Phumla Retreat Centre Ryenjoki Twimukie Development Association

   

   

Community Health Needs Assessment   Kyangyenyi Sub-County

Sheema District, Uganda  

January  2015  

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Acknowledgements

This report was funded by Phillip J. and Frances A. Attwood of Phumla Retreat Centre. The author of this report is the principal investigator of the study. Principal investigator: Lore Herzer, MPH Co-investigator: Grace Nahwera, United Nations High Commission for Refugees (UNHCR) This study was commissioned for Phumla Retreat Centre, Kampala Uganda, and Ryenjoki Twimukie Development Association, Ryenjoki Uganda. We wish to thank the following individuals who assisted with this project: Phillip J. Attwood, Frances A. Attwood, Grace Nahwera, Dr. Able Kamukama, and Kato Nixon. We also extend our sincere gratitude to all village chairpersons of Kyangyenyi sub-county and all study participants.

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Table of Contents Figures & Tables _____________________________________________________ 4 Acronyms ___________________________________________________________4 Executive Summary ___________________________________________________5 Background _________________________________________________________ 6 Uganda and Sheema District ______________________________________ 6 The Ugandan Healthcare System ___________________________________7 Rationale for a Baseline Assessment ________________________________ 8 Methodology _________________________________________________________9 Study Design ___________________________________________________9 Study Location and Population _____________________________________ 9 Sampling Strategy and Sample Size _________________________________9 Study Outcomes ________________________________________________10 Data Collection _________________________________________________10 Data Analysis __________________________________________________11 Results ____________________________________________________________ 12 Overview of Present Conditions ____________________________________12 Family Level Prevalence of Common Illnesses ________________________ 22 Knowledge of Healthy Behavior ____________________________________ 24 Recommendations ____________________________________________________28 Bibliography _________________________________________________________31

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Figures and Tables Figure 1: Map of Uganda Figure 2: Ugandan Healthcare Structure Table 1: Participant and Family Demographics Table 2: Household Physical Condition Table 3: Household Nutrition Status Table 4: Household Health Status Table 5: Village & Household Power Table 6: Household Water & Sanitation Table 7: Health Center Patient Experience Table 8: Family Level Prevalence of Reported Childhood Illnesses Table 9: Family Level Prevalence of Reported Adult Illnesses Table 10: Healthiest Foods According to Participants Table 11: Participant Disease Prevention Methods Table 12: Participant Hand Washing Behavior Acronyms FP – Family Planning HIV/AIDS – Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome MOH – Ministry of Health PHPs – Private Health Practitioners PNFPs – Private Not-For-Profits PPH – Post-partum Hemorrhage RTI – Respiratory Tract Infection VIP – Ventilated Improved Pit

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Executive Summary The health status of Uganda’s population has improved over the past several decades according to many health indicators. Many of these improvements have been made with the decentralization of the public healthcare system, the elimination of user fees, and the increased utilization of the private sector. Although these developments have brought about many improvements, there are still many rural communities experiencing inadequate care as a result of health disparities. This research was conducted in Kyangyenyi sub-county located in Sheema district, Uganda. The purpose was to establish baseline health data for Kyangyenyi in order to understand the prevalence of the population’s major health issues, assess the population’s understanding of healthy behavior, identify health problems in need of improvement through existing and future health programs, and to serve as baseline data for future monitoring and evaluation efforts related to health programs in the sub-county. A cross-sectional study design was used which utilized a family-level survey containing both quantitative and qualitative elements. Six areas were assessed in order to obtain a comprehensive view of family health including household demographic data, household physical condition, family health and nutrition, access to power, water and sanitation, and health center patient experience. A total of 269 participants were interviewed across all six parishes in the sub-county using a multi-stage sampling procedure. The results of the survey were broken down by section. Participants identified access to water, access to power, household cleanliness & organization, and access to quality health services to be among their major concerns. Responses from the survey showed a low community standard for home cleanliness, low village availability of food, limited access to power, dissatisfaction with water cleanliness, and low monthly incomes coupled with high expenditures related to food, health costs, and school fees. With regard to knowledge of healthy behavior, the results showed a low level of knowledge related to nutrition and disease prevention, but adequate knowledge related to hand washing behavior. The prevalence of common childhood and adult illness were also assessed with the most common childhood illnesses being malaria, RTI, skin infections, and allergies and the most common adult illnesses being malaria, RTI, arthritis, stomach pain, and allergies. Based on the results of the survey, it is recommended that health education programs be emphasized within the sub-county. The role of the government village health teams in providing this service should be stressed and developed in order to provide education in the areas of nutrition, crop production, disease prevention methods, family planning, cleanliness and organization, and maternal & child health. In addition to health education, existing government health centers should assess and address issues related to timeliness, payment, and patient satisfaction, as well as private health centers addressing community needs that are accessible by the current standard of living. Future research should focus on the impact of current health services as well as assess areas in need of improvement to support the overall health of the sub-county.

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Background Over the past two decades Uganda has worked to improve its country’s health indicators as a result of donor support and government policy changes. Although several of Uganda’s health indicators have shown recent improvement, such as infant mortality rate (76 deaths per 1000 live births in 2006 to 54 deaths per 1000 live births in 2010) and maternal mortality rate (435 deaths per 100,000 live births in 2006 to 328 deaths per 100,000 live births in 2010)1, many health indicators continue to remain stagnant or have increased. Uganda is currently experiencing wide health disparities, with the most need among rural communities across the country1. Factors contributing to health disparities in Uganda include socioeconomic conditions, gender roles, climate change, limited rural healthcare, and the availability of both government and external resources1. Despite government planning and decentralization efforts to meet these challenges, rural healthcare continues to provide inadequate care across the country. Uganda and Sheema District Uganda is located in East Africa and is bordered by Kenya to the East, Tanzania to the south, Rwanda to the southwest, Democratic Republic of the Congo to the west, and South Sudan to the north. Uganda has a population of 38.85 million and an annual GDP of $21 billion, classifying it as a low-income country2. The country’s population growth rate from 2002-2014 was 3.03%3. Uganda is divided into 112 districts. Sheema district is located in southwest Uganda and is bordered by Buhweju district to the north, Mbarara district to the east, Ntungamo district to the south, Mitooma district to the southwest, and Bushenyi district to the west. Sheema district is comprised of ten sub-counties including Kyangyenyi, which was the focus sub-county for this research. As of 2014, the population of Sheema district was approximately 211,720 and the population of Kyangyenyi sub-county was 31,2633. Kyangyenyi sub-county is comprised of 6 parishes including Kitojo, Rushozi, Muzira, Masyoro, Rwebaare, and Kangundu. The primary trading center of the sub-county is Kakindo trading center, and the nearest town is Kabwohe. Kyangyenyi sub-county’s largest health center is Kyangyenyi Health Center III, located in Kangundu parish.

Figure 1: Map of Uganda4

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The Ugandan Healthcare System The Ugandan National Health System is comprised of all public and private institutions and systems that work to address health issues5. The Ministry of Health (MOH) is in charge of the public healthcare system, which has been decentralized at the district level since 1993. The public healthcare system is categorized using a hierarchical structure with three major levels including National Referral, Regional Referral, and District/Rural Hospitals. District/Rural Hospitals are further categorized into health center IV, health center III, health center II, and health center I (local village health teams). Types of services offered at each level vary, with health center II providing outpatient care and community outreach services, health center III providing laboratory services for diagnosis and maternity care, health center IV adding simple surgery, blood transfusion, and medical imaging, regional referrals adding specialist services and higher level surgeries, and finally national referrals providing comprehensive specialist services, health research, and teaching5.

Figure 2: Ugandan Healthcare Structure

All public healthcare services have been provided at no cost since 2001 when the government abolished user fees in order to provide increased access to services for the most poor. As a result, the government finances its services using general taxes and donor support6. The government of Uganda also established a National Minimum Healthcare Package to address the highest disease burdens among the population which includes health promotion, environmental health, disease prevention and community health initiatives; maternal and child health; prevention, management, and

 

National  Referral  Hospitals

Regional  Referral  Hospitals

Health  Center  IV  (Sub-­‐district  Level)

Health  Center  III  (Sub-­‐county  Level)

Health  Center  II  (Parish  Level)

Local  Village  Health  Teams  (Village  Level)

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control of communicable diseases; and prevention, management, and control of non-communicable diseases. The MOH oversees the private sector healthcare system, which is comprised of Private Not-For-Profits (PNFPs), Private Health Practitioners (PHPs), and traditional healers. PNFPs are traditionally more structured and more prominent in rural areas, while PHPs are the fastest growing sector in the healthcare system5. Since the private sector covers approximately 50% of reported outputs, the government subsidizes PNFPs, several private hospitals, and PNFP training institutions5. Rationale for a Baseline Assessment Over the past two decades Kyangyenyi sub-county has seen major changes in climate, food production, socioeconomic conditions, and availability of natural resources. As a result, these changes have impacted the community in many ways including overall health. For example, changes in climate have brought about longer dry seasons which have impacted the availability of water, forcing many residents to walk long distances to fetch water or to use dirty stagnant “ponds” and “wells” for household use. In addition, the banana bacteria wilt disease has greatly affected crops in the area, creating food shortages and decreasing the amount of money farmers can earn for their families. These conditions not only increase the incidence of disease, but also families’ ability to pay to access quality health services, whether in the private sector or transport to the nearest government hospital. As a result of these conditions, the research team was contracted to carry out a baseline assessment to assess the current health conditions and the need for improved health services within Kyangyenyi sub-county. The purpose of this research was to establish baseline health data for Kyangyenyi sub-county in order to: 1. understand the prevalence of the population’s major health issues 2. assess the population’s understanding of healthy behavior 3. identify health problems in need of improvement through existing and future health programs 4. serve as baseline data for future monitoring and evaluation efforts related to health programs in the sub-county.

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Methodology It is commonly accepted that medical treatment and illness prevention are both equally important in keeping a population healthy. The methods used in this analysis sought to examine the current effectiveness of illness prevention with relation to health knowledge, as well as disease prevalence in order to understand the current health burden within Kyangyenyi. This section describes the methods used to obtain data on the community’s overall health, including the prevalence of common health diagnoses, and assessment of the population’s knowledge of healthy behavior. Study Design This study was conducted using a cross-sectional design in order to assess Kyangyenyi sub-county’s current health status. Within this design a family-level survey was used containing both quantitative and qualitative elements. As this study is intended to gather information related to current conditions and serve as a baseline for future health programs, a longitudinal design was not used. The family-level survey was divided into six sections in order to obtain a comprehensive view of family health including household demographic data, household physical condition, family health and nutrition, access to power, water and sanitation, and health center patient experience. Within each section a set of both quantitative and qualitative questions was asked, concluding with a short discussion regarding the respondent’s major health concerns for the family and community. Following the data collection phase of the study, data were assessed to determine the prevalence of certain conditions and behaviors and common opinions regarding the community’s health status. Based on the analysis, recommendations were made in order to improve the community’s health in the most affected areas. Study Location and Population The study was carried out within Kyangyenyi sub-county, Sheema district, Uganda. This location was selected based on a small pilot study carried out within the sub-county, which indicated a high prevalence of disease, poor general nutrition status, and poor general living conditions. In addition, a lack of beneficial health services was indicated, implying that residents are not receiving optimal health care or health education within the sub-county. The study population was comprised of all residents within the six parishes of the sub-county. Inclusion criteria for the survey consisted of any person age 17 or older that was a current member of the house being sampled. Sampling Strategy and Sample Size In order to identify study participants within Kyangyenyi sub-county, a multi-stage sampling strategy was used. The sampling frame for stage one of the sample consisted of all parishes and villages of the sub-county. Stratified sampling was used to divide the sub-county into the six parishes of Kitojo, Muzira, Masyoro, Rwebaare, Kangundu, and Rishozi. Each parish was then divided into a list of all villages within the parish. During data collection, the sampling frame for stage two consisted of each family located within

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the present village. Data collectors began by traveling to the village chairperson of each village. After explaining the scope of the survey and obtaining the chairperson’s permission, the team then spun a plastic bottle to indicate a randomly chosen sampling direction. Study participants were then randomly selected as the data collectors traveled to every 5th house along the sampling direction until the sampling number for that village had been achieved. This process was repeated for every village within Kyangyenyi sub-county in order to achieve the total sample size. To calculate the sample size for the survey, the sample size calculator provided by Raosoft® was used. The sample size was calculated assuming a margin of error level of 5% and a confidence level of 90%. Given the most recent population of Kyangyenyi sub-county as 31,2634, a total sample size of 269 was calculated. The total sample size was then divided by six, resulting in a total of 44 or 45 surveys per parish. Each parish was then divided by its respective number of villages to calculate the total sample for each village. For parishes or villages with an uneven number, the larger sample was allocated toward the parish or village with the larger population. Study Outcomes The outcomes of interest in this study were 1. an estimate of the prevalence of select health diagnoses common within the region, and 2. an assessment of the population’s knowledge of healthy behavior. In order to identify health diagnoses common within the region a literature review was conducted which reviewed available surveys and results previously used in the area as well as available health reports from local organizations. A list of common health diagnoses was compiled and questions pertaining to each diagnosis were formed within the survey in order to measure disease prevalence. In order to understand the population’s knowledge of healthy behavior several open ended questions related to diet and sanitation/hygiene were formed. The responses for these questions were recorded qualitatively and were later categorized in order to quantify the extent of the population’s knowledge of healthy behavior. In addition to these quantitative assessments, each participant’s perceptions regarding health diagnoses and healthy behavior within the family and population were obtained in order to triangulate and provide a comprehensive view of the current health situation with Kyangyenyi. Data Collection In order to obtain data to assess the study outcomes a comprehensive survey was used which included both qualitative and quantitative elements. The data collection phase took place from March to November 2014. Once a house was identified using the sampling procedure, the data collectors confirmed participant eligibility, explained the purpose, scope, and instructions of the survey, and received oral consent to participate from the participant. The survey contained a total of 99 questions within the areas of household demographics, household physical condition, family health and nutrition, access to power, water and sanitation, and health center patient experience. Survey questions were administered as an interview with one data collector asking questions

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and recording responses in English and a second data collector translating questions and responses using the local language of Runyankole. Following the administration of the survey, a short 5-minute open-ended discussion was held with each participant. The purpose of this discussion was for the participant to verbalize their perceptions regarding the overall health of the family and of the community, to clearly explain problems faced by the family and community that have an effect on health, and to offer any information not included in the survey that they felt related to the health status of the family and community. Due to various limitations faced by the study team, formal key informant interviews and focus groups were not possible. As a result, the interview was used to obtain qualitative data in order to triangulate information obtained in the survey. Data Analysis All data were entered into an Excel database during data collection, eliminating the need for data assistants. This process not only saved time and resources, but also allowed for minimal missing or incorrect data. Quantitative data analysis was performed using R® software. Given the cross-sectional design of this study, descriptive analyses were performed using means, standard deviations, and percentages to describe the population, calculate the prevalence of common diagnoses, and to quantify the population’s knowledge of healthy behavior. Qualitative data obtained in the survey as well as the interviews were coded by hand and assessed for common themes in order to further assess the population’s knowledge of healthy behavior as well as describe additional factors that affect family and population health.

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Results This section describes the results from the survey and major issues discussed by participants. The results from each section of the survey are discussed, followed by the results related to the study outcomes. Overview of Present Conditions Demographics Out of a total of 269 participants, 108 were male and 161 were female. The most common age range of participants was from 31-50 years old and 80.3% of participants reported that they were presently married. With regard to education level, men accomplished a higher level than women with 4.2% more men finishing secondary education compared to women, and 4.6% more men finishing tertiary. The majority of both women and men had a primary education level, however 4.9% more women had no education compared to men. At home, families produced an average of 6.06 children. The number of all people currently living in the house was an average of 6.10 with 4 children and 2 adults. The number of children currently living in the house was largely comprised of both biological and non-biological children, and the majority of houses had at least one child living outside the house. Income earned per month ranged widely from zero to one million Ugandan shillings with a median income of fifty thousand. The majority of participants shared that their total monthly income was not enough to cover the monthly cost of food, school fees, medical fees, and other regular costs, which frequently resulted in a need to borrow money or sell land when faced with large essential expenditures. Table  1:  Participant  and  Family  Demographics                 Number  (n=269)   Relative  Frequency  (%)  Gender     Male           108       40.1     Female         161       59.9  Age  (years)     17-­‐30           63       23.4     31-­‐50           104       38.7     51-­‐70           79       29.4     70-­‐90           20       7.4     Unsure         3       1.1  Marital  Status     Single           10       3.7     Married         216       80.3     Widowed         38       14.1     Divorced         5       1.9  Religion  

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  Christian         255       94.8     Muslim         14       5.2  Husband’s  highest  level  of  education     None           32       12.4     Primary         146       55.9     Secondary         59       22.6     Tertiary         15       5.7     Unknown         9       3.4  Wife’s  highest  level  of  education     None           46       17.3     Primary         167       62.8     Secondary         49       18.4     Tertiary         3       1.1     Unknown         1       0.4                                            Mean(sd)                      Median                Minimum          Maximum    Number  of  birth  children          6.06(3.69)                  6                                          0                                          20      Number  of  people  in  house          6.10(2.89)                  6                                          1                                          19  Number  of  all  children  in  house                    4.29(2.65)                  4                                          0                                          17  Amount  of  money  (UGX)            -­‐              50000                      0                                          1000000  

earned  per  month                  Household Physical Condition   The physical condition of each household was included in the survey to assess living conditions within the sub-county. The average number of buildings on a family’s land was 2.3 with a range of 0 (renters) to 8. The average number of rooms per house was 4.09 with an average of 2.63 rooms used for sleeping by each family. Respondents were asked to categorize the condition, organization, and cleanliness of their house using a three point likert scale of poor, average, and good. Approximately 64.2% and 64.6% of houses were categorized as average condition and average organization respectively, with 33.2% and 30.9% having a poor condition and organization respectively. The general cleanliness of houses was comprised of 76.1% average, 17.5% poor, and 6.3% good. All of the houses interviewed used iron sheets as a roof and 60.0% had mud floors compared to 40.0% cement. The majority of respondents reported that they were not satisfied with the overall physical condition of their house, and that the standard of the community was generally poor. Several participants also stated that they would like to keep their homes better organized, but they were not sure how to go about organizing their rooms. Table  2:  Household  Physical  Condition  

             Mean  (sd)                Median            Minimum          Maximum    

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Number  of  buildings            2.30(1.09)                2                                  0                                          8  Number  of  rooms            4.09(1.50)                4                                  1                                          10  Number  of  rooms  for  sleeping        2.63(1.06)                3                                  1                                          7  

          Number  (n=269)   Relative  Frequency  (%)  

Condition  of  buildings  Poor         89       33.2      Average       172       64.2  Good           7       2.6  

Organization  of  rooms  Poor         83       30.9  Average       173       64.6  Good         11       4.1  Unsure       1       0.4  

Cleanliness  of  rooms  Poor         47       17.5  Average       204       76.1  Good         17       6.3  

Type  of  roof  Iron  sheets       269       100  Banana  fibers       0       0  

Type  of  floor  Mud         185       60.0  Cement       83       40.0  

Health & Nutrition In order to assess nutrition status across Kyangyenyi, questions related to eating habits and food availability were asked to participants. When asked the number of times they had eaten over the past 24 hours, participants responded with a mean number of 2.83 times. The most common foods eaten consisted of bananas, beans, posho, potatoes, milk, millet, and cassava from most eaten to least eaten on a daily basis respectively. Foods such as rice, eggplant, fruits, and bread were eaten sparingly on a daily basis. Respondents reported that in 64.7% of families the man of the household was the one to typically buy food, while 15.6% of families reported that the women bought food and 19.3% reported that another family member bought food. When purchasing food, 74.4% of participants reported that food availability in their village was low, while 24.9% reported average and 0.7% reported a high availability of food. Reasons given for low food availability included poor soil for growing, lack of understanding on how to grow enough food on small land, crop diseases such as the banana bacteria wilt, and poor crop yields during dry seasons. When asked the amount of money spent on food for the family per month, the median response was 60,000 Ugandan shillings with a range of zero to one million shillings. Those who spent a small amount of money on food per month typically only ate food grown on their land while those who spent a large sum on food typically had large families and typically sold the majority of food grown on their land.

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Table  3:  Household  Nutrition  Status                      Mean(sd)            Median   Minimum   Maximum    

Number  of  times  eaten  during              2.83(0.98)              3     1     6         the  past  24  hours  Amount  of  money  (UGX)  spent  on                -­‐                60000   0     1000000  

food  per  month                    

              Number  (n=269)    Relative  Frequency  (%)  Knowledge  of  foods  related  to  a  healthy  diet     Listed  3  foods           215       80.0     Unable  to  list  3  foods         54       20.0  Village  food  availability     Low             200       74.4     Average           67       24.9     High             2       0.7  Foods  Eaten  in  the  Past  24  Hours     Matooke  bananas         201       74.7     Beans             149       55.4     Posho             119       44.2     Potatoes  (sweet  &  Irish)       93       34.6     Milk             62       23.0     Millet             52       19.3     Cassava           41       15.2     Porridge           39       14.5     Tea  (dry)           22       8.2     Dodo  (greens)         21       7.8     G-­‐nuts             14       5.2     Meat             11       4.1     Eggs             11       4.1     Eggplant           7       2.6     Pumpkin           5       1.9     Maize             3       1.1     Rice             2       0.7     Bread             2       0.7     Cabbage           1       0.4     Fruits             1       0.4     Chapatti           1       0.4   With regard to overall health, questions related to maternal health, family planning, malaria, HIV/AIDS, and common diseases were asked within the survey. Families reported that 69.4% of mothers gave birth in a health center while 26% of mothers gave birth at home. Approximately 4.6% of mothers gave birth to some children at home and others at the health center. Similarly, 70.5% of families reported that women received

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assistance during child birth from a nurse, doctor, or health care worker while the remaining 29.5% of families received assistance at home from either a family member, midwife, traditional birth attendant, a neighbor, or with no assistance. Approximately 16.7% of those surveyed reported delivery complications consisting of C-section, stillbirth, miscarriage, prolonged labor, or post-partum hemorrhage (PPH). Eighteen families reported that the woman of the house did not receive prenatal or antenatal care. Reasons for not obtaining care included lack of transport, far distance, and they did not feel it was needed. After birth, mothers typically breastfed their babies for an average of 18.4 months with a minimum of 3 and a maximum of 48 months, and first fed their babies solid food at an average of 7.1 months with a minimum of 3 and a maximum of 24 months. With regard to family planning, 46.5% of respondents reported ever using any method. The most popular form of family planning was injection, followed by contraceptive pills, no plant, hysterectomy, condoms, IUD, withdrawal, vasectomy, and moon beads. Reasons for low use of family planning were most often given as the side effects and the desire to produce many children. Several participants reported that they had used family planning methods in the past, but had stopped due to health care worker’s inability to manage the side effects. With regard to malaria, respondents reported that children acquired malaria an average of 2.6 times per year, and adults an average of 2.2 times per year. As a preventative measure for malaria, 97.4% of families currently owned at least one mosquito net, while 2.6% reported not owning any nets. Mosquito nets were reported being used by 73.9% of children 5-7 nights per week, while 87.1% of adults used the nets 5-7 nights per week. Participants shared that it was difficult to obtain mosquito nets; supplies of free nets from the government quickly ran out before reaching all families in the sub-county, and many families did not see a large enough need for nets to spend money from their monthly incomes. Finally, out of those respondents with children, only 2 reported that their children were not up to date on vaccinations. Reasons for this consisted of their children being raised during a time when vaccination was not always available. Further results related to common health diagnoses found across Kyangyenyi will be discussed in later sections. Table  4:  Household  Health  Status  

           Mean(sd)              Median        Minimum      Maximum    

Age  (months)  that  children        18.4(7.1)   18          3     48     were  breastfed  Age  (months)  that  children  were        7.1(3.9)   6          3     24     first  fed  solid  foods  Number  of  times  per  year  that          2.6(3.1)   2          0     30     children  acquire  malaria  Number  of  children  that  have  had        0.4(0.7)   0          0     3     diarrhea  in  the  past  month  Number  of  children  that  have  had        1.7(1.5)   1          0     9     a  cough  in  the  past  month  Number  of  times  per  year  that        2.2(3.1)   2          0     30  

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  adults  acquire  malaria    

            Number  (n=269)              Relative  Frequency  (%)  Who  assisted  during  childbirth     Healthcare  worker       182       70.5  

Family  member  (Mother/in  law)   33       13.2     Midwife         18       7.0     No  assistance         13       5.0     Traditional  birth  attendant     8       3.1     Neighbor         3       1.2  Where  children  were  born     Health  enter         179       69.4     Home           67       26.0     Some  home  &  health  center     12       4.6  Delivery  complications         C-­‐section         26       9.7     Post-­‐partum  hemorrhage     9       3.3     Stillbirth         4       1.5     Prolonged  labor       4       1.5  

Miscarriage         2       0.7  Family  Planning  (FP)     Ever  heard  of  FP       264       98.1     Never  heard  of  FP       5       1.9     Ever  used  FP         125       46.5     Never  used  FP       144       53.5  Type  of  FP  used  (n=125)     Injection         70       56.0     Contraceptive  pills       28       22.4     No  plant         18       14.4     Hysterectomy         14       11.2     Condoms         8       6.4     IUD           4       3.2     Withdrawal         4       3.2     Vasectomy         3       2.4     Moon  beads         1       0.8  Mosquito  Nets     Family  currently  owns  at     262       97.4       least  1  net     Family  currently  owns  no  nets   7       2.6  Nights  per  week  that  children  use  nets     0  nights         18       7.2     1-­‐2  nights         14       5.6     3-­‐4  nights         33       13.3     5-­‐7  nights         184       73.9  Nights  per  week  that  adults  use  nets  

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  0  nights         14       5.3     1-­‐2  nights         7       2.7     3-­‐4  nights         13       4.9     5-­‐7  nights         230       87.1  HIV/AIDS     Participant  has  ever  tested       232       86.2     Participant  has  never  tested     37       13.8     Families  with  1  or  more  HIV+   42       15.7       member       Families  with  no  HIV+  members   221       82.8     Unsure         4       1.5   Access to Power Access to power was defined as a home that had the physical possibility of using hydroelectricity or solar power. According to respondents, 42.0% reported that their village had access to power while 58.0% reported that their village did not have access to power. Among all respondents who had possible access to either hydroelectricity or solar, 32.2% were currently accessing power while 67.8% were not. Reasons for not having power where accessible included lack of fees for initial connection and for regular monthly access. Within villages that had no access to power, some respondents were able to access solar through personal installation and maintenance. Among all respondents with current access to power, 59.0% used hydroelectricity, 38.5% used solar, and 2.5% had access to both hydroelectricity and solar. Respondents were also asked to rate the reliability of the power which was reported as 46.1% unreliable, 48.7% sometimes reliable, and 5.2% regularly reliable. Due to the majority of respondents having no access to power within their village, power was reported to be a major community problem by the majority of respondents. During the final discussion section of the survey, many participants asked if future projects were being planned to bring power to villages without access and how they could work to obtain access for their villages in the near future. Respondents currently accessing hydroelectricity voiced frustrations about frequent outages at certain times of day or during inclement weather, which affected the overall reliability and user satisfaction. Table  5:  Village  &  Household  Power                 Number       Relative  Frequency  (%)  Village  access  to  power  (n=269)     Yes           113       42.0     No           156       58.0  Household  access  to  power*  (n=121)     Yes           39       32.2     No           82       67.8    Among  those  with  household  power:   Number  (n=39)   Relative  Frequency  (%)  

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 Type  of  power     Hydroelectric         23       59.0     Solar           15       38.5     Hydroelectric  &  solar     1       2.5  Power  reliability     Not  reliable         18       46.1     Sometimes  reliable       19       48.7     Regularly  reliable         2       5.2    *The  total  households  with  access  to  power  is  greater  than  the  number  of  villages  with  access  to  power  due  to  those  houses  with  access  to  solar  within  villages  that  do  not  access  power.   Water & Sanitation Study respondents felt that access to water was one of the biggest challenges throughout the sub-county. Approximately 32.3% of respondents felt that water availability in their village was low, compared to 29.7% average and 37.9% high. Although 64.6% of participants received their water by a government installed gravity system, 35.4% of participants received their water by other methods such as streams, springs, wells, ponds, and tanks. Those who did not use the gravity system shared that they were not satisfied with the cleanliness of their water and felt that their current water system caused some percentage of their family’s illnesses. When purifying water for drinking 91.8% of families used the boiling method followed by 4.5% using no purification method, 2.2% using both filtering and boiling, and 0.7% using both tablet and boiling. Participants were also asked if community members and their containers were generally clean or dirty when fetching water at their local water source. Approximately 62.8% of respondents felt that others in the community were frequently dirty when fetching water while 37.2% reported that others were generally clean. Given that those who use stagnant water sources generally dip their hands and containers into the water source to fill their containers, dirty hands and containers may add additional contamination. When observing various water sources aside from gravity, stagnant sources such as wells and ponds were observed to frequently have algae growing on the surface, while streams and springs typically had a high number of mosquitos present in the area. With regard to sanitation, participants were asked questions related to their toilet facilities, knowledge of illness prevention, and hand washing practices. Approximately 94.8% of families used a local pit latrine while 4.8% used ventilated improved pits (VIP) and 0.4% used no toilet facilities. After using the toilet, 41.6% of families reported that they had water for hand washing at the toilet, and 34.2% reported that soap was also available at the toilet. According to respondents, the median number of times a person washed their hands per day was 4. Participants shared that although water and soap were not always available at the toilet, they were usually available at the house. Some respondents shared that when they had kept water and soap at the toilet in the past

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they had been stolen, prompting them to keep them closer to the house. Further results related to knowledge of sanitation practices will be discussed in later sections. Table  6:  Household  Water  &  Sanitation                 Number  (n=269)   Relative  Frequency  (%)  Village  water  availability     Low           87       32.3     Average         80       29.7     High           102       37.9  Source  of  water     Gravity         174       64.6     Stream/River         12       4.5     Spring           8       3.0     Well           67       24.9     Pond           1       0.4     Tank           7       2.6  Water  purification  methods     None           12       4.5     Boiling         247       91.8     Filtering  &  boiling       6       2.2     Tablet  &  boiling       2       0.7     Covering  water       1       0.4     Unsure         1       0.4  People  in  the  community  fetch  water     when  they  are  dirty       Yes         169       62.8       No         100       37.2  Toilet  facilities     Local  pit  latrine       255       94.8     Ventilated  Improved  Pit     13       4.8     None           1       0.4  Knowledge  of  illness  prevention     Listed  2  ways  to  prevent  illness   182       67.7     Unable  to  list  2  ways  to  prevent     85       31.6       illness     Missing         2       0.7  Knowledge  of  hand  washing     Listed  3  times  when  hands       219       81.4       should  be  washed     Unable  to  list  3  ways  when       50       18.6       hands  should  be  washed  Water  availability  for  hand  washing     Water  available  at  the  toilet     112       41.6     Water  not  available  at  the  toilet   157       58.4  

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Soap  availability  for  hand  washing     Soap  available  at  the  toilet     92       34.2     Soap  not  available  at  the  toilet   177       65.8                 Mean(sd)   Median                Minimum              Maximum  Average  number  of  times  participant     washes  hands  per  day     -­‐      4                    1                                              100   Health Center Patient Experience In order to assess participants’ experiences using local health centers, a series of questions related to their use was asked. Approximately 61.0% of respondents reported that local health centers typically operated on time, while 39.0% reported frequent delays. During their visit to the health center, 60.2% of participants reported that health center staff spared time for them by explaining the cause of their illness, treatment, and prevention, while 39.8% of respondents reported that staff was frequently too busy to speak to them and simply prescribed medication only. In addition, 5.6% of participants reported that health center staff followed up with them after their visit with a phone call or house visit, compared to 94.4% of respondents who received no form of follow up. Those who received follow up were typically patients recently diagnosed with HIV/AIDS. Of those who were prescribed medication at the health center, 88.1% reported that the treatment prescribed was effective while 11.9% reported that the prescribed treatment was ineffective. With regard to drug provider, 47.6% of respondents obtained their drugs from a government clinic, 36.8% obtained their drugs from a private clinic, and 15.2% obtained drugs from both government and private clinics. Survey participants spent a median of 50,000 Ugandan shillings per month on their family’s health. Those families with major health problems and complications spent up to one million shillings per month; for example those with diabetes, hypertension, heart attacks, kidney disease, and other presently unknown health problems. The majority of those who received services from government clinics reported having to spend some amount of money either for timeliness or for certain drugs. This was cause for frustration due to low income levels, high expenditures on health and school, and the fact that government services are intended to operate at no cost. Those respondents who used primarily private clinics explained that their experience at government clinics has been one of untimeliness, regular stock outs, ineffective medication, and the need to pay money to clinic staff when services should be free. As a result of these experiences, those who use private clinics reported that if they must spend money for health services, they would rather spend it to get quality, timely service. Table  7:  Health  Center  Patient  Experience                 Number  (n=269)   Relative  Frequency  (%)  Timeliness  of  health  center  activities     On  time         164       61.0     Not  on  time         105       39.0  

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Effectiveness  of  health  center  treatment       Effective         237       88.1     Not  effective         32       11.9  Staff  bedside  manner     Staff  spares  time  and  speaks     162       60.2       to  me  as  a  patient     Staff  does  not  spare  time  and  does   107       39.8       not  speak  to  me  as  a  patient  Health  center  follow  up       Staff  follows  up  with  me  after  my     15       5.6       visit     Staff  does  not  follow  up  with  me   254       94.4       after  my  visit  Drug  provider       Government         128       47.6     Private         99       36.8     Both  government  &  private     41       15.2     Unsure         1       0.4                   Mean(sd)   Median              Minimum                Maximum    Amount  of  money  (UGX)  spent       -­‐     50000                  0                    1000000  

on  family  health  per  month             Family Level Prevalence of Common Illnesses Children During the pilot study phase of this research, three common childhood illnesses became evident that were included as questions in the research survey. These diagnoses consisted of diarrhea, respiratory tract infection (RTI) or “cough”, and malaria. Within the survey, respondents were asked how many children in the family had had diarrhea and RTI in the past month, and how many times per year family children acquire malaria. An average of 0.4 children per family were reported to have diarrhea per month with a minimum of zero and a maximum of three. Although these numbers do not demonstrate a major burden of diarrhea in the sub-county, it is possible that these numbers are under reported out of embarrassment and shame of the disease. An average of 1.7 children per family were reported to have RTI per month with a minimum of zero and a maximum of nine. This suggests that the majority of families have at least one child experiencing RTI per month. Finally, it was reported that children experience malaria an average of 2.6 times per year. When asked which diseases and conditions family children experience most frequently, the majority of respondents named at least one of the above three conditions.

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Respondents were also asked which illnesses household children frequently acquire or are diagnosed with. The most common illnesses reported within the sub-county consist of malaria, RTI, skin infections, and allergies. For a complete list of reported childhood illnesses and family level prevalence please refer to Table 8. Table  8:  Family  Level  Prevalence  of  Reported  Childhood  Illnesses               Number  of  cases     Prevalence  (%)             (n=255*)    Malaria         187         73.3    RTI           152         59.6  Skin  infections       41         16.1  Allergies         15         5.9  Diarrhea         9         3.5  Worms         9         3.5  Stomach  pain         8         3.1  Typhoid         8         3.1  Pneumonia         8         3.1  Ulcers           4         1.6  Eye  problems         3         1.2  Nosebleed         3         1.2  Arthritis         2         0.8  Ear  problems         1         0.4  Measles         1         0.4  Cancer           1         0.4  No  illnesses         8         3.1    *n  represents  the  total  number  of  families  with  children.    The  number  of  cases  represents  the  number  of  families  that  have  one  or  more  children  frequently  diagnosed  with  the  given  condition.   Adults After conducting the pilot study, two adult illnesses became apparent that were also included within the research survey. These conditions consisted of malaria and HIV/AIDS. Questions related to each condition were asked, as well as general illnesses and conditions frequently experienced by family adults. Respondents reported that family adults typically experienced malaria an average of 2.2 times per year, and malaria was experienced regularly by 52.8% of respondent families. Out of all 269 respondents, only one reported that they had not heard of HIV/AIDS, and 86.6% of study participants reported having ever tested for HIV/AIDS. The prevalence of HIV/AIDS among at least one family member within respondent families was approximately 15.7%. It is possible that this number could be under reported out of shame and stigma associated with the disease.

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Respondents were also asked which illnesses household adults most frequently experienced. The most common illnesses consisted of malaria, RTI, arthritis, stomach pain, and allergies. For a complete list of reported household adult illnesses and family level prevalence please refer to Table 9. Table  9:  Family  Level  Prevalence  of  Reported  Adult  Illnesses               Number  of  cases     Prevalence  (%)             (n=269*)    Malaria         142         52.8  RTI           84         31.2  Arthritis         38         14.1  Stomach  pain         36         13.3  Allergies         33         12.3  Ulcers           24         8.9  Skin  infections       19         7.1  Chest  pain/heart  problems     16         5.9  Eye  problems         15         5.6  Sexually  transmitted  infection   13         4.8  HIV/AIDS         11         4.1  Diabetes         9         3.3  Kidney  problems       7         2.6  Worms         7         2.6  Typhoid         6         2.2  Hernia           5         1.9  High  blood  pressure       5         1.9  Cancer           4         1.5  Hypertension         3         1.1  Edema           3         1.1  Nosebleed         2         0.7  Pneumonia         2         0.7  Sleeplessness         2         0.7  Teeth  problems       2         0.7  Goiter           2         0.7  No  illnesses         14         5.2    *n  represents  the  total  number  of  families.    The  number  of  cases  represents  the  number  of  families  that  have  one  or  more  adult  frequently  diagnosed  with  the  given  condition.   Knowledge of Healthy Behavior Nutrition In order to assess knowledge of nutrition and healthy eating behavior, respondents were asked to list the three healthiest foods available in the sub-county, regardless of

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availability or cost, according to their knowledge of nutrition. A total of 80.0% of respondents were able to list three foods that they felt were healthy, while 20% were unable to list three foods or responded that they did not know what made certain foods healthy. Of those respondents who listed three foods, those listed as healthiest were millet, matooke bananas, potatoes (sweet & Irish), and posho. These five foods are eaten most often within the sub-county, however they are each high in carbohydrates and do not contain some nutrients in quantities that are vital for growth, development, and body maintenance. It was also observed that many children of respondents had developed kwashiorkor, indicating low levels of protein in the body. Some parents of these children were concerned about their child’s health, but did not know what the condition was, what caused it, or how to treat it. The prevalence of kwashiorkor and other types of observed malnutrition and the lack of general knowledge related to these conditions indicate a low level of understanding of general nutrition among study participants. For a complete list of foods listed by participants in order of healthiest please refer to Table 10. Table  10:  Healthiest  Foods  According  to  Participants               Number  (n=269*)     Relative  Frequency  (%)    Millet           125         46.5  Matooke  bananas       121         45.0  Potatoes  (sweet  &  Irish)     118         43.9  Posho           107         39.8  Rice           76         28.3  Cassava         66         24.5  Beans           35         13.0  Meat  (including  fish)       32         11.9  G-­‐nuts           13         4.8  Yams           12         4.5  Milk           10         3.7  Dodo  (greens)       8         3.0  Eggs           4         1.5  Fruits           3         1.1  Sugar           2         0.7  Carrots         2         0.7  Cabbage         2         0.7  Bread           2         0.7  Pumpkin         2         0.7  Maize           1         0.4  Did  not  know         2         0.7    *n  represents  the  total  number  of  participants.    The  number  for  each  food  represents  the  number  of  participants  who  stated  the  given  food  as  one  of  the  three  healthiest  foods  available  in  Kyangyenyi.  

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Disease Prevention In order to assess knowledge of disease prevention, participants were ask to list two ways that they can prevent disease at home, and three times when they should wash their hands during the day. A total of 67.7% of respondents were able to list two ways they could prevent disease at home, while 81.4% were able to list three times when they should wash their hands during the day. The most common ways participants cited for preventing various diseases at home included boiling water, general cleaning, and being clean, while the most often cited times for hand washing were before eating, after using the toilet, after working, and after waking in the morning. These responses illustrate that although respondents were able to list ways of preventing disease, the majority of responses were very general and not distinct. Examples of hand washing behavior were comprised of more specific examples implying that respondents had better knowledge of hand washing behavior as opposed to disease prevention. For a complete list of knowledge of disease prevention methods and hand washing behavior please refer to Tables 11 & 12. Table  11:  Participant  Disease  Prevention  Methods               Number  (n=269*)     Relative  Frequency  (%)    Boiling  water         82         30.5  General  cleaning       64         23.8  Being  clean         60         22.3  Sleeping  under  nets       35         13.0  Washing  hands       26         9.7  Sweeping         24         8.9  Washing  utensils       23         8.6  Cleaning  the  compound     20         7.4  Slashing  bushes       19         7.1  Good  sanitation       17         6.3  Having  a  toilet       16         5.9  Covering  food         8         3.0  Eating  healthy  foods       7         2.6  Destroying  stagnant  water     5         1.9  Abstinence         4         1.5  Covering  the  toilet       4         1.5  Closing  windows  &  doors     3         1.1  Proper  disposal  of  wastes     2         0.7  Having  a  high  income     2         0.7  Condoms         1         0.4  Stop  visiting  neighbors     1         0.4  Breastfeeding         1         0.4  Did  not  know         12         4.5        

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*n  represents  the  total  number  of  participants.    The  number  for  each  method  represents  the  number  of  participants  who  stated  the  given  method  as  one  way  to  prevent  disease  at  home.   Table  12:  Participant  Hand  Washing  Behavior               Number  (n=269*)     Relative  Frequency  (%)    Before  eating         220         82.1  After  using  the  toilet       136         50.7  After  working         94         35.1  After  waking  in  the  morning   94         35.1  After  eating         53         19.8  Before  sleeping       17         6.3  Before  cooking       15         5.6  After  washing  utensils     11         4.1  Before  peeling       9         3.4  Before  breastfeeding       8         3.0  After  milking         7         2.6  After  touching  something  dirty   7         2.6  Before  bathing       6         2.2  Before  drinking       4         1.5  Before  praying       3         1.1  After  peeling         3         1.1  Before  serving       2         0.7  After  shaving         1         0.4  Before  taking  medicine     1         0.4  Before  brushing  teeth     1         0.4  Before  cleaning       1         0.4  After  cleaning         1         0.4  Did  not  know         1         0.4    *n  represents  the  total  number  of  participants.    The  number  for  each  situation  represents  the  number  of  participants  who  stated  the  given  situation  as  one  time  when  a  person  should  wash  his  or  her  hands.  

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Recommendations The results of this study demonstrate that the residents of Kyangyenyi sub-county must improve certain aspects of their health and living conditions in order to improve their overall health status. Based on current knowledge levels related to disease prevention methods and nutrition, it is important that residents receive education in order to improve overall knowledge and maintain behavior changes within these areas. It is also important that education be used in order to teach the community how to improve their standard of living in the home and on important health topics such as family planning and maternal & child health. In addition to community education programs, it is recommended that local government and private health organizations assess their effectiveness and efficiency and address obstacles hindering the community from receiving high quality medical care and patient satisfaction. Participants of the survey frequently shared that they wished they could improve certain areas such as the cleanliness and organization of their house, but they did not know how to improve upon their current conditions. Similarly, after asking participants to list ways they prevent illness at home and when they should wash their hands, the majority of respondents asked to be educated in those areas. These responses as well as the data from the survey show a need and desire for education in the sub-county related to nutrition, crop production, disease prevention methods, family planning, cleanliness and organization, and maternal & child health. Given that the government has established local health teams at the village level, it should be their responsibility to regularly implement these education topics. During discussions with survey participants, many respondents shared that they had never been informed of any health education programs and did not even know that village health teams existed in their area. According to one participant who was also part of a village health team, the government did not provide adequate training for the village health teams and they lacked educational resources to help communities. The government also provides no financial support or reimbursement, which creates a lack of motivation and interest for community members to join. As a result, the teams are largely inactive and do not provide the support needed by the community. Since local village health teams provide a vital service and also serve as a valuable resource for the community, it is recommended that the government work with the local village health teams to find a way of increasing motivation so that the community regularly receives the health education they need. Other countries have successfully used their village health teams to make a difference in local community health by providing monetary compensation, establishing a strong connection with local health centers, providing appropriate training materials and training sessions, and uniformly coordinating teams across the nation7,8. In addition to improving government sponsored village health teams, it is recommended that private health organizations in the area also address the need for health education. While providing large health education programs provides the community with a wide range of specific information, providing information at clinics or having one to one health talks with patients also provides vital health information that can be shared by the patient with family and friends in the community.

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Alongside health education, the support for behavior change is also important in order to assist the community in adapting behaviors. For example, respondents reported having a diet high in carbohydrate foods such as matooke bananas, cassava, posho, beans, and potatoes. The addition of vegetables that are not as commonly eaten such as tomatoes, cabbage, pumpkin, and eggplant that provide vital nutrients may be difficult for families to implement in practice since they are used to eating their traditional foods. Organizations that provide health education must be able to follow up with the community and provide the support needed to help them change long standing traditional behaviors. It is essential that existing health services in the community operate efficiently and effectively so that patients receive the highest quality care. Those study respondents who reported using government health clinics shared experiences of long wait times, frequent stock outs, and the need to pay to receive time with a doctor and quality services. Those who used private clinics shared that although the doctor spent more time with them and drugs were more readily available, the cost was much higher making private services unaffordable or too costly. Respondents also shared a general dissatisfaction with the way they are treated as patients in the sub-county, especially in government clinics. As a result, it is recommended that local clinics assess their standards and procedures and address areas that prevent quality care and a positive patient experience. One area that many participants shared was a major concern was their current and future access to water. The fact that almost one-third of the sampled population currently has low availability of water and that 35.4% obtain their water from stagnant or polluted sources is cause for concern. In general, respondents who lived in mountainous or very rural areas had the least access to regularly available water. One positive solution that has been attempted has been the construction of high quality, long-term durable rainwater tanks shared by a group of families. One village within Rwebaare parish constructed three of these tanks and the result has been a more consistent, reliable water source for those in the immediate area. As a result of this success, it is recommended that local organizations helping with water access explore the construction of these tanks for villages where water access is lowest. The community is also encouraged to investigate grants available from large organizations in order to provide funding for future tank construction. As researchers we recognize that this study is subject to several limitations. As this study was conducted using a cross-sectional design we are only able to measure the prevalence of illness and are not able to make any inference regarding exposure related to disease. Funding and time restrictions also limited our ability to assess valuable qualitative data by holding focus group discussions and key informant interviews. During data collection we also recognize the possibility of interviewer bias during interpretation as well as recall bias resulting in respondent’s failure to report information (such as HIV/AIDS) and fabricate information. In order to control for these different types of limitations several methods were used in the design phase of this study. Clear, specific questions were formed in the survey in order to account for response accuracy

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and understanding. Specific interview techniques were used to form questions for sensitive topics, such as HIV/AIDS and family planning. Local interpreters were also trained in appropriate interview techniques in order to reduce interviewer bias. As one purpose of this research is to serve as baseline data for future health projects and to provide a clear picture of present conditions, it is recommended that more research be conducted in order to assess the impact of current and future projects on the health status of Kyangyenyi sub-county residents. In conclusion, this research shows that the residents of Kyangyenyi sub-county are in need of health education and behavior change support in order to improve conditions having a negative impact on health in the home environment, and improved government and private health services currently operating in the sub-county. Given that the government has opted to provide medical services at no cost and has set up local village health teams, these services should be utilized more effectively in order to have a more positive impact in the community. Private organizations should also make sure they are doing their part to offer the highest quality services needed by the community that are accessible by the current standard of living. Future research should focus on the impact of existing projects related to the community’s needs as well targeting areas still in need of improvement in order to support the overall health of the Kyangyenyi sub-county community.

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Bibliography

1. World Health Organization (2014). Country Cooperation Strategy: Uganda. WHO Regional Office for Africa, World Health Organization. Available online at http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_uga_en.pdf?ua=1 [last accessed January 14, 2015].

2. The World Bank (2015). World Development Indicators: Uganda. The World Bank Group, The World Bank. Available online at http://data.worldbank.org/country/Uganda [last accessed January 14, 2015].

3. Uganda Bureau of Statistics (UBOS) (2014). National Population and Housing Census 2014: Provisional Results. Kampala, Uganda, Uganda Bureau of Statistics.

4. Management Sciences in Health (STAR-E) and Elizabeth Glaser Pediatric AIDS Foundation (STAR-SW) (2011). Community Knowledge and Practices LWAS Survey, 2010. Sheema District, Uganda, Management Sciences in Health.

5. Uganda Ministry of Health (2011). Health Sector Strategic Plan III: 2010-11-2014-15. Kampala, Uganda, Uganda Ministry of Health.

6. Twikirize, J.M. and O’Brien, C (2012). Why Ugandan rural households are opting to pay community health insurance rather than use the free healthcare services. Int J Soc Welfare 21:66-78.

7. The Earth Institute: Columbia University (2012). One Million Community Health Workers. New York, New York, Columbia University.

8. Kaschko, A.N. (2013). Remuneration for community health workers: Recommendations to the World Health Organization. MPH Policy Paper. Boston, University, Boston University School of Public Health.