 58.8-80.8). One fatal injury due to burns was reported. Incidence of injuries was less associated with being female (IRR: 0.56, 95% CI 0.34-0.90) and increasing age of the caretaker (IRR: 0.96, 95% CI 0.92-0.99). The high incidence of childhood injuries necessitates the need for interventions to reduce injuries among children.

Relationship dynamics and sexual risk behaviour of male partners of female sex workers in Kampala, Uganda.

Regular male partners of female sex workers (FSWs) represent an important population to reach with HIV-prevention interventions. This paper discusses the relationship dynamics and HIV/sexually transmitted infection risk behaviour of men involved with self-identified FSWs in Kampala. Between 2011 and 2014 we conducted repeat in-depth interviews with 42 male partners of FSWs attending a clinic for women at high risk of HIV-infection in Kampala. Men publicly struggled with the stigma of dating women who are considered to be engaged in a shamed profession, but privately saw meaning in these relationships. In coping with the stigma, some described the work of their partners in terms that distanced them from sex work, while others struggled to have the control that "being a man" demanded since they could not monitor all movements of their partners. Dealing with HIV disclosure was hard and seeking support was difficult for some of the men, leading to missed opportunities and guilt. Despite challenges, relationships with sex workers offered men some benefits such as access to much needed care and treatment. A few men also admitted to being motivated by material and financial benefits from sex workers who they perceived as being rich and this was one factor that helped them sustain the relationships. These findings offer insights into the complex relationship dynamics within high risk sexual partnerships. However, the findings suggest that effective interventions that are couple centred can be established to promote better health.

Maternal experiences of caring for an infant with neurological impairment after neonatal encephalopathy in Uganda: a qualitative study.

PURPOSE: The study investigated maternal experiences of caring for a child affected by neurological impairment after neonatal encephalopathy (NE) ("birth asphyxia") in Uganda. METHODS: Between September 2011 and October 2012 small group and one-on-one in-depths interviews were conducted with mothers recruited to the ABAaNA study examining outcomes from NE in Mulago hospital, Kampala. Data were analysed thematically with the aid of Nvivo 8 software. FINDINGS: Mothers reported caring for an infant with impairment was often complicated by substantial social, emotional and financial difficulties and stigma. High levels of emotional distress, feelings of social isolation and fearfulness about the future were described. Maternal health-seeking ability was exacerbated by high transport costs, lack of paternal support and poor availability of rehabilitation and counselling services. Meeting and sharing experiences with similarly affected mothers was associated with more positive maternal caring experiences. CONCLUSION: Mothering a child with neurological impairment after NE is emotionally, physically and financially challenging but this may be partly mitigated by good social support and opportunities to share caring experiences with similarly affected mothers. A facilitated, participatory, community-based approach to rehabilitation training may have important impacts on maximising participation and improving the quality of life of affected mothers and infants. Implications for Rehabilitation Caring for an infant with neurological impairment after NE in Uganda has substantial emotional, social and financial impacts on families and is associated with high levels of emotional stress, feelings of isolation and stigma amongst mothers. Improved social support and the opportunity to share experiences with other similarly affected mothers are associated with a more positive maternal caring experience. High transport costs, lack of paternal support and poor availability of counselling and support services were barriers to maternal healthcare seeking. Studies examining the feasibility, acceptability and impact of early intervention programmes are warranted to maximise participation and improve the quality of life for affected mothers and their infants.

'Dented' and 'resuscitated' masculinities: the impact of HIV diagnosis and/or enrolment on antiretroviral treatment on masculine identities in rural eastern Uganda.

There is limited research on the impact of HIV or its treatment on men's identity construction and gender roles in sub-Saharan Africa. Based on in-depth research with 26 men in rural Uganda, this article discusses men's vulnerabilities and shifting gender relations and sense of masculinity resulting from HIV infection or enrolment on treatment in eastern Uganda. The findings suggest two broad categories of masculinity: respectable and reputational. HIV infection and illness dented masculinity as men lost authority within the domestic sphere. A weakened provider role and over-reliance on wives and children undermined masculinity as family head, and social sanctioning of their sexual activity, undermined conventional masculine identities predicted on reputation. However, treatment led to a more reflexive approach to demonstrating masculinity, increased attentiveness to health and restored hope to father children free of HIV, resuscitating respectable masculinities. The balance between eroded and restored masculinity varied between men by their treatment history, age, family composition and state of health. HIV support agencies need to pay attention to the way HIV and antiretroviral treatment (ART) influence men's perception of their masculinity and support them to overcome the anxieties about dented or eroded masculinity, while building on the positive ways in which treatment restores masculinity to support men's adherence to HIV treatment. In particular, there is a need to support men's engagement in productive activities that bring income so that men can regain their provider roles following ART and restore their respectability in both the public and the domestic sphere.

Masculinity, social context and HIV testing: an ethnographic study of men in Busia district, rural eastern Uganda.

BACKGROUND: Uptake of HIV testing by men remains low in high prevalence settings in many parts of Africa. By focusing on masculinity, this study explores the social context and relations that shape men's access to HIV testing in Mam-Kiror, Busia district, rural eastern Uganda. METHODS: From 2009-2010 in-depth interviews were undertaken with 26 men: nine being treated for HIV, eight who had tested but dropped out of treatment, six not tested but who suspected HIV infection and three with other health problems unrelated to HIV. These data were complemented by participant observation. Thematic analysis was undertaken. RESULTS: There were two main categories of masculinity in Mam-Kiror, one based on 'reputation' and the other on 'respectability', although some of their ideals overlapped. The different forms of masculine esteem led to different motives for HIV testing. Men positioned HIV testing as a social process understood within the social context and relationships men engaged in rather than an entirely self-determined enterprise. Wives' inferior power meant that they had less influence on men's testing compared to friends and work colleagues who discussed frankly HIV risk and testing. Couple testing exposed men's extra-marital relationships, threatening masculine esteem. The fear to undermine opportunities for sex in the context of competition for partners was a barrier to testing by men. The construction of men as resilient meant that they delayed to admit to problems and seek testing. However, the respectable masculine ideal to fulfil responsibilities and obligations to family was a strong motivator to seeking an HIV test and treatment by men. CONCLUSION: The two main forms of masculine ideals prevailing in Mam-Kiror in Busia led men to have different motives for HIV testing. Reputational masculinity was largely inconsistent with the requirements of couple testing, community outreach testing and the organisation of testing services, discouraging men from testing. Conversely, concern to perform one's family roles as a respectable man meant accessing treatment to extend one's life, which encouraged men to test. HIV support agencies should reflect on how various testing options might marginalise men from seeking testing services and address the barriers that hinder access.

Dividuality, masculine respectability and reputation: how masculinity affects men's uptake of HIV treatment in rural eastern Uganda.

There is increasing evidence in SSA that once infected with HIV men are disadvantaged compared to women in terms of uptake of treatment. In Uganda fewer men are on treatment, they tend to initiate treatment later, are difficult to retain on treatment and have a higher mortality while on treatment. This article discusses how men's response to HIV infection relates to their masculinity. We conducted participant observation and in-depth interviews with 26 men from a rural setting in eastern Uganda, in 2009-2010. They comprised men receiving HIV treatment, who had dropped treatment or did not seek it despite testing HIV positive, who had not tested but suspected infection, and those with other symptoms unrelated to HIV. Thematic analysis identified recurrent themes and variations across the data. Men drew from a range of norms to fulfil the social and individual expectations of being sufficiently masculine. The study argues that there are essentially two forms of masculinity in Mam-Kiror, one based on reputation and the other on respectability, with some ideals shared by both. Respectability was endorsed by 'the wider society', while reputation was endorsed almost entirely by men. Men's treatment seeking behaviours corresponded with different masculine ideologies. Family and societal expectations to be a family provider and respectable role model encouraged treatment, to regain and maintain health. However, reputational concern with strength and the capacity for hard physical work, income generation and sexual achievement discouraged uptake of HIV testing and treatment since it meant acknowledging weakness and an 'HIV patient' identity. Men's 'dividuality' allowed them to express different masculinities in different social contexts. We conclude that characteristics associated with respectable masculinity tend to encourage men's uptake of HIV treatment while those associated with reputational masculinity tend to undermine it.

How a masculine work ethic and economic circumstances affect uptake of HIV treatment: experiences of men from an artisanal gold mining community in rural eastern Uganda.

BACKGROUND: Current data from Uganda indicate that, compared to women, men are under-represented in HIV treatment, seek treatment later and have a higher mortality while on antiretroviral therapy (ART). By focusing on a masculine work ethic as one of the most predominant expressions of masculinity, this study explores why for some men HIV treatment enhances their masculinity while for others it undermines masculine work identity, leading them to discontinue the treatment. METHODS: Participant observation and 26 in-depth interviews with men were conducted in a gold mining village in Eastern Uganda between August 2009 and August 2010. Interviewees included men who were taking HIV treatment, who had discontinued treatment, who suspected HIV infection but had not sought testing, or who had other symptoms unrelated to HIV infection. RESULTS: Many participants reported spending large proportions of their income, alleviating symptoms prior to confirming their HIV infection. This seriously undermined their sense of masculinity gained from providing for their families. Disclosing HIV diagnosis and treatment to employers and work colleagues could reduce job offers and/or collaborative work, as colleagues feared working with "ill" people. Drug side-effects affected work, leading some men to discontinue the treatment. Despite being on ART, some men believed their health remained fragile, leading them to opt out of hard work, contradicting their reputation as hard workers. However, some men on treatment talked about "resurrecting" due to ART and linked their current abilities to work again to good adherence. For some men, it was work colleagues who suggested testing and treatment-seeking following symptoms. CONCLUSIONS: The central role of a work ethic in expressing masculinity can both encourage and discourage men's treatment-seeking for AIDS. HIV testing and treatment may be sought in order to improve health and get back to work, thereby in the process regaining one's masculine reputation as a hard worker and provider for one's family. However, disclosure can affect opportunities for work and drug side-effects disrupt one's ability to labour, undermining the sense of masculinity gained from work. HIV support organizations need to recognize how economic and gender concerns impact on treatment decisions and help men deal with work-related fears.

HIV serostatus disclosure and lived experiences of adolescents at the Transition Clinic of the Infectious Diseases Clinic in Kampala, Uganda: a qualitative study.

Most studies on HIV serostatus disclosure and adolescents focus on whether, how and when to disclose to adolescents their HIV diagnosis. Fewer studies have examined HIV serostatus disclosure by adolescents who know they are infected with HIV. This study presents qualitative data examining HIV serostatus and treatment disclosure practices and concerns of young people living with HIV in Uganda and the extent to which they are satisfied with current norms around HIV serostatus and treatment disclosure. We conducted two focus groups and interviewed 20 HIV-infected young people aged 15-23 receiving HIV care and treatment at the Transition Clinic in Kampala. Respondents perceived disclosure as a relationship encompassing both communication and self-conduct. Adolescents employed unique strategies to disclose their HIV status, notably joking to "test the waters" and emotionally prepare the other person before later disclosing in a more serious manner. Findings reinforce the idea that HIV disclosure is a process, not a one-time event. Interviewees anticipated both positive and negative outcomes of disclosure, including financial and emotional support, stigma, discrimination and rejection. They described a sense of violation of their autonomy when confidentiality was breached by third party disclosure, and also expressed fear of emotional distress for their loved ones. Although adolescents yearned to be in control of information about their HIV status and treatment, they have little space to call their own, and privacy is often compromised, especially because in traditional African settings, young people are considered to be dependents under the full responsibility of caregivers. Further exploration of disclosure outcomes and strategies specific to adolescents can help better tailor interventions towards youth. Antiretroviral therapy programmes should consider counselling for caretakers to appreciate and respect the privacy and disclosure concerns of their HIV-infected children.