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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract Objectives Malnutrition is a persistent health concern throughout the world. Globally, Indigenous peoples experience poorer health outcomes compared to their non-Indigenous neighbours. Despite this, malnutrition among Indigenous populations is poorly understood. This analysis estimated the prevalence, and modeled possible determinants of, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) for Indigenous Batwa and non-Indigenous Bakiga of Kanungu District in Southwestern Uganda. We then characterize possible mechanisms driving differences in malnutrition. Methods Retrospective cross-sectional surveys were administered to 10 Batwa communities and 10 matched Bakiga Local Councils during April of 2014 (n = 1167). Individuals were classified as MAM and SAM based on middle upper-arm circumference (MUAC) for their age-sex strata. Mixed-effects regression models quantified the variation in malnutrition occurrence, considering individual, household, and community-ethnicity level effects. Models controlled for age, sex, number of dependents, education, and relative wealth. Results Malnutrition is high among Batwa children and adults, with nearly half of Batwa adults (45.34%, 95% CI 34.82 to 55.86 for males; 45.86%, 95% CI 37.39 to 54.33 for females) and nearly a quarter of Batwa children (20.31%, 95% CI 13.07 to 26.93 for males; 25.81%, 95% CI 17.56 to 32.84 for females) meeting MAM criteria. SAM prevalence is lower than MAM prevalence, with SAM highest among adult Batwa males (11.60%, 95% CI 4.83 to 18.37) and adult Batwa females (3.00%, 95% CI 0.10 to 5.90). SAM prevalence among children was higher for Batwa males (7.03%, 95% CI 1.36 to 12.70) compared to Bakiga males (0.57%, 95% CI 0 to 1.69). Models that incorporated community ethnicity explained the greatest variance (>60%) in MUAC values. Conclusion This research demonstrates a malnutrition inequality between the Indigenous Batwa and non-Indigenous Bakiga of Kanungu District, Uganda, with model results suggesting further investigation into the role of ethnicity as an upstream social determinant of health. Highlights • Malnutrition disparities exist among Indigenous and non-Indigenous groups in Uganda. • Distinct malnutrition factors appear at individual, household, and community levels. • Ethnic distinction within communities may act as an upstream determinant of health. [ABSTRACT FROM AUTHOR]

Maternal and newborn health disparities and the health impacts of climate change present grand challenges for global health equity, and there remain knowledge gaps in our understanding of how these challenges intersect. This study examines the pathways through which mothers are affected by seasonal and meteorological factors in sub-Saharan Africa in general, and Kanungu District (Uganda), in particular. We conducted a community-based study consisting of focus group discussions with mothers and interviews with health care workers in Kanungu District. Using a priori and a posteriori coding, we found a diversity of perspectives on the impacts of seasonal and weather exposures, with reporting of more food available in the rainy season. The rainy season was also identified as the period in which women performed physical labour for longer time periods, while work conditions in the dry season were reported to be more difficult due to heat. The causal pathways through which weather and seasonality may be affecting size at birth as reported by Kanungu mothers were consistent with those most frequently reported in the literature elsewhere, including maternal energy balance (nutritional intake and physical exertion output) and seasonal illness. While both Indigenous and non-Indigenous mothers described similar pathways, however, the severity of these experiences differed. Non-Indigenous mothers frequently relied on livestock assets or opportunities for less taxing physical work than Indigenous women, who had fewer options when facing food shortages or transport costs. Findings point to specific entry points for intervention including increased nutritional support in dry season periods of food scarcity, increased diversification of wage labour opportunities, and increased access to contraception. Interventions should be particularly targeted towards Indigenous mothers as they face greater food insecurity, may have fewer sources of income, and face greater overall deprivation than non-Indigenous mothers. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The WHO has established the disability-adjusted life year (DALY) as a metric for measuring the burden of human disease and injury globally. However, most DALY estimates have been calculated as national totals. We mapped spatial variation in the burden of human African trypanosomiasis (HAT) in Uganda for the years 2000–2009. This represents the first geographically delimited estimation of HAT disease burden at the sub-country scale. Methodology/Principal Findings: Disability-adjusted life-year (DALY) totals for HAT were estimated based on modelled age and mortality distributions, mapped using Geographic Information Systems (GIS) software, and summarised by parish and district. While the national total burden of HAT is low relative to other conditions, high-impact districts in Uganda had DALY rates comparable to the national burden rates for major infectious diseases. The calculated average national DALY rate for 2000–2009 was 486.3 DALYs/100 000 persons/year, whereas three districts afflicted by rhodesiense HAT in southeastern Uganda had burden rates above 5000 DALYs/100 000 persons/year, comparable to national GBD 2004 average burden rates for malaria and HIV/AIDS. Conclusions/Significance: These results provide updated and improved estimates of HAT burden across Uganda, taking into account sensitivity to under-reporting. Our results highlight the critical importance of spatial scale in disease burden analyses. National aggregations of disease burden have resulted in an implied bias against highly focal diseases for which geographically targeted interventions may be feasible and cost-effective. This has significant implications for the use of DALY estimates to prioritize disease interventions and inform cost-benefit analyses. Author Summary: Since the 1990s the World Health Organisation has established the disability-adjusted life year (DALY) as a metric for the burden of human disease and injury. However, disease burden has primarily been estimated at the national scale, which does not account for sub-country variations in burden levels. We used the case of human African trypanosomiasis (HAT), a highly focal NTD, in Uganda to calculate and map burden in DALYs. Our results show that HAT burden is highly sensitive to under-reporting estimates, and is particularly high in heavily affected parishes and districts of Uganda. Some districts in southeastern Uganda had HAT burden rates comparable to the national burden rates of major infectious diseases such as malaria and HIV/AIDS. Thus, the spatial scale of burden estimation is crucial, especially for focal diseases such as HAT, and national-level estimates may not reflect the level of impact in afflicted communities. We recommend sub-country burden estimation to identify key areas for prioritization of disease surveillance and targeted interventions. [ABSTRACT FROM AUTHOR]

Background: The WHO has established the disability-adjusted life year (DALY) as a metric for measuring the burden of human disease and injury globally. However, most DALY estimates have been calculated as national totals. We mapped spatial variation in the burden of human African trypanosomiasis (HAT) in Uganda for the years 2000–2009. This represents the first geographically delimited estimation of HAT disease burden at the sub-country scale. Methodology/Principal Findings: Disability-adjusted life-year (DALY) totals for HAT were estimated based on modelled age and mortality distributions, mapped using Geographic Information Systems (GIS) software, and summarised by parish and district. While the national total burden of HAT is low relative to other conditions, high-impact districts in Uganda had DALY rates comparable to the national burden rates for major infectious diseases. The calculated average national DALY rate for 2000–2009 was 486.3 DALYs/100 000 persons/year, whereas three districts afflicted by rhodesiense HAT in southeastern Uganda had burden rates above 5000 DALYs/100 000 persons/year, comparable to national GBD 2004 average burden rates for malaria and HIV/AIDS. Conclusions/Significance: These results provide updated and improved estimates of HAT burden across Uganda, taking into account sensitivity to under-reporting. Our results highlight the critical importance of spatial scale in disease burden analyses. National aggregations of disease burden have resulted in an implied bias against highly focal diseases for which geographically targeted interventions may be feasible and cost-effective. This has significant implications for the use of DALY estimates to prioritize disease interventions and inform cost-benefit analyses. [ABSTRACT FROM AUTHOR]

Abstract: In much of sub-Saharan Africa, availability of standardized and reliable public health data is poor or negligible. Despite continued calls for the prioritization of improved health datasets in poor regions, public health surveillance remains a significant global health challenge. Alternate approaches to surveillance and collection of public health data have thus garnered increasing interest, though there remains relatively limited research evaluating these approaches for public health. Herein, we present a case study applying and evaluating the use of expert knowledge sources for public health dataset development, using the case of vector distributions of Human African Trypanosomiasis (HAT) in Uganda. Specific objectives include: 1) Review the use of expert knowledge sourcing methods for public health surveillance, 2) Review current knowledge on tsetse vector distributions of public health importance in Uganda and the methods used for tsetse mapping in Africa; 3) Quantify confidence of the presence or absence of tsetse flies in Uganda based on expert informant reports, and 4) Assess the reliability and potential utility of expert knowledge sourcing as an alternative or complimentary method for public health surveillance in general and tsetse mapping in particular. Information on tsetse presence or absence, and associated confidence, was collected through interviews with District Entomologist and Veterinary Officers to develop a database of tsetse distributions for 952 sub-counties in Uganda. Results show high consistency with existing maps, indicating potential reliability of modeling approaches, though failing to provide evidence for successful tsetse control in past decades. Expert-sourcing methods provide a novel, low-cost and rapid complimentary approach for triangulating data from prediction modeling where field-based validation is not feasible. Data quality is dependent, however, on the level of expertise and documentation to support confidence levels for data reporting. Results highlight the need for increased evaluation of alternate approaches and methods to data collection. [Copyright &y& Elsevier]

Sleeping sickness reemerged in southeastern Uganda in the 1970s and remains a public health problem. It has continued to spread north into new districts, and gaps remain in the understanding of the causes of its spread and distribution. We report the distribution and magnitude of sleeping sickness in southeastern Uganda from 1970 to 2003. Data were collected from records of the Ugandan Ministry of Health, individual sleeping sickness treatment centers, and interviews with public health officials. Data were used to develop incidence maps over time, conduct space-time cluster detection analyses, and develop a velocity vector map to visualize spread of sleeping sickness over time in southeastern Uganda. Results show rapid propagation of sleeping sickness from its epicenter in southern Iganga District and its spread north into new districts and foci. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined patients diagnosed with human African trypanosomiasis (HAT) in Uganda. The total number of Trypanosoma brucei rhodesiense HAT cases in the country over a 10-year period is 140. Results of the study showed that there is a tendency among patients in Stamp Out Sleeping Sickness (SOS) districts to report cases in late stages of the disease. It also found higher mortality rates in patients with late-stage cases.

Identifying the nature of the association between climate, environmental, socio-economic and political context and disease remains a major challenge, yet a better comprehension of the linkages is imperative if predictive models to guide public health responses are to be devised. Our understanding of the relationships could be improved through investigations of historical epidemics. In this paper we draw on a range of published and unpublished documents to explore the complex relationship between climate, environmental change and epidemic disease (re)emergence in East Africa, and Uganda in particular. This is a region which has experienced climate variability at a range of temporal and spatial scales, but which also has a long history of episodic epidemic disease. We focus on the late nineteenth and early twentieth centuries – a time of social, economic and political reordering in East Africa associated with European colonial intervention, but also a period which witnessed a variety of climatic, ecological and disease events. It will be argued that these developments coalesced, creating a set of spatially distinctive social and environmental conditions which fostered the emergence and prolongation of one of the most deadly episodes of disease in East African history, the sleeping sickness epidemic of c.1900–20. [ABSTRACT FROM AUTHOR]