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1.  Healthcare providers balancing norms and practice: challenges and opportunities in providing contraceptive counselling to young people in Uganda – a qualitative study 
Global Health Action  2016;9:10.3402/gha.v9.30283.
Background
Pregnancies among young women force girls to compromise education, resulting in low educational attainment with subsequent poverty and vulnerability. A pronounced focus is needed on contraceptive use, pregnancy, and unsafe abortion among young women.
Objective
This study aims to explore healthcare providers’ (HCPs) perceptions and practices regarding contraceptive counselling to young people.
Design
We conducted 27 in-depth interviews with doctors and midwives working in seven health facilities in central Uganda. Interviews were open-ended and allowed the participant to speak freely on certain topics. We used a topic guide to cover areas topics of interest focusing on post-abortion care (PAC) but also covering contraceptive counselling. Transcripts were transcribed verbatim and data were analysed using thematic analysis.
Results
The main theme, HCPs' ambivalence to providing contraceptive counselling to sexually active young people is based on two sub-themes describing the challenges of contraceptive counselling: A) HCPs echo the societal norms regarding sexual practice among young people, while at the same time our findings B) highlights the opportunities resulting from providers pragmatic approach to contraceptive counselling to young women. Providers expressed a self-identified lack of skill, limited resources, and inadequate support from the health system to successfully provide appropriate services to young people. They felt frustrated with the consultations, especially when meeting young women seeking PAC.
Conclusions
Despite existing policies for young people's sexual and reproductive health in Uganda, HCPs are not sufficiently equipped to provide adequate contraceptive counselling to young people. Instead, HCPs are left in between the negative influence of social norms and their pragmatic approach to address the needs of young people, especially those seeking PAC. We argue that a clear policy supported by a clear strategy with practical guidelines should be implemented alongside in-service training including value clarification and attitude transformation to equip providers to be able to better cater to young people seeking sexual and reproductive health advice.
doi:10.3402/gha.v9.30283
PMCID: PMC4865766  PMID: 27174861
contraceptive counselling; young people; health service provision; induced abortion
2.  Prevention of mother-to-child transmission of HIV in rural Uganda: Modelling effectiveness and impact of scaling-up PMTCT services 
Global Health Action  2015;8:10.3402/gha.v8.26308.
Background
The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010. However, the coverage estimate is subject to overestimations since it only considers enrolment and not completion of the PMTCT programme. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care (ANC), HIV testing, and ARVs for the woman and the baby.
Objective
The objective was to estimate the number of children infected with HIV in a district population, using empirical data on uptake of PMTCT components combined with data on MTCT rates.
Design
This study is based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008–2010. We later modelled different scenarios assuming increased uptake of specific PMTCT components to estimate the impact on MTCT for each scenario.
Results
In this setting, HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction.
Conclusions
Our results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT. Further, to determine the effectiveness of PMTCT programmes in different settings, it is crucial to analyse at what stages of the PMTCT cascade that dropouts occur to target interventions accordingly.
doi:10.3402/gha.v8.26308
PMCID: PMC4345173  PMID: 25726836
HIV; effectiveness; prevention of mother-to-child transmission; population-based; cohort
3.  Treatment patterns of childhood diarrhoea in rural Uganda: a cross-sectional survey 
Background
Diarrhoea is the second leading cause of death in children under five accounting for 1.8 million deaths yearly. Despite global efforts to reduce diarrhoea mortality through promotion of proper case management, there is still room for ample improvement. In order to seek options for such improvements this study explored the knowledge and practices of diarrhoea case management among health care providers at health centres and drug shops in Uganda.
Methods
Records were reviewed for case management and structured interviews concerning knowledge and practices were conducted with the staff at all health centres and at all identified drug shops in the rural district of Namutumba, Uganda.
Results
There was a significant gap between knowledge and documented practices among staff. Antibiotics, antimalarials and antipyretics were prescribed or recommended as frequently as Oral Rehydration Solution (ORS). In almost a third of the health facilities, ORS was out of stock. 81% of staff in health centres and 87% of staff in drug shops stated that they prescribed antibiotics for common diarrhoea. Zinc was not prescribed or recommended in any case.
Conclusions
The findings indicate that many children presenting with diarrhoea are inadequately treated. As a result they may not get the rehydration they need and are at risk of potential side effects from unjustified usage of antibiotics. Practices must be improved at health centres and drug shops in order to reduce childhood mortality due to diarrhoeal diseases.
doi:10.1186/1472-698X-12-19
PMCID: PMC3489860  PMID: 23009176
Diarrhoea; Diarrhoea case management; Diarrhoea control; Oral rehydration; Child health; Uganda
4.  Missed Opportunities: Barriers to HIV Testing during Pregnancy from a Population Based Cohort Study in Rural Uganda 
PLoS ONE  2012;7(8):e37590.
The aim was to assess population-level HIV-testing uptake among pregnant women, key for access to prevention-of mother to child transmission (PMTCT) services, and to identify risk factors for not being HIV tested,
The study was conducted May 2008–May 2010 in the Iganga/Mayuge Health and Demographic Surveillance Site (HDSS), Eastern Uganda, during regular surveillance of 68,000 individuals. All women identified to be pregnant May–July 2008 (n = 881) were interviewed about pregnancy-related issues and linked to the HDSS database for socio-demographic data. Women were followed-up via antenatal care (ANC) register reviews at the health facilities to collect data related to ANC services received, including HIV testing. Adjusted relative risk (aRR), and 95% confidence intervals (CI) for not being HIV tested were calculated using multivariable binomial regression among the 544 women who remained after record review.
Despite high ANC attendance (96%), the coverage of HIV testing was 64%. Only 6% of pregnant women who sought ANC at a facility without HIV testing services were referred for testing and only 20% received counseling regarding HIV. At ANC facilities with HIV testing services, 85% were tested. Only 4% of the women tested had been couple tested for HIV. Living more than three kilometers away from a health facility with HIV testing services was associated with not being tested both among the poorest (aRR,CI; 1.44,1.02–2.04) and the least poor women (aRR,CI;1.72,1.12–2.63).
The lack of onsite HIV testing services and distant ANC facilities lead to missed opportunities for PMTCT, especially for the poorest women. Referral systems for HIV testing need to be improved and testing should be expanded to lower level health facilities. This is in order to ensure that the policy of HIV testing during pregnancy is implemented more effectively and that testing is accessible for all.
doi:10.1371/journal.pone.0037590
PMCID: PMC3420922  PMID: 22916089
5.  Mistrust in marriage-Reasons why men do not accept couple HIV testing during antenatal care- a qualitative study in eastern Uganda 
BMC Public Health  2010;10:769.
Background
A policy for couple HIV counseling and testing was introduced in 2006 in Uganda, urging pregnant women and their spouses to be HIV tested together during antenatal care (ANC). The policy aims to identify HIV-infected pregnant women to prevent mother-to-child transmission of HIV through prophylactic antiretroviral treatment, to provide counseling, and to link HIV-infected persons to care. However, the uptake of couple testing remains low. This study explores men's views on, and experiences of couple HIV testing during ANC.
Methods
The study was conducted at two time points, in 2008 and 2009, in the rural Iganga and Mayuge districts of eastern Uganda. We carried out nine focus group discussions, about 10 participants in each, and in-depth interviews with 13 men, all of whom were fathers. Data were collected in the local language, Lusoga, audio-recorded and thereafter translated and transcribed into English and analyzed using content analysis.
Results
Men were fully aware of the availability of couple HIV testing, but cited several barriers to their use of these services. The men perceived their marriages as unstable and distrustful, making the idea of couple testing unappealing because of the conflicts it could give rise to. Further, they did not understand why they should be tested if they did not have symptoms. Finally, the perceived stigmatizing nature of HIV care and rude attitudes among health workers at the health facilities led them to view the health facilities providing ANC as unwelcoming. The men in our study had several suggestions for how to improve the current policy: peer sensitization of men, make health facilities less stigmatizing and more male-friendly, train health workers to meet men's needs, and hold discussions between health workers and community members.
Conclusions
In summary, pursuing couple HIV testing as a main avenue for making men more willing to test and support PMTCT for their wives, does not seem to work in its current form in this region. HIV services must be better adapted to local gender systems taking into account that incentives, health-seeking behavior and health system barriers differ between men and women.
doi:10.1186/1471-2458-10-769
PMCID: PMC3018443  PMID: 21167040
6.  Quality of antenatal care in rural southern Tanzania: a reality check 
BMC Research Notes  2010;3:209.
Background
Counselling on the danger signs of unpredictable obstetric complications and the appropriate management of such complications are crucial in reducing maternal mortality. The objectives of this study were to identify gaps in the provision of ANC services and knowledge of danger signs as well as the quality of care women receive in case of complications.
Findings
The study took place in the Rufiji District of Tanzania in 2008 and was conducted in seven health facilities. The study used (1) observations from 63 antenatal care (ANC) sessions evaluated with an ANC checklist, (2) self-assessments of 11 Health workers, (3) interviews with 28 pregnant women and (4) follow-up of 12 women hospitalized for pregnancy-related conditions.
Blood pressure measurements and abdominal examinations were common during ANC visits while urine testing for albumin or sugar or haemoglobin levels was rare which was often explained as due to a lack of supplies. The reasons for measuring blood pressure or abdominal examinations were usually not explained to the women. Only 15/28 (54%) women were able to mention at least one obstetric danger sign requiring medical attention. The outcomes of ten complicated cases were five stillbirths and three maternal complications. There was a considerable delay in first contact with a health professional or the start of timely interventions including checking vital signs, using a partograph, and detailed record keeping.
Conclusion
Linking danger signs to clinical and laboratory examination results during ANC with the appropriate follow up and avoiding delays in emergency obstetric care are crucial to the delivery of coordinated, effective care interventions.
doi:10.1186/1756-0500-3-209
PMCID: PMC3161364  PMID: 20663202
7.  Health information, an area for competition in Swedish pharmacies 
Pharmacy Practice  2008;6(2):74-78.
Objective
To investigate the views and expectations of a selected group of customers regarding health information in Swedish pharmacies.
Methods
A repeated cross sectional, questionnaire study carried out in 2004 and 2005. Customers buying calcium products answered questions on osteoporosis and general questions on health promotion and information.
Results
Respondents had a positive attitude towards receiving health information from the pharmacies and towards the pharmacies’ future role in health promotion. However, only 30% of the respondents expected to get information on general health issues from the pharmacy. In spite of this, 76% (2004) and 72% (2005) of the respondents believed that the pharmacies could influence people’s willingness to improve their health.
Conclusion
There is a gap between the respondents’ positive attitudes towards the Swedish pharmacies and their low expectations as regards the pharmacies’ ability to provide health information. In the light of the upcoming change to the state monopoly on medicine sales, this gap could be an important area for competition between the actors in the new situation for medicine sales in Sweden.
PMCID: PMC4141868  PMID: 25157284
Pharmacies; Community Pharmacy Services; Health Promotion; Sweden

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