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Background: In 2020, non-communicable diseases (NCDs) currently account for 40% of deaths in east Africa and are expected to surpass communicable diseases as the leading causes of death in sub-Saharan Africa by 2030. However, there remain many gaps in the provision of high quality, patient-centred NCD service delivery in low-income countries such as Uganda, especially in rural settings. We developed a discrete choice experiment (DCE) to understand how patients with common NCDs, such as hypertension and diabetes, make health-care-seeking decisions. A DCE is a quantitative tool that measures the weight of different factors that affect a decision. Participants are presented with two hypothetical scenarios to choose between. Here we report on the formative, qualitative phase of DCE development. Methods: For this DCE, choice sets consist of two health facilities described in terms of various attributes (factors) that affect decision-making. To develop a locally relevant DCE, we conducted formative qualitative research consisting of 18 in-depth interviews with patients seeking care for hypertension or diabetes, or both, at three health facilities in rural Nakaseke District, Uganda. We purposively selected participants so that each disease and facility were represented. Interviews explored how participants choose which facility to visit and challenges that she or he faces in accessing care or medicines, or both. A team of three researchers coded the interviews using a directed approach to reveal 11 potential attributes on which patients make decisions. After review of the data and analysis with local and international content experts, we narrowed this list to six attributes to be included in the DCE. Findings: The six selected attributes included: provision of education; availability of medicines; transport to the facility; costs associated with treatment; interactions with health-care providers; and presence of peer support groups. Attribute levels encompassed the range of experiences for each attribute as emerged from qualitative analysis. We then developed a full profile, fractional factorial DCE with three surveys. Interpretation: The process of developing this NCD-focused DCE relied on reference to the literature, primary qualitative data collection, and expert consensus to create a tool that would yield actionable data to improve NCD health service delivery in rural Uganda. Little is known about how rural patients in low-income and middle-income countries navigate the health-care system, nor is there much description of how to develop DCEs to investigate patient preferences in these countries. This work will guide public health officials in developing NCD service delivery options and inform investigators on DCE development. Funding: Yale Institute of Global Health Hecht Global Health Faculty Network Award Downs International Health Student Travel Fellowship

Background: The prevalence of non-communicable diseases (NCDs) is increasing in rural sub-Saharan Africa. Implementation and adaptation of recommended self-care practices is crucial for successful management of NCDs to prevent complications. However, little is known about self-care practices in patients living in rural sub-Saharan Africa. In this study, we aimed to understand patients' adherence to self-care practices for hypertension, diabetes, or both, in rural Uganda and their reasons for non-adherence. Methods: We conducted a mixed-methods study in adult patients previously diagnosed with diabetes or hypertension, or both, who attended outpatient NCD clinics at three health facilities in Nakaseke district. We concurrently collected quantitative data from a random sample of patients using pretested, structured questionnaires and held focus group discussions and in-depth interviews with a purposive sample of patients. Descriptive statistics were calculated for the quantitative data. Qualitative analysis was conducted using a thematic approach. Findings: Between April and August, 2019, we administered questionnaires and carried out six focus group discussions and 19 in-depth interviews with 385 participants. Mean age was 54·0 years (SD 14·57) and most respondents, 257 (66·8%), were female. Of the 385 participants, 39·2% (151) had diabetes; 36·9% (142) had hypertension, and 23·9% (92) had both conditions. Most respondents reported daily adherence to medication for hypertension (79·5% [186/234]) and diabetes (84·8% [206/243]). Few participants (15·6% [60/385]) reported daily vigorous physical activity, but 63·1% (243/385) reported moderate physical activity at least once per week. Most respondents reported adherence to recommendations for dietary changes (75·6% [291/385]), non-smoking (98·7% [380/385]), alcohol abstinence (90·1% [347/385]), and weight management (75·6% [291/385]). From the interviews and discussions, patients reported that they tried to adhere to recommended medications but were limited by the inability to obtain them. Most patients reported irregular self-monitoring and many reported confusion about recommended practices due to mixed messages, mainly from their peers. Respondents also reported use of herbal remedies, soaking swollen feet in salt water, and coping with stress through prolonged sleep, social isolation, and alcohol use. Interpretation: Varied self-care practices exist among rural Ugandan NCD patients. Patients inconsistently engage in recommended practices because of uncertain access to medicines, structural barriers, and inconsistent messaging. Locally adapted educational self-care programmes and consistent access to medicines could help improve self-care in these patients. As low-income countries like Uganda continue to advance their NCD policies, specific attention should be focused on strategies to ensure equitable access to essential NCD medicines. Additionally, the unique circumstances of people living in rural settings should be taken into account when developing programmes for management of NCDs. Funding: Yale Institute of Global Health Hecht Global Health Faculty Network Award