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For many Indigenous Peoples, relationships to the land are inherent in identity and culture, and to all facets of health and wellbeing, physically, emotionally, psychologically, and spiritually. The Batwa are Indigenous Peoples of rural, southwest Uganda who have experienced tremendous social and economic upheaval, due to relatively recent forced displacement and land dispossession. This loss of physical connection to their ancestral lands has significantly impacted Batwa health, and also affected available healthcare options for Batwa. This exploratory study (1) identified and characterized factors that influence Batwa health-seeking behaviour, using acute gastrointestinal illness, a critical public health issue, as a focal point for analysis; and (2) explored possible intersections between the Batwa's connection to place-and displacement-and their health-seeking behaviour for acute gastrointestinal illness. Twenty focus group discussions, stratified by gender, were conducted in ten Batwa settlements in Kanungu District, Uganda and eleven semi-structured interviews were conducted with primary healthcare workers, community health coordinators, clinical officers, and development program coordinators. Qualitative data were thematically analyzed using a constant comparative method. Batwa identified several significant motivators to engage with Indigenous and/or biomedical forms of healthcare, including transition to life outside the forest and their reflections on health in the forest; 'intellectual access' to care and generational knowledge-sharing on the use of Indigenous medicines; and Batwa identity and way of life. These nuanced explanations for health-seeking behaviour underscore the significance of place-and displacement-to Batwa health and wellbeing, and its relationship to their health-seeking behaviour for acute gastrointestinal illness. As such, the results of this study can be used to inform healthcare practice and policy and support the development of a culturally- and contextually-appropriate healthcare system, as well as to reduce the burden of acute gastrointestinal illness among Batwa., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Brubacher et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Competing Interests: CZ-C declares that the university where she works received funds from the UK Research and Innovation (UKRI) agency under a Global Challenges Research Fund and Newton Fund Consolidation Account (GCNA) award, via the University of Leeds, to complete the current research in Peru. DBN declares that the institution where he works received funds from UKRI under a GCNA award, via the University of Leeds, to complete the current research in Uganda. JJM declares that grant support and payments have been made to his institution from the Alliance for Health Policy and Systems Research, Bloomberg Philanthropies (via the University of North Carolina Gillings School of Global Public Health), the Chilean National Fund for Scientific and Technological Development (via CIENCIACTIVA/CONCYTEC), the British Council, the British Embassy and the Newton-Paulet Fund, Wellcome Global Health Trials, Fogarty International Center, Grand Challenges Canada, International Development Research Center Canada, the Inter-American Institute for Global Change Research, the US National Cancer Institute, the US National Heart, Lung and Blood Institute, the US National Institute of Mental Health, the Swiss National Science Foundation, the UKRI Biotechnology and Biological Sciences Research Council, the UKRI Engineering and Physical Sciences Research Council, the UKRI Medical Research Council, and the World Diabetes Foundation, and had a contract with Health Action International, all of which were unrelated to this work. JJM is also co-chair of the UN Independent Group of Scientists 2023 Global Sustainable Development Report, a member of the Scientific Expert Committee of the Global Data Collaborative for CV Population Health of the World Heart Federation, Microsoft, and Novartis Foundation, a member of the Scientific and Technical Advisory Committee of the Alliance for Health Policy and Systems Research, WHO, a member of the WHO Technical Advisory Group on NCD-related Research and Innovation of the Department of Noncommunicable Diseases, WHO, and a member of the Advisory Scientific Committee of the Instituto de Investigación Nutricional (Peru). JJM also participated in the data safety monitoring board for the Nigeria Sodium Study (NaSS), the trial steering committee of the Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage trial (INTERACT 3), the international advisory board of the Latin American Brain Health Institute of Universidad Adolfo Ibáñez (Chile), the consultative board of the Programa de Gastronomía of the Facultad de Estudios Interdisciplinarios, Pontificia Universidad Católica del Perú, and an advisory board for the InterAmerican Heart Foundation. All other authors declare no competing interests.

COVID-19 has had uneven impacts on health and well-being, with Indigenous communities in the Global South facing some of the highest risks. Focusing on the experience of Sri Lanka, this study identifies key policy responses to COVID-19, documents how they evolved over two years of the pandemic, and examines if and how government responses have addressed issues pertaining to Indigenous Peoples. Drawing upon an analysis of policy documents (n = 110) and interviews with policymakers (n = 20), we characterize seven key policy responses implemented by the Sri Lankan government: i) testing for and identifying COVID-19; ii) quarantine procedures; iii) provisional clinical treatments; iv) handling other diseases during COVID-19; v) movement; vi) guidelines to be adhered to by the general public; and vii) health and vaccination. The nature of these responses changed as the pandemic progressed. There is no evidence that policy development or implementation incorporated the voices and needs of Indigenous Peoples., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

In 2017, the Global Task Force for Cholera Control (GTFCC) set a goal to eliminate cholera from ≥ 20 countries and to reduce cholera deaths by 90% by 2030. Many countries have included oral cholera vaccine (OCV) in their cholera control plans. We felt that a simple, user-friendly monitoring tool would be useful to guide national progress toward cholera elimination. We reviewed cholera surveillance data of Uganda from 2015 to 2021 by date and district. We defined a district as having eliminated cholera if cholera was not reported in that district for at least 4 years. We prepared maps to show districts with cholera, districts that had eliminated it, and districts that had eliminated it but then "relapsed." These maps were compared with districts where OCV was used and the hotspot map recommended by the GTFCC. Between 2018 and 2021, OCV was administered in 16 districts previously identified as hotspots. In 2018, cholera was reported during at least one of the four previous years from 36 of the 146 districts of Uganda. This number decreased to 18 districts by 2021. Cholera was deemed "eliminated" from four of these 18 districts but then "relapsed." The cholera elimination scorecard effectively demonstrated national progress toward cholera elimination and identified districts where additional resources are needed to achieve elimination by 2030. Identification of the districts that have eliminated cholera and those that have relapsed will assist the national programs to focus on addressing the factors that result in elimination or relapse of cholera.

Past influenza pandemics including the Spanish flu and H1N1 have disproportionately affected Indigenous Peoples. We conducted a systematic scoping review to provide an overview of the state of understanding of the experience of Indigenous peoples during the first 18 months of the COVID-19 pandemic, in doing so we capture the state of knowledge available to governments and decision makers for addressing the needs of Indigenous peoples in these early months of the pandemic. We addressed three questions: (a) How is COVID-19 impacting the health and livelihoods of Indigenous peoples, (b) What system level challenges are Indigenous peoples experiencing, (c) How are Indigenous peoples responding? We searched Web of Science, Scopus, and PubMed databases and UN organization websites for publications about Indigenous peoples and COVID-19. Results were analyzed using descriptive statistics and content analysis. A total of 153 publications were included: 140 peer-reviewed articles and 13 from UN organizations. Editorial/commentaries were the most (43%) frequent type of publication. Analysis identified Indigenous peoples from 19 different countries, although 56% of publications were centered upon those in Brazil, United States, and Canada. The majority (90%) of articles focused upon the general adult population, few (<2%) used a gender lens. A small number of articles documented COVID-19 testing (0.04%), incidence (18%), or mortality (16%). Five themes of system level challenges affecting exposure and livelihoods evolved: ecological, poverty, communication, education and health care services. Responses were formal and informal strategies from governments, Indigenous organizations and communities. A lack of ethnically disaggregated health data and a gender lens are constraining our knowledge, which is clustered around a limited number of Indigenous peoples in mostly high-income countries. Many Indigenous peoples have autonomously implemented their own coping strategies while government responses have been largely reactive and inadequate. To 'build back better' we must address these knowledge gaps., (© 2023 The Author(s). Published by IOP Publishing Ltd.)

Adequate complementary foods contribute to good health and growth in young children. However, many countries are still off-track in achieving critical complementary feeding indicators, such as minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD). In this study, we used the 2016 Ugandan Demographic Health Survey (UDHS) data to assess child feeding practices in young children aged 6-23 months. We assess and describe complementary feeding indicators (MMF, MDD and MAD) for Uganda, considering geographic variation. We construct multivariable logistic regression models-stratified by age-to evaluate four theorized predictors of MMF and MDD: health status, vaccination status, household wealth and female empowerment. Our findings show an improvement of complementary feeding practice indicators in Uganda compared to the past, although the MAD threshold was reached by only 22% of children. Children who did not achieve 1 or more complementary feeding indicators are primarily based in the northern regions of Uganda. Cereals and roots were the foods most consumed daily by young children (80%), while eggs were rarely eaten. Consistent with our hypotheses, we found that health status, vaccination status and wealth were significantly positively associated with MDD and MMF, while female empowerment was not. Improving nutrition in infant and young children is a priority. Urgent nutritional policies and acceptable interventions are needed to guarantee nutritious and age-appropriate complementary foods to each Ugandan child in the first years of life.

Background: Malaria epidemics are increasing in East Africa since the 1980s, coincident with rising temperature and widening climate variability. A projected 1-3.5 °C rise in average global temperatures by 2100 could exacerbate the epidemics by modifying disease transmission thresholds. Future malaria scenarios for the Lake Victoria Basin (LVB) are quantified for projected climate scenarios spanning 2006-2100., Methods: Regression relationships are established between historical (1995-2010) clinical malaria and anaemia cases and rainfall and temperature for four East African malaria hotspots. The vector autoregressive moving average processes model, VARMAX (p,q,s), is then used to forecast malaria and anaemia responses to rainfall and temperatures projected with an ensemble of eight General Circulation Models (GCMs) for climate change scenarios defined by three Representative Concentration Pathways (RCPs 2.6, 4.5 and 8.5)., Results: Maximum temperatures in the long rainy (March-May) and dry (June-September) seasons will likely increase by over 2.0 °C by 2070, relative to 1971-2000, under RCPs 4.5 and 8.5. Minimum temperatures (June-September) will likely increase by over 1.5-3.0 °C under RCPs 2.6, 4.5 and 8.5. The short rains (OND) will likely increase more than the long rains (MAM) by the 2050s and 2070s under RCPs 4.5 and 8.5. Historical malaria cases are positively and linearly related to the 3-6-month running means of monthly rainfall and maximum temperature. Marked variation characterizes the patterns projected for each of the three scenarios across the eight General Circulation Models, reaffirming the importance of using an ensemble of models for projections., Conclusions: The short rains (OND), wet season (MAM) temperatures and clinical malaria cases will likely increase in the Lake Victoria Basin. Climate change adaptation and mitigation strategies, including malaria control interventions could reduce the projected epidemics and cases. Interventions should reduce emerging risks, human vulnerability and environmental suitability for malaria transmission., (© 2022. The Author(s).)

The Batwa (Twa), an Indigenous People of southwest Uganda, were evicted from their ancestral forest lands in 1991 due to establishment of the Bwindi Impenetrable Forest. This land dispossession forced Batwa to transition from a semi-nomadic, hunting-gathering livelihood to an agricultural livelihood; eliminated access to Indigenous food, medicines, and shelter; and shifted their healthcare options. Therefore, this exploratory study investigated why Batwa choose Indigenous or biomedical treatment, or no treatment, when experiencing acute gastrointestinal illness. Ten gender-stratified focus groups were conducted in five Batwa settlements in Kanungu District, Uganda ( n  = 63 participants), alongside eleven semi-structured interviews (2014). Qualitative data were analysed thematically, using a constant comparative method. Batwa emphasised that health-seeking behaviour for acute gastrointestinal illness was diverse: some Batwa used only Indigenous or biomedical healthcare, while others preferred a combination, or no healthcare. Physical and economic access to care, and also perceived efficacy and quality of care, influenced their healthcare decisions. This study provides insight into the Kanungu District Batwa's perceptions of biomedical and Indigenous healthcare, and barriers they experience to accessing either. This study is intended to inform public health interventions to reduce their burden of acute gastrointestinal illness and ensure adequate healthcare, biomedical or Indigenous, for Batwa.

Background: There is concern in the international community regarding the influence of climate change on weather variables and seasonality that, in part, determine the rates of malaria. This study examined the role of sociodemographic variables in modifying the association between temperature and malaria in Kanungu District (Southwest Uganda)., Methods: Hospital admissions data from Bwindi Community Hospital were combined with meteorological satellite data from 2011 to 2014. Descriptive statistics were used to describe the distribution of malaria admissions by age, sex, and ethnicity (i.e. Bakiga and Indigenous Batwa). To examine how sociodemographic variables modified the association between temperature and malaria admissions, this study used negative binomial regression stratified by age, sex, and ethnicity, and negative binomial regression models that examined interactions between temperature and age, sex, and ethnicity., Results: Malaria admission incidence was 1.99 times greater among Batwa than Bakiga in hot temperature quartiles compared to cooler temperature quartiles, and that 6-12 year old children had a higher magnitude of association of malaria admissions with temperature compared to the reference category of 0-5 years old (IRR = 2.07 (1.40, 3.07))., Discussion: Results indicate that socio-demographic variables may modify the association between temperature and malaria. In some cases, such as age, the weather-malaria association in sub-populations with the highest incidence of malaria in standard models differed from those most sensitive to temperature as found in these stratified models., Conclusion: The effect modification approach used herein can be used to improve understanding of how changes in weather resulting from climate change might shift social gradients in health., (© 2022. The Author(s).)

Improving breastfeeding and complementary feeding practices is needed to support good health, enhance child growth, and reduce child mortality. Limited evidence is available on child feeding among Indigenous communities and in the context of environmental changes. We investigate past and present breastfeeding and complementary feeding practices within Indigenous Batwa and neighbouring Bakiga populations in south-western Uganda. Specifically, we describe the demographic and socio-economic characteristics of breastfeeding mothers and their children, and individual experiences of breastfeeding and complementary feeding practices. We investigate the factors that have an impact on breastfeeding and complementary feeding at community and societal levels, and we analysed how environments, including weather variability, affect breastfeeding and complementary feeding practices. We applied a mixed-method design to the study, and we used a community-based research approach. We conducted 94 individual interviews (n = 47 Batwa mothers/caregivers & n = 47 Bakiga mothers/caregivers) and 12 focus group discussions (n = 6 among Batwa & n = 6 among Bakiga communities) from July to October 2019. Ninety-nine per cent of mothers reported that their youngest child was currently breastfed. All mothers noted that the child experienced at least one episode of illness that had an impact on breastfeeding. From the focus groups, we identified four key factors affecting breastfeeding and nutrition practices: marginalisation and poverty; environmental change; lack of information; and poor support. Our findings contribute to the field of global public health and nutrition among Indigenous communities, with a focus on women and children. We present recommendations to improve child feeding practices among the Batwa and Bakiga in south-western Uganda. Specifically, we highlight the need to engage with local and national authorities to improve breastfeeding and complementary feeding practices, and work on food security, distribution of lands, and the food environment. Also, we recommend addressing the drivers and consequences of alcoholism, and strengthening family planning programs., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: J.E.C. is Director of Dietary assessment Ltd. No other competing interests to declare., (Copyright: © 2022 Scarpa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The global burden of maternal mortality remains high and inequitably distributed between countries. Antenatal care (ANC) was identified as critical component in achieving the Millennium Development Goal of improving maternal health. This scoping review aimed to summarize trends and critically explore research about ANC attendance for East African women conducted during the Millennium Development Goals initiative, with a specific focus on barriers to ANC access., Methods: Using a scoping review methodology, aggregator databases were searched for relevant articles. Articles were screened by independent reviewers using a priori inclusion criteria. Eligible articles were retained for data charting and analysis., Results: Following screening, 211 articles were analyzed. The number of relevant articles increased over time; utilized primarily quantitative methods; and involved authors with affiliations from various African countries. Many interrelated physical, social, and cultural factors influenced women's seeking, reaching, and receiving of quality ANC. The extent of studies identified suggest that ANC is a priority research area, yet key gaps in the literature exist. Limited qualitative research, and few articles examining ANC experiences of women from vulnerable groups (e.g. adolescents, women with a disability, and Indigenous women) were identified., Discussion: These context-specific findings are important considering the Sustainable Development Goals aim to nearly triple the maternal mortality reductions by 2030. In order to achieve this goal, interventions should focus on improving the quality of ANC care and patient-provider interactions. Furthermore, additional qualitative research examining vulnerable populations of women and exploring the inclusion of men in ANC would help inform interventions intended to improve ANC attendance in East Africa., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Comprehensive food lists and databases are a critical input for programs aiming to alleviate undernutrition. However, standard methods for developing them may produce databases that are irrelevant for marginalised groups where nutritional needs are highest. Our study provides a method for identifying critical contextual information required to build relevant food lists for Indigenous populations. For our study, we used mixed-methods study design with a community-based approach. Between July and October 2019, we interviewed 74 participants among Batwa and Bakiga communities in south-western Uganda. We conducted focus groups discussions (FGDs), individual dietary surveys and markets and shops assessment. Locally validated information on foods consumed among Indigenous populations can provide results that differ from foods listed in the national food composition tables; in fact, the construction of food lists is influenced by multiple factors such as food culture and meaning of food, environmental changes, dietary transition, and social context. Without using a community-based approach to understanding socio-environmental contexts, we would have missed 33 commonly consumed recipes and foods, and we would not have known the variety of ingredients' quantity in each recipe, and traditional foraged foods. The food culture, food systems and nutrition of Indigenous and vulnerable communities are unique, and need to be considered when developing food lists.

Introduction: The number of maternal deaths remains high in sub-Saharan Africa. Effective antenatal care (ANC) reduces maternal morbidity and mortality; therefore, provision of improved antenatal care services has been prioritised across sub-Saharan Africa. Yet, research is limited on the ANC experiences of Indigenous women in sub-Saharan Africa. This study characterised ANC attendance patterns at a hospital, and characterised factors influencing attendance among Bakiga and Indigenous Batwa women in Kanungu District, Uganda., Methods: A community-based, mixed-methods approach was used. Quantitative data were collected from a local hospital (records for 2299 ANC visits) and analysed by using descriptive statistics and multivariable regression analysis. Qualitative data from eight key informant interviews (n=9 healthcare providers) and 16 focus group discussions (n=120 Batwa and Bakiga women) were analysed by thematic analysis., Results: Most ANC patients attended between one and three ANC visits per pregnancy (n=1259; 92.57%), and few attended the recommended four or more visits (n=101; 7.43%). Distance from a woman's home to the hospital was significantly associated with lower ANC attendance (p<0.05, 95% confidence interval 0.01-0.96), after adjusting for maternal age and number of previous pregnancies. The qualitative data revealed that many factors influenced ANC attendance for both Batwa and Bakiga: long distances from the home to a health centre, high direct and indirect costs of ANC, lack of power in household decision-making, and poor interactions with healthcare providers. While the types of barriers were similar among Batwa and Bakiga, some were more pronounced for Indigenous Batwa women., Conclusion: This study partnered with and collected in-depth data with Indigenous Peoples who remain underrepresented in the literature. The findings indicated that Indigenous Batwa continue to face unique and more pronounced barriers to accessing ANC in Kanungu District, Uganda. Ensuring access to ANC for these populations requires an in-depth understanding of their experiences within the local healthcare context. To reduce health inequities that Indigenous Peoples experience, policy-makers and healthcare workers need to adequately understand, effectively address, and appropriately prioritise factors influencing ANC attendance.

Objective: To develop an online food composition database of locally consumed foods among an Indigenous population in south-western Uganda., Design: Using a community-based approach and collaboration with local nutritionists, we collected a list of foods for inclusion in the database through focus group discussions, an individual dietary survey and markets and shops assessment. The food database was then created using seven steps: identification of foods for inclusion in the database; initial data cleaning and removal of duplicate items; linkage of foods to existing generic food composition tables; mapping and calculation of the nutrient content of recipes and foods; allocating portion sizes and accompanying foods; quality checks with local and international nutritionists; and translation into relevant local languages., Setting: Kanungu District, south-western Uganda., Participants: Seventy-four participants, 36 Indigenous Batwa and 38 Bakiga, were randomly selected and interviewed to inform the development of a food list prior the construction of the food database., Results: We developed an online food database for south-western Uganda including 148 commonly consumed foods complete with values for 120 micronutrients and macronutrients. This was for use with the online dietary assessment tool myfood24. Of the locally reported foods included, 56 % (n 82 items) of the items were already available in the myfood24 database, while 25 % (n 37 items) were found in existing Ugandan and Tanzanian food databases, 18 % (n 27 items) came from generated recipes and 1 % (n 2 items) from food packaging labels., Conclusion: Locally relevant food databases are sparse for African Indigenous communities. Here, we created a tool that can be used for assessing food intake and for tracking undernutrition among the communities living in Kanungu District. This will help to develop locally relevant food and nutrition policies.

Background: Climate change is expected to decrease food security globally. Many Indigenous communities have heightened sensitivity to climate change and food insecurity for multifactorial reasons including close relationships with the local environment and socioeconomic inequities which increase exposures and challenge adaptation to climate change. Pregnant women have additional sensitivity to food insecurity, as antenatal undernutrition is linked with poor maternal-infant health. This study examined pathways through which climate change influenced food security during pregnancy among Indigenous and non-Indigenous women in rural Uganda. Specific objectives were to characterize: 1) sensitivities to climate-associated declines in food security for pregnant Indigenous women; 2) women's perceptions of climate impacts on food security during pregnancy; and 3) changes in food security and maternal-infant health over time, as observed by women., Methods: Using a community-based research approach, we conducted eight focus group discussions-four in Indigenous Batwa communities and four in non-Indigenous communities-in Kanungu District, Uganda, on the subject of climate and food security during pregnancy. Thirty-six women with ≥1 pregnancy participated. Data were analysed using a constant comparative method and thematic analysis., Results: Women indicated that food insecurity was common during pregnancy and had a bidirectional relationship with antenatal health issues. Food security was thought to be decreasing due to weather changes including extended droughts and unpredictable seasons harming agriculture. Women linked food insecurity with declines in maternal-infant health over time, despite improved antenatal healthcare. While all communities described food security struggles, the challenges Indigenous women identified and described were more severe., Conclusions: Programs promoting women's adaptive capacity to climate change are required to improve food security for pregnant women and maternal-infant health. These interventions are particularly needed in Indigenous communities, which often face underlying health inequities. However, resiliency among mothers was strong and, with supports, they can reduce food security challenges in a changing climate., Competing Interests: The authors have declared that no competing interests exist.

Background: The effects of food insecurity linked to climate change will be exacerbated in subsistence communities that are dependent upon food systems for their livelihoods and sustenance. Place-and community-based forms of surveillance are important for growing an equitable evidence base that integrates climate, food, and health information as well as informs our understanding of how climate change impacts health through local and Indigenous subsistence food systems., Methods: We present a case-study from southwestern Uganda with Batwa and Bakiga subsistence communities in Kanungu District. We conducted 22 key informant interviews to map what forms of monitoring and knowledge exist about health and subsistence food systems as they relate to seasonal variability. A participatory mapping exercise accompanied key informant interviews to identify who holds knowledge about health and subsistence food systems. Social network theory and analysis methods were used to explore how information flows between knowledge holders as well as the power and agency that is involved in knowledge production and exchange processes., Results: This research maps existing networks of trusted relationships that are already used for integrating diverse knowledges, information, and administrative action. Narratives reveal inventories of ongoing and repeated cycles of observations, interpretations, evaluations, and adjustments that make up existing health and subsistence food monitoring and response. These networks of local health and subsistence food systems were not supported by distinct systems of climate and meteorological information. Our findings demonstrate how integrating surveillance systems is not just about what types of information we monitor, but also who and how knowledges are connected through existing networks of monitoring and response., Conclusion: Applying conventional approaches to surveillance, without deliberate consideration of the broader contextual and relational processes, can lead to the re-marginalization of peoples and the reproduction of inequalities in power between groups of people. We anticipate that our findings can be used to inform the initiation of a place-based integrated climate-food-health surveillance system in Kanungu District as well as other contexts with a rich diversity of knowledges and existing forms of monitoring and response.

East Africa is highly affected by neglected tropical diseases (NTDs), which are projected to be exacerbated by climate change. Consequently, understanding what research has been conducted and what knowledge gaps remain regarding NTDs and climate change is crucial to informing public health interventions and climate change adaptation. We conducted a systematic scoping review to describe the extent, range, and nature of publications examining relationships between NTDs and climatic factors in East Africa. We collated all relevant English and French publications indexed in PubMed ® , Web of Science™ Core Collection, and CAB Direct © databases published prior to 2019. Ninety-six publications were included for review. Kenya, Tanzania, and Ethiopia had high rates of publication, whereas countries in the Western Indian Ocean region were underrepresented. Most publications focused on schistosomiasis ( n = 28, 29.2%), soil-transmitted helminthiases ( n = 16, 16.7%), or human African trypanosomiasis ( n = 14, 14.6%). Precipitation ( n = 91, 94.8%) and temperature ( n = 54, 56.3%) were frequently investigated climatic factors, whereas consideration of droughts ( n = 10, 10.4%) and floods ( n = 4, 4.2%) was not prominent. Publications reporting on associations between NTDs and changing climate were increasing over time. There was a decrease in the reporting of Indigenous identity and age factors over time. Overall, there were substantial knowledge gaps for several countries and for many NTDs. To better understand NTDs in the context of a changing climate, it would be helpful to increase research on underrepresented diseases and regions, consider demographic and social factors in research, and characterize how these factors modify the effects of climatic variables on NTDs in East Africa.

Introduction: Indigenous populations in low-income regions are often the most acutely affected by social gradients that impact health, including high burdens of infectious disease. Using a mixed methods approach, this study characterized the lived experience of acute gastrointestinal illness (AGI) in an Indigenous Batwa population in south-western Uganda., Methods: Quantitative data analyses were conducted on data from three cross-sectional census surveys of Batwa conducted in January 2013 (n=583), January 2014 (n=569) and April 2014 (n=540). Using a 14-day recall period, cases of AGI were defined as three or more loose stools or any vomiting in a 24-hour period. These analyses were supplemented by qualitative data from key informant interviews (n=11 interviews) and Batwa focus group discussions (n=61 participants)., Results: From the surveys, episodes of diarrhea and episodes of vomiting lasted on average 3.6 (95%CI 2.3-4.3) and 3.0 (95%CI 2.1-3.9) days, and individuals experienced an average of 4.3 (95%CI 3.9-4.8) and 2.6 (95%CI 2.1-3.1) loose stools and vomiting episodes in 24 hours. Focus group participants and key informants indicated that episodes of AGI for Batwa were not limited to symptom-based consequences for the individual, but also had economic, social and nutritional impacts., Conclusion: Despite efforts to increase health literacy in disease transmission dynamics, risks and prevention measures, the perceived barriers and a lack of benefits still largely underscored adopting positive AGI prevention behaviors. This study moved beyond surveillance and provided information on the broader community-level burden of AGI and highlighted the current challenges and opportunities for improved uptake of AGI prevention measures for the Batwa.

Background: With an increasing number of women attending antenatal care for the recommended number of contacts, focus now must be placed on the quality and utility of care; without understanding adherence, the true contribution of antenatal care to improved maternal health outcomes is difficult to determine., Objective: This research explored the practicality of antenatal care recommendations for women and the factors which facilitate or hinder adherence and shape the overall utility of care., Design: Qualitative data were collected using a community-centred approach by means of focus group discussions with women and key informant interviews with healthcare providers throughout May and June of 2017. Data were analysed via thematic analysis guided by an essentialist/realist paradigm., Setting: Kanungu District, Uganda; a district in southwestern Uganda., Participants: A convenience sample of 38 Indigenous Batwa and non-Indigenous Bakiga women from four matched communities and three healthcare providers., Findings: A number of barriers to antenatal care adherence were identified which included a lack of monetary and material resources, a lack of a shared understanding and perceived value of care, and gender and position-based power dynamics, all of which were compounded by previous experiences with antenatal care. The factors identified which influenced adherence were highly complex and non-linear, affected by individual, community, health centre, and health system-level factors. Promotion of spousal involvement in antenatal care had different effects based on pre-existing individual levels of spousal support, either improving or hindering adherence. A lack of resources created a double burden for women through which maternal health was jeopardized by the inability to adhere to antenatal care recommendations and the poor quality patient-provider relationships which resulted and deterred future antenatal care attendance., Key Conclusions and Implications for Practice: The capacity to avail oneself of antenatal care varied significantly for women based on their socio-economic status, levels of autonomy, and spousal support. Strategies to improve antenatal care need to focus on health equity to ensure care has a high degree of utility for all women. The interconnectedness of care and those who deliver care necessitates healthcare providers to develop strong patient-provider relationships through their attitudes, behaviours, and the delivery of equitable care. In light of a historical emphasis on attendance, this research highlights the significance of improving the quality and utility of antenatal care, inclusive of Indigenous perspectives, to deliver high-value care., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Half of all Ugandans (49%) turn to the private or private-not-for-profit (PNFP) sectors when faced with illness, yet little is known about the capacity of these sectors to deliver surgical services. We partnered with the Ministry of Health to conduct a nationwide mixed-methods evaluation of private and PNFP surgical capacity in Uganda., Methods: A standardized validated facility assessment tool was utilized to assess facility infrastructure, service delivery, workforce, information management, and financing at a randomized nationally representative sample of 16 private and PNFP hospitals. Semi-structured interviews were conducted to qualitatively explore facilitating factors and barriers to surgical, obstetric and anaesthesia (SOA) care. Hospitals walk-throughs and retrospective reviews of operative logbooks were completed., Results: Hospitals had a median of 177 beds and two operating rooms. Ten hospitals (62.5%) were able to perform all Bellwether procedures (cesarean section, laparotomy and open fracture treatment). Thirty-day surgical volume averaged 102 cases per facility. While most hospitals had electricity, oxygen, running water, and necessary equipment, many reported pervasive shortages of blood, surgical consumables, and anesthetic drugs. Several themes emerged from the qualitative analysis: (1) geographic distance and limited transportation options delay reaching care; (2) workforce shortages impede the delivery of surgical care; (3) emergency and obstetric volume overwhelm the surgical system; (4) medical and non-medical costs delay seeking, reaching, and receiving care; and (5) there is poor coordination of care with insufficient support systems., Conclusion: As in Uganda's public sector, barriers to surgery in private and PNFP hospitals in Uganda are cross-cutting and closely tied to resource availability. Critical policy and programmatic developments are essential to build and strengthen Ugandan surgical capacity across all sectors., Competing Interests: The authors have declared that no competing interests exist.

Acute gastrointestinal illness (AGI) is a global public health priority that often disproportionately effects Indigenous populations. While previous research examines the association between meteorological conditions and AGI, little is known about how socio-cultural factors may modify this relationship. This present study seeks to address this research gap by comparing AGI prevalence and determinants between an Indigenous and non-Indigenous population in Uganda. We estimate the 14-day self-reported prevalence of AGI among adults in an Indigenous Batwa population and their non-Indigenous neighbours using cross-sectional panel data collected over four periods spanning typically rainy and dry seasons (January 2013 to April 2014). The independent associations between Indigenous status, precipitation, and AGI are examined with multivariable multi-level logistic regression models, controlling for relative wealth status and clustering at the community level. Estimated prevalence of AGI among the Indigenous Batwa was greater than among the non-Indigenous Bakiga. Our models indicate that both Indigenous identity and decreased levels of precipitation in the weeks preceding the survey period were significantly associated with increased AGI, after adjusting for confounders. Multivariable models stratified by Indigenous identity suggest that Indigenous identity may not modify the association between precipitation and AGI in this context. Our results suggest that short-term changes in precipitation affect both Indigenous and non-Indigenous populations similarly, though from different baseline AGI prevalences, maintaining rather than exacerbating this socially patterned health disparity. In the context of climate change, these results may challenge the assumption that changing weather patterns will necessarily exacerbate existing socially patterned health disparities., Competing Interests: The authors have declared that no competing interests exist.

Malaria forecasts from dynamical systems have never been attempted at the health district or local clinic catchment scale, and so their usefulness for public health preparedness and response at the local level is fundamentally unknown. A pilot preoperational forecasting system is introduced in which the European Centre for Medium Range Weather Forecasts ensemble prediction system and seasonal climate forecasts of temperature and rainfall are used to drive the uncalibrated dynamical malaria model VECTRI to predict anomalies in transmission intensity 4 months ahead. It is demonstrated that the system has statistically significant skill at a number of sentinel sites in Uganda with high-quality data. Skill is also found at approximately 50% of the Ugandan health districts despite inherent uncertainties of unconfirmed health reports. A cost-loss economic analysis at three example sentinel sites indicates that the forecast system can have a positive economic benefit across a broad range of intermediate cost-loss ratios and frequency of transmission anomalies. We argue that such an analysis is a necessary first step in the attempt to translate climate-driven malaria information to policy-relevant decisions., Competing Interests: The authors declare no conflicts of interest relevant to this study., (©2019. The Authors.)

Background: Little is known about operative volume, distribution of cases, or capacity of the public sector to deliver essential surgical services in Uganda., Methods: A standardized mixed-methods surgical assessment and retrospective operative logbook review were completed at 16 randomly selected public hospitals serving 64·0% of Uganda's population., Results: A total of 3014 operations were recorded, annualizing to a surgical volume of 36,670 cases/year or 144·5 operations/100,000people/year. Absolute surgical volume was greater at regional referral than general hospitals (p < 0·001); but, relative surgical volume/catchment population was greater at the general versus regional level (p = 0·03). Most patients undergoing operations were women (78·3%) with a mean age of 26·9 years. The overall case distribution was 69·0% obstetrics/gynecology, 23·7% general surgery, 4·0% orthopedics, and 3·3% other subspecialties. Cesarean sections were the most common operation (55·8%). Monthly operative volume was strongly predicted by number of surgical, anesthetic, and obstetric physician providers (훽=10·72, p = 0·005, R 2  = 0·94) when controlling for confounders. Notably, operative volume was not correlated with availability of electricity, oxygen, light source, suction, blood, instruments, suture, gloves, intravenous fluid, or antibiotics., Conclusion: An understanding of operative case volume and distribution is essential in facilitating targeted interventions to strengthen surgical capacity. These data suggest that surgical workforce is the critical driver of operative volume in the Ugandan public sector. Investment in the surgical workforce is imperative to ensure access to safe, timely, and affordable surgical and anaesthesia care.

Background: Season and weather are associated with many health outcomes, which can influence hospital admission rates. We examined associations between hospital admissions (all diagnoses) and local meteorological parameters in Southwestern Uganda, with the aim of supporting hospital planning and preparedness in the context of climate change. Methods : Hospital admissions data and meteorological data were collected from Bwindi Community Hospital and a satellite database of weather conditions, respectively (2011 to 2014). Descriptive statistics were used to describe admission patterns. A mixed-effects Poisson regression model was fitted to investigate associations between hospital admissions and season, precipitation, and temperature. Results: Admission counts were highest for acute respiratory infections, malaria, and acute gastrointestinal illness, which are climate-sensitive diseases. Hospital admissions were 1.16 (95% CI: 1.04, 1.31; p = 0.008) times higher during extreme high temperatures (i.e., >95th percentile) on the day of admission. Hospital admissions association with season depended on year; admissions were higher in the dry season than the rainy season every year, except for 2014. Discussion : Effective adaptation strategy characteristics include being low-cost and quick and practical to implement at local scales. Herein, we illustrate how analyzing hospital data alongside meteorological parameters may inform climate-health planning in low-resource contexts.

Background: Access to safe surgery is critical to health, welfare, and economic development. In 2015, the Lancet Commission on Global Surgery recommended that all countries collect surgical indicators to lend insight into improving surgical care. No nationwide high-quality data exist for these metrics in Uganda., Methods: A standardized quantitative hospital assessment and a semi-structured interview were administered to key stakeholders at 17 randomly selected public hospitals. Hospital walk-throughs and retrospective reviews of operative logbooks were completed., Results: This study captured information for public hospitals serving 64.0% of Uganda's population. On average, <25% of the population had 2 h access to a surgically capable facility. Hospitals averaged 257 beds/facilities and there were 0.2 operating rooms per 100,000 people. Annual surgical volume was 144.5 cases per 100,000 people per year. Surgical, anesthetic, and obstetrician physician workforce density was 0.3 per 100,000 people. Most hospitals reported having electricity, oxygen, and blood available more than half the time and running water available at least three quarters of the time. In total, 93.8% of facilities never had access to a CT scan. Sterile gloves, nasogastric tubes, and Foley catheters were frequently unavailable. Uniform outcome reporting does not exist, and the WHO safe surgery checklist is not utilized., Conclusion: The Ugandan public hospital system does not meet LCoGS targets for surgical access, workforce, or surgical volume. Critical policy and programmatic developments are essential to build surgical capacity and facilitate provision of safe, timely, and affordable surgical care. Surgery must become a public health priority in Uganda and other low resource settings.

Background: Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception., Methods: From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis., Results: The Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need., Conclusion: Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda's surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.

Background: In low- and middle-income countries (LMICs), an estimated 85% of children do not have access to surgical care. The objective of the current study was to determine the geographic distribution of surgical conditions among children throughout Uganda., Methods: Using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey, we enumerated 2176 children in 2315 households throughout Uganda. At the district level, we determined the spatial autocorrelation of surgical need with geographic access to surgical centers variable., Findings: The highest average distance to a surgical center was found in the northern region at 14.97km (95% CI: 11.29km-16.89km). Younger children less than five years old had a higher prevalence of unmet surgical need in all four regions than their older counterparts. The spatial regression model showed that distance to surgical center and care availability were the main spatial predictors of unmet surgical need., Interpretation: We found differences in unmet surgical need by region and age group of the children, which could serve as priority areas for focused interventions to alleviate the burden. Future studies could be conducted in the northern regions to develop targeted interventions aimed at increasing pediatric surgical care in the areas of most need., Level of Evidence: Level III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Understanding variations in malaria transmission and exposure is critical to identify populations at risk and enable better targeting of interventions. The indigenous Batwa of southwestern Uganda have a disproportionate burden of malaria infection compared with their non-indigenous neighbors. To better understand the individual- and community-level determinants of malaria exposure, a seroepidemiological study was conducted in 10 local council cells in Kanungu District, Uganda, in April 2014. The Batwa had twice the odds of being seropositive to two Plasmodium falciparum -specific antigens, apical membrane antigen-1 and merozoite surface protein-1 19 , compared with the non-indigenous Bakiga (odds ratio = 2.08, 95% confidence interval = 1.51-2.88). This trend was found irrespective of altitude level and after controlling for cell location. Seroconversion rates in the Batwa were more than twice those observed in the Bakiga. For the Batwa, multiple factors may be associated with higher exposure to malaria and antibody levels relative to their non-indigenous neighbors., (© The American Society of Tropical Medicine and Hygiene.)

Background: Globally, a staggering five billion people lack access to adequate surgical care. Sub-Saharan Africa represents one of the regions of greatest need. We sought to understand how geographic factors related to unmet surgical need (USN) in Uganda., Methods: We performed a geographic information system analysis of a nationwide survey on surgical conditions performed in 105 enumeration areas (EAs) representing the national population. At the district level, we determined the spatial autocorrelation of the following study variables: prevalence of USN, hub distance (distance from EA to the nearest surgical center), area of coverage (geographic catchment area of each center), tertiary facility transport time (average respondent-reported travel time), and care availability (rate of hospital beds by population and by district). We then used local indicators of spatial association (LISA) and spatial regression to identify any significant clustering of these study variables among the districts., Results: The survey enumerated 4248 individuals. The prevalence of USN varied from 2.0-45 %. The USN prevalence was highest in the Northern and Western Regions. Moran's I bivariate analysis indicated a positive correlation between USN and hub distance (p = 0.03), area of coverage (p = 0.02), and facility transport time (p = 0.03). These associations were consistent nationally. The LISA analysis showed a high degree of clustering among sets of districts in the Northern Sub-Region., Conclusions: This study demonstrates a statistically significant association between USN and the geographic variables examined. We have identified the Northern Sub-Region as the highest priority areas for financial investment to reduce this unmet surgical disease burden.

Objective: Climate change is projected to increase the burden of food insecurity (FI) globally, particularly among populations that depend on subsistence agriculture. The impacts of climate change will have disproportionate effects on populations with higher existing vulnerability. Indigenous people consistently experience higher levels of FI than their non-Indigenous counterparts and are more likely to be dependent upon land-based resources. The present study aimed to understand the sensitivity of the food system of an Indigenous African population, the Batwa of Kanungu District, Uganda, to seasonal variation., Design: A concurrent, mixed methods (quantitative and qualitative) design was used. Six cross-sectional retrospective surveys, conducted between January 2013 and April 2014, provided quantitative data to examine the seasonal variation of self-reported household FI. This was complemented by qualitative data from focus group discussions and semi-structured interviews collected between June and August 2014., Setting: Ten rural Indigenous communities in Kanungu District, Uganda., Subjects: FI data were collected from 130 Indigenous Batwa Pygmy households. Qualitative methods involved Batwa community members, local key informants, health workers and governmental representatives., Results: The dry season was associated with increased FI among the Batwa in the quantitative surveys and in the qualitative interviews. During the dry season, the majority of Batwa households reported greater difficulty in acquiring sufficient quantities and quality of food. However, the qualitative data indicated that the effect of seasonal variation on FI was modified by employment, wealth and community location., Conclusions: These findings highlight the role social factors play in mediating seasonal impacts on FI and support calls to treat climate associations with health outcomes as non-stationary and mediated by social sensitivity.

Background: The indigenous Batwa of southwestern Uganda are among the most highly impoverished populations in Uganda, yet there is negligible research on the prevalence of malaria in this population. Plasmodium falciparum malaria parasitaemia prevalence was estimated in an indigenous Batwa and a non-indigenous neighbouring population, and an exploration of modifiable risk factors was carried out to identify potential entry points for intervention. Additionally, evidence of zooprophylaxis was assessed, hypothesizing that livestock ownership may play a role in malaria risk., Methods: Two cross-sectional surveys of Batwa and non-Batwa communities were carried out in Kanungu District, Uganda in July 2013 and April 2014 based on a census of adult Batwa and a two-stage systematic random sample of adult non-Batwa in ten Local Councils where Batwa settlements are located. A community-based questionnaire and antigen rapid diagnostic test for P. falciparum were carried out in the cross-sectional health surveys. A multivariable logistic regression model was built to identify risk factors associated with positive malaria diagnostic test. A subset analysis of livestock owners tested for zooprophylaxis., Results: Batwa experienced higher prevalence of malaria parasitaemia than non-Batwa (9.35 versus 4.45 %, respectively) with over twice the odds of infection (OR 2.21, 95 % CI 1.23-3.98). Extreme poverty (OR 1.96, 95 % CI 0.98-3.94) and having an iron sheet roof (OR 2.54, 95 % CI 0.96-6.72) increased the odds of infection in both Batwa and non-Batwa. Controlling for ethnicity, wealth, and bed net ownership, keeping animals inside the home at night decreased the odds of parasitaemia among livestock owners (OR 0.29, 95 % CI 0.09-0.94)., Conclusion: A health disparity exists between indigenous Batwa and non-indigenous community members with Batwa having higher prevalence of malaria relative to non-Batwa. Poverty was associated with increased odds of malaria infection for both groups. Findings suggest that open eaves and gaps in housing materials associated with iron sheet roofing represent a modifiable risk factor for malaria, and may facilitate mosquito house entry; larger sample sizes will be required to confirm this finding. Evidence for possible zooprophylaxis was observed among livestock owners in this population for those who sheltered animals inside the home at night.

Major efforts for malaria prevention programs have gone into scaling up ownership and use of insecticidal mosquito nets, particularly in sub-Saharan Africa where the malaria burden is high. Socioeconomic inequities in access to long lasting insecticidal nets (LLINs) are reduced with free distributions of nets. However, the relationship between social factors and retention of nets after a free distribution has been less studied, particularly using a longitudinal approach. Our research aimed to estimate the ownership and use of LLINs, and examine the determinants of LLIN retention, within an Indigenous Batwa population after a free LLIN distribution. Two LLINs were given free of charge to each Batwa household in Kanungu District, Uganda in November 2012. Surveyors collected data on LLIN ownership and use through six cross-sectional surveys pre- and post-distribution. Household retention, within household access, and individual use of LLINs were assessed over an 18-month period. Socioeconomic determinants of household retention of LLINs post-distribution were modelled longitudinally using logistic regression with random effects. Direct house-to-house distribution of free LLINs did not result in sustainable increases in the ownership and use of LLINs. Three months post-distribution, only 73% of households owned at least one LLIN and this period also saw the greatest reduction in ownership compared to other study periods. Eighteen-months post distribution, only a third of households still owned a LLIN. Self-reported age-specific use of LLINs was generally higher for children under five, declined for children aged 6-12, and was highest for older adults aged over 35. In the model, household wealth was a significant predictor of LLIN retention, controlling for time and other variables. This research highlights on-going socioeconomic inequities in access to malaria prevention measures among the Batwa in southwestern Uganda, even after free distribution of LLINs, and provides critical information to inform local malaria programs on possible intervention entry-points to increase access and use among this marginalized population.

We investigate the short-term effects of air temperature, rainfall, and socioeconomic indicators on malaria incidence across Rwanda and Uganda from 2002 to 2011. Delayed and nonlinear effects of temperature and rainfall data are estimated using generalised additive mixed models with a distributed lag nonlinear specification. A time series cross-validation algorithm is implemented to select the best subset of socioeconomic predictors and to define the degree of smoothing of the weather variables. Our findings show that trends in malaria incidence agree well with variations in both temperature and rainfall in both countries, although factors other than climate seem to play an important role too. The estimated short-term effects of air temperature and precipitation are nonlinear, in agreement with previous research and the ecology of the disease. These effects are robust to the effects of temporal correlation. The effects of socioeconomic data are difficult to ascertain and require further evaluation with longer time series. Climate-informed models had lower error estimates compared to models with no climatic information in 77 and 60% of the districts in Rwanda and Uganda, respectively. Our results highlight the importance of using climatic information in the analysis of malaria surveillance data, and show potential for the development of climate informed malaria early warning systems.

Although malnutrition and malaria co-occur among individuals and populations globally, effects of nutritional status on risk for parasitemia and clinical illness remain poorly understood. We investigated associations between Plasmodium falciparum infection, nutrition, and food security in a cross-sectional survey of 365 Batwa pygmies in Kanungu District, Uganda in January of 2013. We identified 4.1% parasite prevalence among individuals over 5 years old. Severe food insecurity was associated with increased risk for positive rapid immunochromatographic test outcome (adjusted relative risk [ARR] = 13.09; 95% confidence interval [95% CI] = 2.23-76.79). High age/sex-adjusted mid-upper arm circumference was associated with decreased risk for positive test among individuals who were not severely food-insecure (ARR = 0.37; 95% CI = 0.19-0.69). Within Batwa pygmy communities, where malnutrition and food insecurity are common, individuals who are particularly undernourished or severely food-insecure may have elevated risk for P. falciparum parasitemia. This finding may motivate integrated control of malaria and malnutrition in low-transmission settings., (© The American Society of Tropical Medicine and Hygiene.)