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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.)

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.

Objective: To assess the extent of pregnancy loss (i.e., miscarriage and/or stillbirth) and examine its association with socio-demographic characteristics among Bakiga and Indigenous Batwa women in Kanungu District, southwest Uganda., Methods: As part of a larger community-based, participatory project, a retrospective survey of maternal health histories was conducted in ten Batwa and ten Bakiga communities (n = 555 participants) collecting data on self-reported pregnancy loss (i.e., miscarriage and stillbirth) and socio-demographic characteristics. Socio-demographic associations with pregnancy loss (i.e., total miscarriages and stillbirths) were examined using multivariable Poisson and negative binomial regression., Results: Batwa women experienced pregnancy loss more commonly than Bakiga women did (149.8/1000 vs. 96.3/1000 pregnancies). In the final adjusted model for Batwa women, being in the middle (RR 1.92; CI: 1.21-3.07) and highest (RR 1.79; CI: 1.14-2.82) wealth tertiles (compared to lowest wealth tertile) and living in Community X (RR 4.33; CI 2.27-8.28) (compared to all other communities) were associated with increased pregnancy loss. For Bakiga women, the proportion of pregnancy loss was higher for those who reported drinking alcohol during pregnancy (RR: 1.54; CI: 1.04-2.13) and being food insecure (RR 1.39; CI: 1.02-1.91)., Conclusion: The proportion of, and the socio-demographic associations with, pregnancy loss differed for Bakiga and Indigenous Batwa women. These differences underscore the importance of collecting Indigenous health data to understand not only the extent of, but also the varied contextual circumstances that are associated with pregnancy loss. This nuanced and stratified information is critical for planning meaningful health programming to reduce pregnancy loss for Indigenous women., (Copyright © 2022 Elsevier B.V. All rights reserved.)

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.)

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: 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.

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.)

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., (Copyright © 2017. Published by Elsevier Ltd.)

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.