Health Barrier Analysis to Inform Community Outreach in Kitgum, Northen Uganda

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Health Barrier Analysis to Inform Community Outreach in Kitgum, Northen Uganda
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Project in lieu of thesis
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Stirling, Daniel
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University of Florida
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Master's
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University of Florida
Committee Chair:
Rheingans, Richard
Committee Members:
McKune, Sarah

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Sustainable Development Practice (MDP) Program final field practicum report
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The MDP Program is administered jointly by the Center for Latin American Studies and the Center for African Studies.

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HEALTH BARRIER ANA LY SIS TO INFORM COMMUNITY OUTREACH IN KITGUM, NORTHERN UGANDA Dr. Albert Grau Valencian Community Foundation St. Joseph Hospital, Kitgum Daniel Stirling Committee Chair Richard Rheingans Committee Member Sarah Mckune Danielstirling@ufl.edu

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TABLE OF CONTENTS FIELD PRACTICUM INTR ODUCTION ................................ ................................ ................................ 1 N ATIONAL AND REGIONAL BACKGROUND ................................ ................................ ................................ ... 1 Uganda ................................ ................................ ................................ ................................ ................... 2 Kitgum district ................................ ................................ ................................ ................................ ........ 3 ................................ ................................ ................................ .............................. 5 The Grau Foundation ................................ ................................ ................................ .............................. 6 RESEARCH METHODS ................................ ................................ ................................ ............................. 8 S TUDY A REA ................................ ................................ ................................ ................................ ............... 8 E XTENT OF STUDY ................................ ................................ ................................ ................................ ....... 9 Justification for focus on preventable diseases ................................ ................................ .................... 10 Justification for focus on maternal health ................................ ................................ ............................ 1 1 P ARTICIPATORY RESEARC H METHODS ................................ ................................ ................................ ....... 12 Data collection ................................ ................................ ................................ ................................ ..... 12 Surveys ................................ ................................ ................................ ................................ .................. 13 Focus group/workshops ................................ ................................ ................................ ........................ 13 Key informant interviews ................................ ................................ ................................ ...................... 14 In village direct observation ................................ ................................ ................................ ................. 15 Global positioning systems information ................................ ................................ ............................... 15 RESULTS ................................ ................................ ................................ ................................ .................... 16 H EALTH SEEKING BEHAVI OR ................................ ................................ ................................ ..................... 17 FOAM A NALYSIS ................................ ................................ ................................ ................................ ..... 20 Diarrheal disease ................................ ................................ ................................ ................................ 21 Malarial disease ................................ ................................ ................................ ................................ ... 26 Maternal health ................................ ................................ ................................ ................................ .... 30 F OCUS GROUPS ................................ ................................ ................................ ................................ .......... 33 I NTERVIEWS ................................ ................................ ................................ ................................ .............. 35 DISSCUSSION AND RECOMMENDATIONS ................................ ................................ ...................... 3 9 H EALTH SEEKING BEHAVI OR ................................ ................................ ................................ ..................... 3 9 B ARRIERS IN MALARIAL DISEASE PREVENTION ................................ ................................ .......................... 40 B ARRIERS IN D IARRHEAL DISEASE PRE VENTION ................................ ................................ ........................ 4 2 M ATERNAL H EALTH ................................ ................................ ................................ ................................ .. 4 3 L IMITATIONS ................................ ................................ ................................ ................................ ............. 4 4 C O NCLUSIONS AND RECOMMENDATIONS ................................ ................................ ................................ .. 45 B IBLIOGRAPHY ................................ ................................ ................................ ................................ .......... 4 8 ANNEXES ................................ ................................ ................................ ................................ ................... 4 9 S URVEY INSTRUMENT ................................ ................................ ................................ ................................ 4 9 I NTERVIEW TRANSCRIPTI ONS ................................ ................................ ................................ .................... 57 Outreach coordinator ................................ ................................ ................................ .......................... 5 7 Maturity ward head nurse ................................ ................................ ................................ .................... 61 ................................ ................................ ................................ ................. 6 7 Anti natal ward head nurse ................................ ................................ ................................ .................. 6 9 Hospital head nurse ................................ ................................ ................................ .............................. 71 C OPY OF M OU FOR S NUTRITION PROGRAM ................................ ................................ ..................... 7 2 C OPY OF 2012 REPORT ON NUTRITION ACTIVITIES ................................ ................................ ...................... 82 C OPY OF COMMUNITY BAS ED SUPPLEMENTAL FEED ING PROGRAM END OF P ROGRAM REPORT ................... 94

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1 Field Practicum I ntroduction For the field practicum for the University Of Florida Masters Of Sustainable Development Program, I was contracted by the Grau Albert Valencian Community Foundation (The Grau Foundation) as a research coordinator to do preliminary investigations to help de velop future Hospital, Kitgum Ditrict, Uganda based hospital funded by the multiple private donor funds, the Ugandan government and patie nt payments. In the past, the Grau Foundation funded brick and mortar construction of the hospital and the acquisition of large medical equipment supplies. Outreach is a challenging new endeavor for the Grau Foundation As research coordinator, my main e study system that included in villa ge surveys and observations, in depth interviews with key hospital staff and village health team members (V HTs), workshops and focus group discussions after preliminary data analysis and Clear health behavioral patterns and barriers became evident as well as ways to incorporate pa st programs and local expertise into effective, efficient future programs. National and Regional background Uganda Since 1990, Uganda has made significant reductions in the under 5 and infant mortality rates nationwide with 50% reduction in under 5 mortality and a 49% reduction in infant mortality 1 Maternal mortal ity has been much slower with only a 16% reduction since 1995 1 The Uganda

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2 Ministry of Health notes that there is a need for continued community mobilization a nd involvement of new community based interventions to continue these reductions. C hildren under 5 years of age can encounter a range of life threatening illnesses in Uganda. It is reported that 10% of the total under 5 mortality is attributed to diarrhea, which equals roughly 99 d eaths per thousand live births 2 .. Diarrheal disease in Northern Uganda has two major factors related to under 5 deaths; (1) mortality directly related to diarrheal illness and (2) susceptibility to other illness due to diarrheal outbreaks. This is significant because pneumonia constitutes 17% of under 5 mortality in Uga nda 2 and 26% of all childhood pneumoni a episodes worldwide are linked to d iarrhea induced susceptibility 3 If left untreated diarrhea can lead to malnutrition and to reduce under 5 mortality in this regi on. Kitgum District Kitgum District is one of the most remote and impoverished districts of U ganda with a lan d area measuring about 7,557 square kilometers (Fig. 1) 1 It has suffered the worst effects of a 20 year LRA) and the Uganda government 4 In the Northern part of the nation lying on the border with the Republic of Sudan, with Kotido District to its East, Pader District to the South and Gulu District to the West. The diseas e burden is high and the health situation poor. Accessibility to health care was estimated at only 8.9%, against a national average of 49% in 2001 1 The burden of disease consists mostly of communicable diseases, including malaria, diarrhea, acute respiratory infections, intestinal worms, trauma and injury 1 The HIV prevalence rate in north central Uganda averages about 8.2% above the nati onal average of 6.7% The most recent data estimates infant mortality in Kitgum as 274 deaths per 1000 live birth more than three times the national average rate in 2001 5 According

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3 to 2006 DHS surv eys as compiled by WHO in 2012 2 inequalities exist among the rural and urban and between different socioeconomic statuses. The 2006 rural under 5 mortality rate was 148/1000 compared to an urban rate of 111/1000. The poorest quintile rate was 165/1000 compared to the wealthiest at 111/1000 2 These inequalities highlight that poor rural communities are at the greatest risk. The villages in Kitgum district match these at risk demographics and understanding specific responses to preventable health barriers crucial in the villages in Kitgum district and the St. Joseph Hospital catchment area as there is still a noted shortage of health workers throughout both 5 Figure 1: Map of Africa, Uganda and Kitgum

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4 St Joseph's Hospital, a private non profit hospital founded in 1925 owned and by the and other relevant stakeholders at the distr ict and national level in order to be a center of excellence in providing quality services to the population of Kitgum and Northern Uganda as well as the country at large especially for the vulnerable, less privileged and the poorest of the communi 5 education department that develops community activities in close partnership with the Village Health Teams (V HTs). The VHTs are local volunteer health groups from within the commu nities promoted by the Ugandan g overnment. St Joseph's works to enhance the capacity of these groups to assure different activities can be carried out in the communities. Examples of VH T programs include immunization campaigns, HIV testing, treatment and counseling, Can cer screening campaigns, and p reventive health, hygiene a nd nutrition training programs 6 tgum, Lamwo and Pader districts and has significant number of patients from South Sudan districts of Kabong and Kotido. The Hospital also forms part of Kitgum District Health Systems. It is a general hospital based on the current National Hospital Policy and operates in line with the Government of Uganda National Health Policy. All components of the Uganda Minimu m Health Care Package are offered at the hospital level (SJH) Total Population:118,135 Women 15 49 years: 23,863 Under 1 years: 5079 Number of births:5730 Under 5 years:23,863 People under 15 years:54,342 Pregnant women:5906 Suspected TB cases:354 Table 1: St. Joseph catchment area population statistics of concern to St. Joseph Hospital 14

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5 Based on the hospital s mission statement, the hospital is a key player for community or primary health ca re services as well as technical support supervisions to the lower level health fac ilities that include Health C enter II and III (HCII and HCIII respectively) as well as VHTs which are commonly known to be the village l evel Health C enter Is The population of the service area is 118,135 and the majority of users of the hospital services come from the Amida, Layamo and Akwang sub district s and the Kitgum town council. The hospital denotes the major target groups estimated populations for h ea l th interventions are in table 1. From the hospital s recommendations in the Annual analytical report, the government of Uganda and improve community livelihoo d and health sector indicators specificall y ensuring innovative community based activities aimed at improving socio economic status of the community 5 These efforts need donor funding programs working alongside government initiatives such as support the government of delivering insecticide treated bed nets (INTs) to all women attending anti natal care The Grau Foundation is now in a position to help fund these programs by insuring the INT supply and increasing direct access to INT to all villagers. The Grau Foundation The Spain based Fundacin De La Comunidad Valenciana Dr. Grau Albert (Dr. Grau Albert since 1999 after the death of its name sake and longtime hos pital superintendent, Dr. Albert Grau. Dr. Grau is almost a folk hero in Kitgum area and worked tirelessly at the hospital through the war and in Uganda up until his death. In Spain, the term "foundation" is synonymous with

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6 non profit. The organization is headquartered in Valencia, Spain and works exclusively with St. The main objective of the Grau Foundation is to begin community specific preventive health campaigns in four sub districts in the coming years The Gr au Foundation does not have a full time in country supervisor and intends to work through existing hospital staff and VHTs. This is an entirely feasible approach and through hospital outreach staff and VHT assistance can be achieved but the protocols for accountability and strengthening in village support need to be more established. The willingness among informed villagers exists and can be realized. With careful consideration and patience the lack of a foreign in county supervisor could prove to be thi s outreach program s greatest strength and lead to viable sustainable impact pathways into the communitie s for far more than just health initiatives This dire need for this careful, effective planning is what informed my data collection methods. An import begins by better understand ing the local needs and possibilities. This requires a comprehensive study of the village level realities of health seeking behavior, preventative health sector barriers and in village groups to be the main target of the socio economic programs.

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7 Research methods Study area Sub districts and villages The three sub districts selected by the Grau Foundation are Labogo Amida, Labongo Akwang and Labongo Layamo Sub district Village Households Est. population Dist. to HC ** Labo n go Amida Kampala 142 913 6 km Lokira 182 952 4 km Labongo Akwang Tumungu 186 1074 15 km Oget 152 765 8 km Labongo Layamo Paibwa East 135 700 7 km Ocetoke North 176 770 10 km Village chief estimates ** GPS approximation from road entrance of village Each village was selected by the Grau Foundation after meetings with the health assistants of the sub county health centers. Each health assistant was asked to identify two villages that would benefit from health education programs and that had little to no previous interventions or assistance from oth er NGOs since resettlement ( approximately 5 years ) The reason for selecting villages with no previous interventions is to promote equity among villages and to ensure that the Grau Foundation would not conflict with any past or on going health interventio ns. Table 2: Village and sub counties names and important statistics that participated in this study

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8 This three sub districts and the sub district of Kitgum Matidi s Hospital catchment area. During preliminary health education programs that took place from January 2013 to July 2013 by Ana Grau and Benjee Casio on behalf of the Grau Foundation, VHTs from these communities or neighboring ones were identified to be able to facilitate in village surveys and direct observations. Focus of the study Justification for a focus of preventable diseases Most of the deaths contributing to under 5 mortality are c onsidered preventable. Seventy percent of global child mortality are attributed to five major causes : pneumonia, diarrhea, malaria, Figure 2. Map of the four sub districts in Northern Uganda in the SJH catchment area 15

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9 measl es and malnutrition 7 Many children who fall sick fr om these illnesses and conditions will die, despite the existence of well recognized, internationally recommended treatments that are low cost, highly effective, and easy to use. A shortage of health care workers, particularly in rural areas, contributes t o the challenges of getting treatments to children living in remote communities 8 There is a growing recognition that child health care programs that involve the community in partnership have great potential for reducing under 5 deaths at minimal cost According to M inistry o f Health documents in 2012, under 5 deaths are due to neonatal conditions (23%), malaria (25%), AR I/pneumonia (19%), diarrhea (17%) 1 Healthy Child Uganda (2012) found that the two primary constraints in the implementation of maternal and child health interventions are (1) shortages of health service providers and (2) child survival comm odities (such as O ral rehydration solution (ORS) and insecticide treated bed nets( ITNs) ) 8 Both diarrheal disease and a cute respiratory infections are considered preventable via eff ective interventions such as access to and use o f adequate sanitation, improved access to clean water, and frequent hand was hing with soap 9 Justification for focus on Skilled Birth Attendants and ante natal care attendance Globally, 80% of maternal mortality is due to direct obstetric complications with hemorrhaging (25%) and sepsis (15%) being the leading causes. Death of new borns during the first week of life is larg ely the result of inadequate or inappropriate care during preg nancy, childbirth, or the first critical hours after birth. The major c auses of neonatal mortality are neonatal infections, birth asphyxia and trauma 10 Uganda specifically has a high maternal mortality rate (438/100,000 births) and there is much attention focused on it by the Min istry of Health in pursuit of t he Millennium Development Goal Five to re duce maternal mortality by 75% 1 Around 80% of

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10 Uganda is considered rural and with little or no emergency obstetric care 11 The definition. Rural Ugandan numbers for births attended by a traditional birth attendant (TBAs) average around 60% and less than 20% attended by a sk illed birth attendant 11 Studies show child birth is considered a natural event and sometimes a n endurance ritual for mothers 12 Training traditional birth attendants with modern techniques and sterilization methods has be shown to be effective in reducing sepsis in mothers and neonatal infections in children 11 Core training genera lly focuses on teaching TBAs to perform deliveries in a more hygienic and safer fashion, discouraging harmful practices, recognizing danger signs and refe rring women with complications to facilities where essential obstetric care is available A program Safe motherhood strategies (2001) suggests implementing a five day basic course for TBAs 13 It is assumed that each village has a traditional birth attendant and these women will be approached and asked if they would like to partici pate in the training program. Participatory data collection methods Participatory d ata was aimed at understanding the barriers on the village and health systems levels to provide information to inform future outreach programs. I employed a myriad of me thodologies to attempt to examine and understand the barriers from many different angles. Data collection o Surveys (n=165) Comprehensive demographic, health and sanitation survey Adapted Focus on Opportunity, Ability and Motivation ( FOAM ) methodologies 9 to malaria, diarrheal diseases and maternal health.

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11 ( FOAM framework methodology is explained in detail in the results section ) o Focus groups/workshops (N=5, n=96) Conducted after rapid analysis of surveys o Semi structured interviews (n=11) Medical superintendent, Head nurse and Outreach coordinator Head nurses of ante natal maternity s ward Village health team members trained volunteer village level health consultants o In village direct observation (n=72) 7 indicators in home observations Survey s I developed health knowledge and access specific surveys that w ere used as primary data sources for the prevalence of preventable disease in ea ch community. These surveys were also designed to attain information for the FOAM analysis. As literacy rates are low throughout Kitgum, these surveys were administered orally a nd in most cases through the VHTs acting as Acholi translators. The surveys consisted of 133 questions (see annex 1). The collection numbers in each village were aim ed to collect a 20% population coverage. Due to little background geographical data and t ime constraints a truly randomized sample of households was impossible. To get a geographic cross section of each village before beginning the surveys the village was split into three distinct geographic areas and an equal number of surveys were conducte d in each area.

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12 Demographic data questions included indicators including: Demographic information Sex Age Number of household members Marital status Education level Children in the household C hildren under 5 Childhood deaths and causes since village resettlement Health and sanitation indicators Water source and distance from homestead Water storage Water treatments Hand washing capabilities Hand washing behavior Toilet facilities Diarrheal illness incidence including children under 5 Ante natal and hospital birth attendance FOAM indicators for diarrheal disease, malaria and maternal health Health symptom knowledge Disease vector knowledge and threat Health seeking during symptoms Medical product knowledge, access and usage Focus groups /workshops : I conduct ed village focus groups /workshops after a rapid assessment on general topics of health and the specific issues surrounding the FOAM analysis. Specific

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13 topics include susceptibility, prevention and treatment of diarrheal disease and malaria and the use and access of trained birth attendant by villagers The main object ives of the focus group was to learn the social norms and group beliefs, expectations and per ceived threats surrounding these issues. I was able to complete five focus groups, one in each village except Tumungu. Each focus group had from 13 to 20 participates selected by the VHTs and all of whom participated in the surveys. The focus groups wer e paired with a preliminary returning of key results from the survey, mainly that health knowledge was high but access to health goods was critical barrier, and a demonstration of how to correctly make homemade oral rehydration solution. Each participant was given a half liter plastic water bottle with the correct amount of salt and sugar to be added printed on the bottle. The focus groups were then used to test the accuracy of my results and understand the collective thoughts on health care delivery at b oth the health center and hospital levels. Key informant interviews VHTs : I conducted structured interviews with each of the VHTs I worked with. Questions aimed to understand VHTs time constraints, willingness to participate, payment requirements and the ability to learn and teach survey collection tools. Hospital staff : The interviews with hospital staff were designed to understand possibilities and constraints of outreach programs, specific needs they understood from patient interactions and major barriers to maintain a healthy population. They also revealed projects they had been involved with and their abilities to coordinate or contribute to outreach programs. These interviews included the hospital head nurse, the outreach coordinator and the h ead n urses of the maturity, children and anti natal wards Specific questions were designed for each of their specializations and all were asked want are the major issues outreach should address.

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14 Direct Observation data collection Visual observation and n otation : During the in village surveys I made direct observations of seven indicators of health knowledge and product usage. These observations included the visual confirmation of Water treatment supplies Bednets available and hung above beds All household members wearing footwear Soap and handwashing basins Water storage devices Latrines Pesticide spray application Global positioning systems (GPS) information : I collect ed longitude and latitude coordinates using a handheld GPS unit in each vill age. By recording coordinates and i nputting those G able to create village specific maps that show relative distances to water and health services I made these m aps available to sub district offices for possible preliminary project planning. During the focus groups the two most mentioned needs were more boreholes and health centers with closer proximity to the villages These projects are well out of contact with the sub district offices while introducing my project to them and while getting security clearance during each visit. Maps were delivered by email to each sub district outreach officer. I also made it clear to participants in the focus grou ps/workshops that I would make these claims and maps available to this officer and encouraged them to voice their needs to this officer. This was done to empower the villagers to be in charge of the village demands and to make it clear that I could not be expected to deliver any additional support on these issues.

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15 Results The analysis of results from all data collections fall into three categories, health seeking behavior, FOAM analysis of diarrheal disease, malaria and maternal health and preserved limitation of health care delivery. First overall burden of diseases was l ooked at. Two key indicators were surveyed, childhood deaths and deaths during pregnancy or childbirth. First, childhood mortality was gauged utilizing (approximately 5 year ago) have any children in your household die d households surveyed 94 child deaths were reported. Malaria was the predominant cause accounting for 46% of those reported deaths, stillbirths both malaria related and for unknown causes accounted for 5% and diarrhea accounted for 4%. Figure 3: Percentage of the reported cause of death among children of survey respondents. 92 child deaths were report among the 165 households surveyed

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16 Maternal mortality that has died during childbirth? low response compared to the literature of maternal mortality in Northern Uganda Only two people responded as knowing someone and it was the same woman from Paibwo East My data show one death in a population of approximately 5173 while the Uganda health ministries reported one death in every 238 live births 1 The interview with the head nurse of the maternity ward reveal she had seen a great decrease in maternal mortality stating that they had become very skilled at saving mothers with complications but is more common that the child could not be saved. I did no t collect any specific data showing the death of children during childbirth outside of the stillbirths mentioned as causes of childhood death. Health care seeking behaviors The survey instrument was designed to collect quantitative data about when and how villagers access health care from either health centers or the hospital and the usage and effectiveness of health advice. Overall, health care seeking behaviors were high. Again attention was focused on the three most critical health problems: childhood diarrheal disease, malaria and maternal health. Looking first at childhood diarrheal disease t How long after notic Sixty one percent of respondents said that they sought p rofessional health advice at the first signs of a childhood diarrheal event and only two percent claimed see king no professional help (fig.4 ). These numbers are significant because diarrhea was the smallest reported cause of death at 2% (Fig.3 ) but 90% of respondents agreed children could die from diarrhea and understood professional health care was required. The vil lage of Tumungu reported the lowest percentage (38%) of people seeking care

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17 at first signs of diarrhea. This could be related to Tumungu bein g the furthest vil lage from a health center, but another 50% of people still sought care with in 2 to 4 days Health care seeking b ehavio r during pregnancy was also higher than expected. Ninety eight percent of all responde nts stated that childbirth required professional health care and only 2% utilized a traditional birth attendant. Moreover, males responded una ni mous ly that women in their households should give birth in a health center or hospital. Women that reported using a birth attendant were all older than 46 years of a ge. The seeking of ante natal care was also widespread Only one r esponde nt reported not seeking ante natal care and 78% r e ported monthly ante natal visits (fig.5 )

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18 Respondents also indicated high health seeking behavior when malaria was suspected Ninety five percent of respondents sought professional health care for fevers and malaria and another 3% used medicine from a profess ional health care provider (fig. 6 ). The qualitative responses of why they used medicine from a health center was that they would use medicine provided from past visits to the health center for malaria symptoms before as a first response and would visit a health center if fever con tinued. natal care visits during pregn ancy Every month after first visit indicates more than 3 total visits in the response

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19 FOAM analysis framework The FOAM analysis framework looks at each specific disease burden and breaks it down by the variables related to opportuni ty, ability and motivation (Fig.7 ). These three compnents can then be analized to determine specific barriers that can determine behavioral change among a population. Through this analysis specific behavoir changes can be targeted in an complete education outreach 9 care products th at can improve health outcomes 9 knowledge of and u se of these products 9 Due to the communal nature of the Acholi and time constraints, I did not collect information on social support. I did originally have indicator about social support and field tested th em in the first two villages but the exact definitions of neighbor, friends and Figure 6: Respondent count of malaria professional health care seeking behavior

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20 family proved cumbersome. Motivation looks specifically to determine if a population has sufficeint concern and awareness of adverse health outcomes that would drive them to c hange behavoir 9 Diarrheal Disease FOAM analysis Opportunity T he main health products observ ed in this study pertaining to diarrheal disease was soap for preventative sanitation measur es and oral rehydration solution (or sometimes called oral rehydration salts) or ORS as a treatment measure. There are hospital provided packets of ORS and also a homemade version that can be made with wa ter, sugar and salt. The homemade version is taught by the St. Joseph Hospital as a preventative measure to be administered before leaving for the health center or hospital to keep a patient hydrated during the travel time to the hospital. Figure 7: FOAM framework conceptual design 9

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21 Ninety nine percent of respondents know a local place to purchase soap but only 23% of respondents said there was always enough mo ney to buy soap which shows c ost represents a barrier to universal usage About 50% of respondents indicated that they always had soap available after d efe cation while only 47% had soap available before cooking or eating. Another important dimension to soap usage is a place to wash your hands. Sixty one percent of respondents had a hand washing facility inside their house and 87% had one near the house. For ORS 75% of respondents could not name a place to buy ORS packets and 70% of respondents could not buy sugar and salt specifically for homemade ORS You know a place to buy soap? Frequency Percent 95% CI Lower 95% CI Upper Disagree 1 0.61% 0.02% 3.33% Always Agree 164 98.79% 95.69% 99.85% TOTAL 165 100.00% Is there always enough money to buy soap? Frequency Percent 95% CI Lower 95% CI Upper Disagree 127 77% 70% 83% Always Agree 38 23% 16% 29% TOTAL 165 100.00% Soap and water are available for you after you defecate? Frequency Percent 95% CI Lower 95% CI Upper Disagree 76 46% 38% 54% Always Agree 89 54% 43% 66% TOTAL 165 100.00% Soap and water are available before you eat or prepare food? Frequency Percent 95% CI Lower 95% CI Upper Disagree 79 48% 40% 56% Always Agree 86 52% 41% 56% Table 3: Respondent results for diarrheal disease opportunity analysis survey questions

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22 TOTAL 165 100.00% Do you have a place to wash your hands inside the house Frequency Percent 95% CI Lower 95% CI Upper Yes 102 62% 54% 69% No 63 38% 31% 46% TOTAL 165 100.00% Do you have a place to wash your hands near the house Frequency Percent 95% CI Lower 95% CI Upper Yes 144 87% 81% 92% No 21 13% 8% 19% TOTAL 165 100.00% You know a place to buy ORS packets? Frequency Percent 95% CI Lower 95% CI Upper Disagree 123 75% 68% 81% Always Agree 41 25% 18% 32% TOTAL 164 100.00% You can buy suga r and salt to make ORS solution at home? Frequency Percent 95% CI Lower 95% CI Upper Disagree 116 71% 63% 78% Always Agree 48 29% 22% 37% TOTAL 164 100.00%

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23 Ability Ninety six percent of respondents said it was important to use so ap when washing their hands. Ninety to percent of respondents agreed hand washing could prevent illness. Nearly 99% of respondents stated it was important to wash their hands after using the toilet. Knowledge for ORS packets and sol ution was reasonable high. Ninety percent of respon dent stated it was important to use ORS when a child has diarrhea. The skill knowledge of making ORS at home was significantly lower though. Forty percent of respondent claimed to be able to make ORS at home but further qualitative questioning revealed m any could not describe the current hospital recommend ed amount of sugar and salt. It is important to use soap when washing hands Frequency Percent 95% CI Lower 95% CI Upper Disagree 4 2% 1% 6% Always agree 161 98% 91% 98% TOTAL 165 100.00% Handwashing with soap is an important way of preventing illness Frequency Percent 95% CI Lower 95% CI Upper Disagree 9 5% 3% 10% Always agree 156 94% 87% 96% TOTAL 165 100.00% It is important to wash your hands after using the toilet Frequency Percent 95% CI Lower 95% CI Upper Disagree 2 1% 0% 4% Always agree 163 99% 96% 100% TOTAL 165 100.00% It is important to use ORS packets every time a child has diarrhea Frequency Percent 95% CI Lower 95% CI Upper Disagree 14 8% 5% 14% Always agree 151 92% 85% 95% Table 4: Respondent results for diarrheal disease ability survey questions

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24 TOTAL 165 100.00% You can make ORS solution at home Frequency Percent 95% CI Lower 95% CI Upper Disagree 97 59% 51% 66% Agree 1 1% 0% 3% Always agree 67 41% 33% 49% TOTAL 165 100.00% Motivation The perception that diarrheal disease represent s a serious threat to children was also high and was the prime motivation quantifier The perceived mortality and morbidity of childhood diarrheal illness was near 90% for death, malnutrition and long term harm from diarrheal illness This shows a significant motivation to be concerned with the threat and effects of diarrheal illness. Children can die from diarrhea? Frequency Percent 95% CI Lower 95% CI Upper Disagree 15 9% 5% 15% Always Agree 150 91% 85% 94% TOTAL 165 100.00% Diarrhea can cause malnutrion? Frequency Percent 95% CI Lower 95% CI Upper Disagree 17 10% 6% 16% Always agree 148 90% 84% 94% TOTAL 165 100.00% Diarrhea can cause harm to the long term health of a child? Frequency Percent 95% CI Lower 95% CI Upper Disagree 18 11% 7% 17% Always agree 147 89% 82% 92% TOTAL 165 100.00% Table 4: Respondent results for diarrheal disease ability survey questions Table 5: Respondent results for diarrheal disease motivation survey questions

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25 Malarial disease FOAM analysis Opportunity The main health products used to prevent malarial disease in the St. Joseph Hospital catchment area are indoor residual pesticide spraying and ITNs. The Ugandan government conducts a biannual campaign to spray all village homes with indoor residual pesticide. All but one home, which the family resettled and built after th e last campaign had been sprayed Since home spraying is largely a government program and out of the control of the individuals, I did not that there is no spray available direct ly to the consumer and they are unable to request any special visit from the government sprayers. I visually noted all huts that had the chalk marking denoting the date of the spraying and used qualititive questioning and focus groups to u nderstand ? The reasoning for asking if ITNs can purchased at the village level instead of i f they are mearly available is to determine if the respondants have the ability to proactivly protect themselves as opposed to relying on a timed delivery from the government, hospital or a NGO. Fivety five percent of respondants named insect nets as thei r main source of protection from m osquito bites followed by 38% naming house spray. The house spray campaign had near total coverage in all the villages so it can be assum ed that the respo nants that answered nets methods. Nearly the same 54% of respondants stated they were provided the nets from the government, hospital or NGO Qualitatively I learned that the hospital only provid es ITNs to mother attending ante natal care through government provided ITNs. The government has no acti ve program to deliver ITNs at the village level and since these

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26 villages were chosen because of little NGO presence since resettlement it can be assumed those ITNs are at least five years old. Hospital delivery of ITN is evident in the respondants sleepi ng under nets nightly, the highest population was children and pregnant women at about 21% and children only at 16% suggesting that anti natal care is the most reliable source of ITNs. Only 14% of households reported everyone sleeping under an ITN and 45% currently had no ITNs in the household. Six percent of households claimed to have bought the ITNs themselves or were purchased by another family member for them. Only 18.25% of households knew of a specific place to buy an ITN and qualitatively they an swered the place to be in Kitgum town proper creating a logistical and additional cost barrier to purchasing ITNs. every Nearly 79% of respondents stated that ITNs were easy to use. Seventy two percent of respondents stated that ITNs were not uncomfortable to sleep under What is your main protection from mosquito bites? Frequency Percent 95% CI Lower 95% CI Upper Insect net 90 55% 47% 62% House spray 63 38% 31% 46% Burning something 2 1% 0% 4% Nothing 10 6% 3% 11% TOTAL 165 100.00% Where do you get insect nets? Frequency Percent 95% CI Lower 95% CI Upper Buy it yourself 9 5% 3% 10% Someone buy it for you 1 1% 0% 3% Table 6: Respondent response for malarial disease opportunity survey questions

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27 Provided by a hospital/NGO/government 89 54% 46% 62% Never owned a net 66 40% 32% 48% TOTAL 165 100.00% Who sleeps under the insect nets? Frequency Percent 95% CI Lower 95% CI Upper Everyone 17 14% 8% 21% Children and Pregnant women 25 20% 14% 29% Children only 20 16% 10% 24% Pregnant women only 1 1% 0% 4% Adults only 4 3% 1% 8% No nets 55 45% 36% 54% TOTAL 122 100.00% You know a place to buy an insect net? Frequency Percent 95% CI Lower 95% CI Upper Disagree 134 82% 75% 87% Always Agree 30 18% 13% 25% TOTAL 164 100.00% Insect nets are easy to use every night? Frequency Percent 95% CI Lower 95% CI Upper Disagree 35 21% 15% 28% Always Agree 129 79% 71% 84% TOTAL 164 100.00% Insect nets are uncomfortable to sleep under? Frequency Percent 95% CI Lower 95% CI Upper Disagree 118 72% 64% 79% Agree 1 1% 0% 3% Always Agree 47 28% 21% 35% TOTAL 165 100.00% Ab ility Ninety seven percent of respondents believed that it was important to use ITNs and 94.5% stated that ITNs can prevent malaria. No respodants stated that they did not know what an ITN was or needed additional clarification of the product when they were asked. An additional 89%

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28 answered it was more important to use ITNs during the r ainy season showing at least an elementary knowledge of malaria disease vectors and the mosquito life cycle. It is important to use a mosquito net Frequency Percent 95% CI Lower 95% CI Upper Disagree 5 3% 1% 7% Always agree 160 97% 91% 98% TOTAL 165 100.00% A mosquito net can prevent malaria Frequency Percent 95% CI Lower 95% CI Upper Disagree 9 5% 3% 10% Always agree 156 95% 88% 97% TOTAL 165 100.00% It is more important to use an insect net in the rainy season Frequency Percent 95% CI Lower 95% CI Upper Disagree 18 10% 6% 16% Always agree 146 89% 83% 93% TOTAL 165 100.00% Motivation I began measuring household prevelence of malaria after the first village survey in Occetoke North so the survey is out of 136 households. Sixty percent of households had an case of malaria with in the family with 36% reporting only one case and 18% reporting only 2 cases. Ninety eight percent of respondents stated malaria is dangerous all year long. Table 7: Respondent results for malarial disease ability survey questions

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29 Forty two percent of respondents said they would be willing to pay for an ITN if they were available. Qualitatively respondents stated they could either not afford an ITN or that a hospital or N GO should provide them for free. Has anyone in this household ever had malaria? Frequency Percent 95% CI Lower 95% CI Upper Yes 82 60% 52% 69% No 54 40% 31% 48% TOTAL 136 100.00% How many people have had malaria? Frequency Percent 95% CI Lower 95% CI Upper 0 35 30% 22% 39% 1 43 37% 28% 46% 2 21 18% 11% 26% 3 13 11% 6% 18% 4 2 2% 0% 6% 5 2 2% 0% 6% 16 1 1% 0% 5% TOTAL 117 100.00% Malaria is dangerous all year long? Frequency Percent 95% CI Lower 95% CI Upper Disagree 3 2% 0% 5% Always Agree 162 98% 95% 100% TOTAL 165 100.00% Would you pay for a mosquito net if they were available? Frequency Percent 95% CI Lower 95% CI Upper Disagree 96 58% 50% 66% Always Agree 69 42% 33% 49% TOTAL 165 100.00% Table 8: Respondent results for malarial motivation survey questions

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30 Maternal health FOAM analysis Opportunity The m aternal attendants or midwives. Ninety five percent of respondents said they could get to a health center or hospital during childbirth. Although there is a high opportunity to get to a skilled birth attendant, opportunity cost of visiting the health center or hospital were perceived to be too high. Only 30% of respondents agreed the health center or hospital was a cheap option for giving birth. It is free to give birth in a health center but they do require mothers to bring their own blankets, towels and water basins. Qualitativel y, the loss of time at home was mentioned as great expense. Loss of field work time and the cost of feeding relatives that helped with child care were often mentioned. You c an get to the health center while you are pregnant and during childbirth? Frequency Percent 95% CI Lower 95% CI Upper Disagree 8 5% 2% 9% Always Agree 157 95% 90% 97% TOTAL 165 100.00% The health center is cheap enough to have a baby at? Frequency Percent 95% CI Lower 95% CI Upper Disagree 115 70% 62% 77% Always Agree 50 30% 23% 37% TOTAL 165 100.00% Ability Ninety seven percent of respondents stated that most birth required a health center to be safe 91% of respondents disagreed with the statement that women should give birth alone or with Table 9: Respondent results for maternal health opportunity survey questions

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31 family only. This demonstrates that view that childbirth is seen as an endurance ritual for women 12 has been largely eroded in these villages. Ninety eight percent of households responded that their women and women they know give birth at health centers, the 3 respondents that said they used traditional birth attendants in the village were 45, 46 and 56 years old. This suggest s that the use of traditional birth att endants is an old fashion concept and the younger generations are supporting the exclusive use of health centers. Quantitatively, many respondents mentioned no longer knowing of village women that performed live births anymore. Most births require a health center to be safe Frequency Percent 95% CI Lower 95% CI Upper Disagree 4 2% 1% 6% Always agree 161 98% 93% 99% TOTAL 165 100.00% Women should give birth alone or with their family only? Frequency Percent 95% CI Lower 95% CI Upper Disagree 151 92% 86% 95% Always Agree 14 8% 2% 9% TOTAL 165 100.00% Women should visit the health center 3 times during pregnancy? Frequency Percent 95% CI Lower 95% CI Upper Disagree 5 3% 1% 7% Always Agree 160 97% 93% 99% TOTAL 165 100.00% When you or women you know give birth, they most likely Frequency Percent 95% CI Lower 95% CI Upper With village traditional birth attendant 3 2% 0% 5% At a birth center 159 98% 95% 100% TOTAL 162 100.00% Table 10: Respondent res ults for maternal health ability survey questions

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32 Motivation Over 98% of respondents believed women and children could die from giving birth in the village. This shows a strong awareness of the threat to life from using a traditional birth attendants. This would be a strong motivation to use the Health Center or Hospital for birth delivery and drive woman to want to attend ante natal care. Threat perception is further underlined by the more 99% of respondents stating that the hospital is the only option in difficult childbirth situations. During birth, mothers and children can Frequency Percent 95% CI Lower 95% CI Upper Disagree 3 2% 0% 5% Always agree 162 98% 93% 99% TOTAL 165 100.00% If pregnancy is difficult, what do people do? Frequency Percent 95% CI Lower 95% CI Upper Birth at home as before 1 1% 0% 3% Go to Health Center/Hospital 161 99% 97% 100% TOTAL 162 100.00% Focus group results Survey analysis The focus groups that took place after the return of preliminary results of the survey that stress that access to health goods was the largest barrier to preventative health. It was overall agreed that most people had a good understanding of the dangers o f diarrhea and malaria but they had Table 11: Respondent results for maternal health motivation survey questions

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33 little ability to stop the diseases. The main recourse to these diseases was to go directly to the health center but it was sometimes of no use because health centers were too busy or did not have medical supplies Healt h Centers There was a lot of variation on opinions to the health centers. All of the groups considered them too far from the village. Four groups mentioned a lack of supplies at the health centers, specifically ORS was mentioned twice. Three of the group s said that they could not get ITNs for pregnant mothers from their health center. One group believed the health center had them but did not want to give them out. unfriendly in three group s. Two groups mentioned that health centers were too busy and it took a whole day or more to see a doctor. All groups did say there was always a midwife available if they went to the health center. There was a general mistrust of the government that was also cast on the health centers. The government was blamed twice for purposefully not providing promised goods. All the groups still said they went to the health center for all childhood diarrheal and malarial disease. Most adults would go if they had h igh fever in fear of malaria but it was always important to take children. In all groups SJH was considered a very good hospital. All the groups said if there was a serious problem they would go there because the doctors and nurses w ere considered better. The additional cost of SJH was not a deterrent but the distance was. SJH was mentioned as a good Christian hospital and not part of the government. It was said three times that they were open during the war and took care of people in IDP camps. A few people mentioned the good service of SJ H even though they themselves had not been there but they heard it from family and friends.

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34 These remakes may have been biased as I was seen as a representative of SJH but it could be important to further outreach that the SJH stamp of approval carries a very positive connotation with most villagers. In terviews Outreach coordinator The interview with the outreach coordinator revealed that there has been limited outreach done by the hospital outside of the Kitgum town district. He recognized the need to work with villages further away because poverty and hygiene conditions were worse in those communities. The main need he expressed for outreach was sanitation and a way of tracking health outcomes to see how sanitation was improving. In designing future programs he express the need to make clear schedules and budgets for VHTs so they know what, when and how much the will be paid village was important to have commun ity support and commitment to any new programs. Maternity Head Nurse The interview with the maturity head nurse revealed that in her opinion maternity health had increased over the last few years. She said that now they were able to save the lives of most mother s that came to the hospital but there were still a large number of children dying. Lack of urgency of the part of both mothers and health centers to get difficult deliveries to the hospital in a timely manner was a big issue As for outreach progr amming, she thought that general nutrition outreach would be the best avenue to get mothers and children to the hospital in better health condition. Specifically for pregnant women the outreach message should be to arrive at

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35 the health center or hospital well before the delivery. Transportation is poor so if there is a problem it must be known early. s Ward Head N urse illness. Many of the malaria referrals and attendants have given children so kind of medicine already and this can make it difficult to correctly treat malaria and sometimes cause a false negative of the malaria slide. The diarrheal cases they see are usually cas es lasting more than 4 days. They provide 4 ORS packets at the release of all diarrheal patients and teach how to make ORS at home and encourage mother to provide ORS to children before leaving for the hospital. The biggest area for better outreach she s aw was the importance of proper nutrition especially during illness stating that people will focus on giving medicine but forget the importance of nutrition to a sick child. A nte natal Ward Head Nurse This interview revealed the high levels of ante natal visits by mothers, confirming what had been seen in the surveys. Attendance now was very high but they were still pushing to have more men attend with their wives. Outreach through the anti natal ward is solely in the effort to stop the spread of HIV fro m mother to child. There are quite a few donor s and the government is supporting t his campaign to end mother to child transmission by 2015. She state d that the supply of ITNs was desperately low in the past few years. Over the last four months, they had only given out three ITNs and only to HIV positive mothers. The ITNs distributed were not from the government supply but provided by one of the groups working with the HIV positive mothers. As specific out reach measure for maternal health, she suggested having the fathers more involv ed with ante natal care so that they knew the importance of arriving early to the hospital

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36 for birth. She thought that mothers were usually inhibited by the fathers from going to the health center at the correct time. Hospital Head Nurse Interview The interview with the hospital head nurse focused on the logistics and outcomes from a nutrition program that she had work with for 3 years under the World Food Programme (WFP) She each sub district that were able to perform outreach education. Through two day education programs and financial support of these groups, women in the groups could ke ep village level statistics on births and death of children, determine which children had been fully immunized and which children were suffering from malnutrition. The WFP project had a huge coverage area and a large budget but the model could be adapted well to the local SJH catchment area. She was still in touch with some of the women leaders and believed the formation of such groups at the village level was possible.

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37 Discussion a nd Recommendations Health care seeking behaviors Health care seeking behaviors for all three preventable disease and death indicators were shown to be quite high. Profession al medical attention and advice was stated as sought in a timely manner for both diarrheal and malarial symptoms with most people going to the health center at first signs of illness. The high rate of ante natal visits also shows a high health seeking behavior although I have no specific data showing that women arrive at a health center in a timely manner for delivery. Health care seeking bar riers The m ate r n ity nurse interview and the high perceived opportunity cost going to a health center early suggest that continued education of the importance of early arrival to a health center during birth could have benefit. This is already a stro ng mes sage delivered during ante natal visits Better communication and transportation between the health centers and hospitals could have an effect on the burden of child mortality during birth. Both of these are beyond the scope of The ity and probably require governmental assistance. There is a question of response bias due to the fact that I was introduced to respondents as a the amount and timeliness of health visits during diarrheal or malarial incidence. I made no main reason for this oversight is that the reason for this study was to understa nd barriers to preventative health. By demonstrating a knowledge of the threat of disease and importance of professional care motivation to attend health centers is shown Although health center visits

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38 maybe over estimated due to this bias, there are mu ch larger barriers to preventative health that need to be addressed first. Barriers in malarial disease prevention In the next two section s, I will represent some of the data from before in a format that translates the large amount presented before into a stoplight visual to express the area of greatest possible impact from outreach The blue areas represent these impact areas. The childhood m ortality due to malarial disease is the highest burden in this area. Outreach aimed at lessening this burden should be considered first. An alysis show s that access to ITNs at the village level is the largest barrier followed by the willingness to pay for an ITN. For these reasons, outreach targeting malarial burden should provide ITNs for sale at the village level. This sale would probably have to be s ubsidized due to the cost restraints of villagers but free delivery is well beyond the means of the Grau Foundation. Furthermore, free delivery of ITNs would continue the belief that ITNs are a free commodity and is responsibility of some entity other tha n the villages. With an overall decrease in NGO activity in the Kitgum area, it is very dangerous to perpetuate the idea that someone will provide ITNs if they are important. By focusing on those willing to pay for an ITN, local markets may be able to re alize a demand for ITNs. Other approaches need to be considered that can provide free ITNs to pregnant women and children that did not receive them from a hospital or health center.

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39 Barriers in diarrheal disease prevention It becomes visual ly clear from figure 9 that the main barrier to the universal use of soap as preventive measure against diarrheal disease is the cost of soap as access, knowledge and motivation are all high. This is also reflected in the specific knowledge that it is important to use soap aft er defecation but a low availability of soap and water at the time of defecation. Figure 8: Visual dashboard to represent malarial disease outreach impa ct potentials

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40 For the use of ORS packets or homemade ORS, barriers are more varied. There is a clear knowledge that ORS is an important treatment for diarrheal illnesses, but access to buying packets outside of the health center or hospital and the correct formula of h omemade ORS and the cost of ingredients (particularly sugar) are prohibitive. Figure 9: Visual dashboard to represent soap use outreach impact potentials

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41 The knowledge level of preventing diarrheal disease show that simple education is not enough to impact the burden of disease. Outreach programs designed for diarrheal disease should include the delivery of free or subsides soap to participants if possible. I t is important to understand that sugar is a prohibitive cost to making ORS at home Any outreach should expressly note that salt cannot be substituted for sugar and ORS should not be made without sugar. Due to confusion and lack of sugar to make ORS, pr ovision of ready made packets to be used before and during travel to the health center or hospital could have an impact on children arriving to the hospital in better condition during diarrheal incidence. A large discrepincy in homemade ORS recipes were observed qualitatively leading to the demonstration and provision of the measured half liter bottles of correct homemade ORS during the focus groups. In addition, the hospital outreach coordinator and I prepared a radio br oa dcast of correct measurements and timly delivery of homemade ORS, but as of now I am unsure if the local radio station that offered assistance has been able to broadcast it. Cost or lack of money being the largest barrier for diarrheal health Figure 10: Visual dashboard to represent ORS outreach impact potentials

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42 suggest that overall wealth generating out reach programs could have a direct impact of diarrheal health issues. Maternal health Maternal health issues were shown not to be as large a problem as the literature on Northern Uganda wo uld suggest. Attendance of ante natal care and delivery at a health center were nearly universal. The perceived opportunity costs of being at a birthing facility longer than needed and blankets, towel and basin when the most prohibitive factor from the analysis Most of the nurse mentioned th e maternal health conditions had improved recently natal outreach was not investigated but this could be an area that could be strengthened either by creating awareness posters or having someone from the hospital conduct outreach on sight. Communication and transportation of risky cases between the health center and the hospital would be the logical avenue for improvement. Overall, these particular results show a substantial behavior change among these population compared to the rest of Uganda. This is an opportunity that cannot be overlooked by outreach programs in the area. Women expect and want ITNs when they visit ante natal care facilities. To allow a lack of this vital provision care jeopardize this behavioral change. A primary goal of any outreach in this area should be to insure the availability of ITNs at hospitals and health centers. Supplying St. effort, will support past educ ation and perpetuate a positive and difficult behavior change that has already taken place. Specific recommendations for the Grau Albert Valencia Foundation The sale or free delivery of health goods should be coupled with village vaccine campaigns and outreach programs. I have outlined in another report how ITNs can be distributed with the

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43 vaccine campaigns and the Hospital Superintendent at the time, Dr. Ojom Lawerence thought it was feasible to devote staff to this mission. The nutrition program out lined by the hospital head nurse is one that showed significant results and touched on a broad area of preventable disease education. The formation or utilization of r ealities. As many of the nurses mentioned nutrition as a key factor in outreach potential there is reason to believe this outreach would have considerable support within the hospital. The CHAPS program has dedicated VHT volunteers that are currently colle cting village level information on HIV/AIDS patients. With little additional training and some compensation, they could easily collect data and set up group meetings at the village level for future outreach programs. Clear schedules and pay scales need t o be made for VHTs helping with village level outreach. The VHTs, especially the ones who volunteer with CHAPS are a valuable asset and should not be undervalued. Limitations Sample size Although in each village a 20% sample was reached to make a conclus ive estimate of health barriers, having only 6 villages surveyed due to time restraints makes it difficult to compare between villages. Household malaria incidence varied from 60% in Kampala to 32% in Pabiwo East but the small sample of villages makes it difficult to predict why these differences were seen.

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44 Health center information A lack of access to the village health centers means we can only rely on the opinions expressed in the focus groups as to the realities of how these center operate and treat p atients. It is not well understood if any specific health center does or does not regularly have health supplies or if they follow government mandates for referrals to higher level hospitals often. Staffing and in patients statistics from the health cent ers could provide valuable insight to some health barriers. Other diseases Information of other preventable disease such as parasites and river blindness was left out of this study due to time restraints and assumed burden of disease. Education outreach o n these disease may be needed as the knowledge level of these was not examined. Nodding syndrome was noted as a major health concern in three of the five villages, but due to strict government oversight of the disease there is little that can be done eithe at this time. That sentiment was expressed to the groups. Income indicators These surveys had no specific questions to measure the variable incomes among villagers. There was a question about transportati on means that offers some insight to income levels, but without a true metric for income differences it is impossible to know the extent that income barriers effect certain groups. Conclusions Access to goods (Soap, ITNs, ORS, water cleaning tablets) is the largest barrier to preventative health. Any outreach into the village needs to address this and provide some delivery mechanism, preferable one that could be sustainable and commonly accessible.

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45 Health knowledge and health care seeking behavior are both high. The aim of outreach now should be getting to people to the hospital healthier. A model comprehensive nutrition programs district level. This can be replicated in the catchment area villages

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46 Bibliography 1. Ministry of Health Uganda. Ministry of Health Annul Health Sector Performance Report. (2012). 2. World Health Organiz ation. Uganda Health Profile. (2010). 3. Bartram, J. & Cairncross, S. Hygiene, sanitation, and water: forgotten foundations of health. PLoS Med. 7, e1000367 (2010). 4. Mutambi, R., Hasunira, R. & Oringa, V. INTERSECTORAL ACTION ON HEALTH IN A CONFLICT SITU ATION A Case Study of Kitgum District Northern Uganda. (2007). 5. June 2014. 1 39 (2014). 6. Ministry of Health Uganda. Situation Analysis Village Health Teams Uganda 2 009 (2009). 7. Winch, P. J., Leban, K., Casazza, L., Walker, L. & Pearcy, K. An implementation framework for household and community. 17, 345 353 (2002). 8. Healthy Child Uganda. Healthy Child Uganda Community Health Workers and Community Case Review of the Literature and Situational Analysis. (2011). 9. A Framework to Analyze Handwashing Behavior s to Design Effective Handwashing Programs. (2010). 10. World Health Organization. Regional Health Forum (2002). 11. Keri, L., Kaye, D. & Sibylle, K. Referral practices and perceived barriers to timely obstetric care among Ugandan traditional birth attendants (TBA). Afr. Health Sci. 10, 75 81 (2010). 12. Parkhurst, J. O., Rahman, S. A. & Ssengooba, F. Overcoming access barriers for facility based delivery in low income settings: insights from Bangladesh and Uganda. J. Health. Popul. Nutr. 24, 438 45 (2006). 13. Vincent De Brouwere and Wim Van Lerberghe. Studies in HSO&P,17,2001 1 (2001). 14. Kitgum, S. J. H. nual Analytical Report, FY 2011/2012 (2012).

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47 15. OCHA. UG Health 69_A3_26May10_Kitgum District Health Service Accessibility. 2010, 2010 (2010).

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48 Annex 1 Survey instrument

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56 Annex 2 Outreach Coordinator Interview I: Interviewer R: Respondent I: How many years have you been working with the outreach program? R: For me it is now two years. I: What are the main diseases and educations you look to spread through the outreach? R: Okay, actually mostly these communicable d iseases, which we always give an education on. And those of vectors, diseases transmitted through vectors. I: Flies and mosquitos? R: Yes, mosquitos mostly, and also we give an education on water and water sanitation in the community. And even what, sanita tion that is education we give to the community. I: Like latrine use? R: Latrine use even water use also because that one is also hygiene. Ideal homestead, ideal homestead has to be with all the necessary things. Like in the house it have to be with a sle eping room and a kitchen separately. And there also in the home there should be a drying rack where by they hang their clothes and drying stand also for cooking utensils, after washing you dry them. And also there should be a rubbish pit in the homestead where the collect all the refuse from the house and deposit them there. Yes, and they have to be with proper drainage of water s there should not be water puddles around. It is the education that we always give them. I: And what villages and district sub c ounties have you worked with? R: Actually we have 5 sub counties which we are working in. We have Kitgum Matidi, Layamo, Amida, Akuang and then Kitgum town council. Those are the catchment area of St. Joseph Hospital where we give a health education ther e. I: And are these homesteads checked or visited frequently? R: Actually we design a program so that we go and give cause it is not only us. In the sub county where we are going we have an assistant there. They are doing the same activities. I: From the health centers? R: Yes, they also give a health education on this sanitation and if we go there they are the one to identify for us the place where you are supposed to give a health education there. Like when we went with

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57 Benjee in Amida, Layamo here. T hey have giving us Ocettoke and Paibwo, those are the two places they give us. We cannot go just anyhow. We just go and get from them where we are supposed to give an education. Yes. I: Ahh, and before the Grau foundation workers educations, how did the educations usually work? R: Actually before Grau most of the education we were doing was within what, town council. In the villages surrounding the what, the hospital here. Because going outside, we have not ye t designed that program for outreach, but it was there before I joined here. But generally I have been working here for 10 years, I started as a nursing assistant but went for further education on environmental health. Practicing environmental health is now 2 years. Yes. I: And where do you see the outreach program in the future, working with the communities? R: Actually, With the group support, the way we are seeing since the people came back from the camp, cause they actually have some knowledge, they have been given an education, but only that their problem is poverty. And they pretend that they cannot do well if there is no support. But if total health education is given they can change and more support has to be given on environmental health so tha t we reduce communicable diseases. Which actually like cholera, cholera is not there now but diarrhea is there and there are many and it is communicable. There is need of support there. Yeah. I: there is a need for education on diarrhea? R: Not diarrhea only, I am just generalizing, but sanitation mostly. I: is there a need for education on mosquito nets? R: Yes mosquitos nets actually the government, they are doing, but not all the household are getting. And also handwashing facilities in the toilet hav e to be provided to show that they have to do practice it. There should be training on it and soaps have to be provided to demonstrate to them. That this thing is in need to supported. I: In your opinion, what would be the best areas of health to emphasi s in future outreach? R: In the catchment area of St. Joseph hospital, because like in the sub counties there are many villages, it would depend on the area in which we were working. I: So for each sub county or parish there is a need for a different desig n? R: We can do like this one, we can do the same program for hygiene health education promotion but with the support, actually a computation. Say village B compared with Village A so that we can see how they are improving. That is what we are thinking of so that the sanitation level have to raise up. I: So you can track the sanitation understanding and usage levels? R: Yes to track cause if there is a rise in sanitation there is a reduction in these communicable diseases like diarrhea or what ever.

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58 I: Do you know of any subcounties that are more in need of assistance? R: Yes, like in Kitgum Matidi, there is need of it, when we went for assessment to find their knowledge with Benjee. We see the level of sanitation is low and they were complaining of water. know how you see in Tumungu where you move but Akwang and Oget there is need. Actually all the areas in which we move there is need. Like Tumungu there is a shortage of water sources and in Oget there is a well that animals are drinkin g from the same surface well and there is only one borehole in the village, so that is what they show us. I: Do you see a need for chlorine tablets to clean the water? R: Borehole is the best because actually because that one in Oget in the dry season it goes off but it is clean. I: If additional funding is provided to the outreach program how do you think that funding would be best spent? R: Funding, huh, for the outreaches. It depends on the categories of the people we work with. We have to use these wo men leaders. They are the people who can lead the community. And then the VHTs (village health teams) we give them an education so that the number of people in the sub county and in the village is lower actually. So if you are using 10 of them, so out of that many how much are we supposed to pay them also. That is needed and we have to design this budget. Cause, you know these NGOs, they were here, and there were very many those days when the insurgency was here. And people also they demand a lot. Whe n we travelled before, they were paid 5000 UGX and they were complaining, so I was thinking that they should have to be told openly and sign something so the have to know they are being paid like this one. Because I was even fearing they could make a bad reputation for us here at the hospital, because it the hospital where they are doing the what, the activities. So we need to make something that the people know that this is the money they are supposed to pay. So it depends on how we design how much they are to visit the outreaches and how it is supposed to used like this one. I: Do you think provision of mosquito nets or soap is required in these outreaches? R: Actually that is just for demonstration, not to provide it everytime. When we go for home improvement, we give the tippy tap, the jerican and the soap. We give once and then we begin monitoring how they are using it. If the soap is always remaining there and they are using it or they remove the soap and use for other purposes like washing clot hes. So that one we can see from there. Just to make them know that this is a good practice we have to provide once and see how they a doing because you cannot give it throughout like that. Just demonstration. I: And mosquito nets, do they need to be p rovided? R: Not so, because they can last a number of years. Also it reduce the number of household. You can have this families with many people inside there, children and those who are married also in there. So in the homestead it can be how many? So i f you give like that they can misuse so it is not good.

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59 I: And the hospital provides for free to pregnant women? R: Yes, those who come for anti natal care and probably the two of the couple have to come together. If only the woman comes she is going to miss what, a mosquitos net. Both have to be there. I: Anything else you would like to say about the outreach program? R: The outreach, we need to plan cause there if there is no plan it cannot work well. There must be a timetable of who goes where whe n, and the community must be aware because we are working for them. I: When planning with the communities is it best to go through the sub district office or who? R: That is the problem with not having a time table that is a problem before, we learn we should move today here but if we are busy that is a problem. If there is no program there is nothing that works. So the work plan should cover the periods that you are going to work over. There should be a plan th at for how many days, how many people are to participate and how much money should be spent. If we see this plan, two weeks, we can know that this is possible or this is too much or too little. We cannot just move anyhow. I: How far in advance? R: For 1 month, we can plan for 1 month ahead very easily. So in a week how many times are you supposed to go so it make you to plan well. Yes. Cause if you go just anyhow these people they are doing their farming. If you go you will find no body because they are in the field. It has happened like I: I have heard that planning with the villages more than two weeks ahead can be difficult. R: It is us to plan. It is us who know mo re about than the people in the village and how they behave. Because if you plan things and contact them on the ground, then they will make an appointment, because last time, we have also to train these VHTs, like when we are going for home improvement th ere should be training for the VHTs. These have to be planned objectives so that the VHTs can teach while we are not there. If we go there these are the ones to assist us in planning to mobilize people. But these places are wide so you need someone ther e and that you are paying that knows this area and is happy to help because they are volunteers and have to plant the gardens also so need pay if they cannot work. And time to them to before so they know more than the others and can be seen to help. Peop le will remember this person and ask him for help. These ones and they womens group, they can help us count and know sanitation numbers, like latrine for example. So that is that.

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60 Annex 3 Maternity Ward Head Nurse Interview I :Interviewer R: Respondent R: Actually there are categories of referrals. The first one they refer the mother after they decide the mother is having risk factors. Risk factors here I mean maybe a mother here who has two or three previous kind, they always refer and they actually wait for delivery from the hospital. Then there are other mothers maybe prime gravity, when they know the mother cannot delivery from down ther e they always refer to the hospital. I: So they are referred while in labor? R: They can be referred before and if they are referred before they are kept in the waiting center, those ones who are not yet due for labor. We first keep them then we get in touch with them. They come every morning for fetal control. We check their fetal heart those who are not yet in labor but have been referred from there to wait for the labor is here. But in labor there are other referrals where by they referred women mot hers in labor. So that one, we have those ones with obstructed labor, prolonged labor, called prolapse, breach presentations, retained twins, maybe one has come and the other one is stuck. Tranverse lying, aph or pph. I: Which is what? R: Anti partial he morrhage or post partial hemorrhage. Pre clampsia and eclampsia. Ruptured uterus and then at times IUFD when the baby has already died. I: These referrals are coming from the health centers? R: Yes they bring from the health centers, if they pass they are coming from the government health centers. Some from Pajule, Agago, Lamore. In fact all these health centers all over they refer their mother to here. I: If it is a referral how do they travel here, especially during labor? R:Okay now their transport here, what I have ever seen they come with a motorcycle, the majority. Others come with bicycle. I: While they are in labor?

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61 R: Yes because they fail to get the means. Few they come in ambulance, they call for ambulance and we send for the ambulance. I : And they pay for the ambulance? R: yes there is some money they have to give to the driver to facilitate the drivers and maybe the nurse who is brought the what, the patients. And some can hire a business car if they have the means. I: And from referrals and the hospital itself, have you seen a reduction in maternal mortality rates? R: Yeah, according to me, what I have seen, when they referred, the problem we have is late referral to us. You can save the life of the mother but at times you may not be able to save the baby. But at those times we try our level best to save the mother and then the baby. Therefore, you may find the baby has come in with severe asphyxia or severe distress. We always try our level best to resuscitate the baby to bring it back to life. To save the two lives if possible, but sometimes you find that durin g our struggle we fail to save the life of the baby but we would have tried really. Yeah so to me, the number of babies that are dying, they are few, unless now the baby has already died from the health center. Then there is no way to do but help the mot her. But if there is fetal heart beat we try our level best. I: And are all mothers here feeding the babies colostrum or first milk? R: from here the feeding of the babies, okay, like those who have delivered within one hour after, immediately after the d elivery we put the baby on the what, the breast milk. We put the baby directly on the breast feeding because that one will help us to control the bleeding and also to control early inception of the breast milk. This one will help to not cause malnutrition so we know the importance of putting the baby on the what, the breast milk immediately. I: And do you find women referred or coming straight from the village without anti natal care, do they understand the importance of colostrum? R: Okay, here we do giv e health education, if they are in anti natal care we give a health talk about the importance of the baby to initiate on the breast. Then even from here in the maternity I give a health talk every morning. First when they are in labor and then after deli very. I have a doll and I show the correct attachment and the early putting the baby onto the breast. I: From the Health Centers do you see referrals of pregnant mothers with malaria or other severe illnesses? R: Yes, there are those cases which we receiv e them, severe anemia, severe malaria. Actually many conditions, mostly malaria, chronic and acute PID. I: PID is what R: Pelvic Inflammatory Disease. Yeah, they also what, be referred here. I: Are they general referred early or late in the pregnancy?

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62 R: Yeah, actually, the majority they come in the what, the early pregnancy. At times you find that the woman is vomiting a lot in the what, the early pregnancy they are also referred here. I: And do they receive bed nets and birth supplies here only if they attend anti natal care? R: Okay, those who always come we always encourage to attend the what, the anti natal care. But majority of those ones they improve and they go home well. And another referral is premature delivery and the other one is birth asph yxia where by the baby fails to breathe or cry well. So they are referring them here. These there are many and birth before arriving to the hospital. They say I was coming to the hospital but they give birth before arriving. But we receive them and giv e them care also because they are part of us and there is no way we can ignore them. I: The health centers require mothers to bring supplies, does St. Joseph require the mothers to bring anything? R: From here when they have done the anti natal care, they provide them with kits with, you know, the position paper for delivery, so gloves and cotton and small things like soap. The basin they used to provide from the town council because of lobbying of St. Joseph, but sometimes it is not there so some mothers I: And mosquito nets? R: The ones who have done anti natal care here they receive but those who are just coming anyhow they may not get the nets. Or they receive from where they are doing anti natal care. We in maternity. I: And when the mother and child are discharged, do they leave with any medicines? R: Ideally if the basin is there, maybe the mother gets the basin and birth certificate and we health educate the mother of the care of the b aby and the care of the mother on hygiene and nutrition. We do this teaching before they leave. I: And is there any vaccine scheduling when they leave here? R: Yes, from here after give birth, if the mother gives birth last night or this morning wecall t he teams. There are teams of vaccinators in out patient that come and give the baby straight away the what, the BCG and the polio right away and to the mother they give the vitamin A and ferra sulphate for the anemia, because when she has delivered she ha s lost the blood and then the whatever as anemia can arise later. So the ferra sulphate and also the what, benezole to de worm them. And if she has not received the TT (Tetanus) vaccine. I: And in future outreach programs in the community, what educati ons would you like to see delivered to pregnant mothers and women reaching pregnancy age? R: The two most important things are the what, the education of not to delay and the nutrition of the mother during pregnancy. The mothers are always busy even preg nant so they can delay at home

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6 3 without thinking that they may harm the child but this is very dangerous, so people must tell them it is more important than cooking or digging in the garden, your baby can suffer severely. Next they, must eat well and work less. Many mothers are working in the field with little food all day, they must not avoid eating and they can eat the right things at home if they are taught well enough. You see, we can make safe delivery and teach when they leave here but before they get here the baby has developed maybe improperly so it is now not easy to make healthy. So education should be made before they are here or even starting anti natal care.

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64 Annex 4 I: Were are looking at outreach at the village level for preventative health of children, and I was wondering what are the common referrals you have from the villages and the Health centers? R: We are actually mostly working with referrals from near by health centers and health centers from the neighboring district. Even up to Southern Sudan, we receive referral from there and from Karanga. I: Are the referrals for malaria or other diseases? R: Some are for malaria cases when attempts have been made to treat them a nd probably they are not responding so when they come to this side it is usually a more resistant strain so when they come here it is a bit challenging for us because it is a difficult case and when something has already been tamepered with it is not easy to reverse. I: So these patinets are given the wrong medications? R: They are given correct medications but not in full doses, so when they come we need to repeat the doses and back up with antibiotics. I: And are there diarrheal cases coming here? R: So m any, some referral, some new attendants. I: Is ORS provided to them? R: All of them are giving ORS to take even after diarrhea is stopped, we encourage to give the ORS from home. We give them 4 packets but in the ward they can take more than 6 packets a d ay. I: What are the diarrhea cases like here? R: We get the ones that the diarrhea has taken more than 4 days and they come with severe dehydration and they are put on the IV fluids. I: How long do the ward malaria treatments last? R: 2 to 3 days actually 2 to 4 days, and we test for malaria at admissions but the test can be negative because they have tampered with treatment at home so we have to get a positive slide is rare case but these children come with high fever and we give antibiotics with no improv ement but we then give anti malarial and we see what, we see the improvement. I: So what is the referral process like? R: If the antibiotics are not responding we repeat the slide and with the history of fever after the results are negative but signs are malaria we treat as malaria. So it is difficult for a mother to know if it is with fever.

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65 R: Admissions last 4 to 6 days average because it is dangerous to release the child even if they are looking better because the mothers do not always follow the prescriptions. They stop and there is no drug consistence. I: And you are in charge of the Neo natal room? R: Yes I: And have you seen cases of neo natal sep sis or tetanus? R: Not in the last three months, it has gone down in the last years. I: And these cases, was it from a health center or village delivery? R: the last one we saw was from a health center delivery. I: What percentage of people complaining of malaria actually have malaria do you think? R: Of the complaints, if there is ten cases, six have malaria. I: Do you ever provide bed nets or teach homemade ORS here? R: We have no bed nets but we teach them the ORS, we give them the what, the packets but also encourage them to make it locally before you leave for the hospital and then you rush to the health center. I: What other disease do you commonly see? R: Pneumonia is themost common now because we have the oxygen. I: What outreach message would you like to see delivered to the villagers? importance of food in times of sickness. They think that when a child is sick they only need the think about the what, the nutrition aspects. So that is what I would go and give.

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66 Annex 5 Interview with anti natal head nurse I: Interviewer R: Respondent I: What sort of outreach do you do through anti natal? R: We are working to encourage the m ales to come with their wives. And we are testing for HIV every time they come to anti natal so we can follow the ones that have HIV and work to keep the transmission to the baby. I: Do you recommend the males attend all visits or just the first? R: Norma lly we encourage them but they say they have a lot of work is the reason they cannot come every month with their women, but we do encourage the first or second time so we can do the small small test on both of them. In the second time if the man is busy h e does not have to come. I: What kind of referrals do you see for the health centers? R: most of the referrals we receive are very later. Someone is referred at 34 weeks only two or one month to deliver. Sometimes due so risk of complications she will come to this side. If they baby is not lying well and there is no ultrasound machine to do the what, the scanning. So sometimes they come themselves and sometimes they are referred by the nurses. Normally the ones with the complications come during the late pregnancy and we refer to the doctor, gynecologist or the ultrasound and then they do delivery from us. And we test again for HIV if they a negative from there because we want to be sure. Maybe the test she did it may be once and again I test becau se I am not sure and after 3 months after delivery we test again. The anti natal services here are free so sometimes the husband will be tested here. All services are free except c section which is 10,000UGX. But right up to the end services is free so we want the men to be involved. We get some mother from 20 kilometers away because we are always open and have good staff. Men tend to come here more than other facilities. Last month we had 19 men who were tested for HIV. Due to good encouragement we can help those through anti natal. I: After a completed anti natal visits are the women given anything like ITNs or birthing goods? R: Previously we were giving ITNs for the mothers who come for anti natal services but for some 3 months ago the hospital net were not there. Currently we have few that some group donated that we are giving to HIV infected mothers. There are not enough for all of them but we encourage those who can afford to buy and sleep under the mosquito net. We also give them a package of things that can be used in delivery. I: Is there a certain number of Anti natal visits they must do to get the package? R: The package we get from the district and we give to all mothers who are 7 months. Generally we want them to complete four visi ts but if they have come late we still provide. If they come with the man we give them the packet the first time. They say in the village they have not given this packet without the man so it is a way to encourage the man to come with the wives.

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67 I: Who w as funding these ITNs? R: I am not sure but the financial problems of the hospital to have? I: What is average number of anti natal visits? R: In a day we can see 40 and last month it was 490 mothers attending. That is new and re attendants. I: And how many visits does one mother normally make? R: The average is 4. Some if they came early can see 5 times. I: When is the first visits usual? R: It is usual that she comes in the first 3 months. At the end of the first trimester most arrive, but it is our wo rk to go deep down in the community and tell them. And these young girls in schools we give them at 14 years old. We tell them the period should be like this, my body should be like this and if it is different I need to go to the hospital, so this is wha t we tell them in the schools. I: Do you see referral from some sub districts or health centers more than others? R: From the health center 2 we get many referrals because they only have the anti natal but no midwives. I: Do you see or hear of much us e a traditional birth attendants in the villages? R: They have been active before but now there is not so much due to the information that health workers are giving the community they know the importance of attending anti natal from the hospital and delive ring from the hospital. The work of these traditional birth attendants and even the number has reduced because we normally tell the mothers the risk that can come from these traditional birth attendant. First of all the health center of the traditional does not have all the protective gadgets the way we use in the hospital to protect the baby and the mother. So all these risks, we make the community aware of and they decide where to go and where not to go. So over time we see the number of those giving birth in the community is reducing and now very low. Also we tell them that if they have HIV the babies do not have to have HIV and can be delivered uninfected. So they say if I go to the hospital, I receive t he what, the quality care for my body and my child. It used to be they pay some little money to the traditional birth attendant maybe a be less than the t raditional birth attendant. So all that information we give them and they make the right decision. I: In your opinion, what would be best approach for overall outreach programs? R: We need to go into the communities and desensitize and screen so the pe ople know the care they need for HIV and other disease and where to go for that care.

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68 Annex 6 Interview with Hospital Head Nurse. I: Interviewer R: Respondent I: We talked informally about a nutrition program you were working with in the past that was su ccessful. Do think that it would be feasible to do again? R: It is feasible, the current program is small and only within the hospital, but when I worked with World Food Programme the coverage was very large. The all of Kitgum and Lamore, and we had a lot of mothers taught how to prepare locally available food. How to keep this food. How to preserve it and how to dig the kitchen gardens. I: And when were you working with the World Food Programme? R: The program ended just last year, we started in 2010 on a three years project and the achievement was very big. And what they did also was with micronutrients they for different mothers groups in all the sub counties. So we trained all these mothers groups on how the importance of eating well balanced diet, h ow to prepare the food, how to maintain it and how to give it to the babies. I: Are you still in contact with these mothers groups? R: Yes, I have all the contacts. So what we also did was plant these micronutrients. The fruit trees like the mango, the or anges and the popos. Which up to now we can see one of these gardens. Sonow these mothers groups they go to the community and give health education. Teaching how to prepare and feed the babies. Tis is because every month they were given so small moneys, 30,000 UGX to all of these mothers group has some little moneys in their accounts that they were using as loans. So all these groups up to know have money which is helping them. This can even pay schools fees for the children. These mothers they go and dig as a team. They can be paid for digging in somebodies farm. So the group can grow so much. So the good thing that is to educate the people in the community and now most of these people are well versed.. Before they did not know it was important. T hey did not know the important food nutrients of the g nut, chicken, goats and cows. They sell them all and they were the small ones. So after getting the proper information they were able to understand after growing let us sell some and keep some for ourselves. So they learned a lot of things from that. So up to know, even yesterday they were on a radio program so of those groups are still teaching. But in those days they were being facilitated by WFP but know they have to wait and see if they are given a chance to tlk to the people. It was not only that one. They were also giving information about hygiene and latrines. How to use the eating utensils and how to keep the environment clean. They are also taught the importance of taking children for immunization and completing really the immunization. These mothers also learned how to check the child health card. They were able to check if the mothers were finished immunizing their children or not and they were making referrals to health facilities. They were making sure that all children in their villages were immunized. They were recording all the new births and death of children for three years the y were reporting that. We designed some reporting format where they write and then give us.

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69 I: For each sub county there is one leader? R: Yes, for each sub county there is one leader that I was given contact to talk to all of them. That one was working to coordinate them. WFP gave us a vehicle, which they have taken back, that made this possible. We could move in all the sub counties to see if we are doing the program or not. (There is long period here where she talked about a specific health center an d village well outside the I: So how long are the nutrition trainings? R: Two days, the first day we teach the food groups, the importance, and the signs of malnutrition. We food. Then achievement, if you make your child e at good food from the beginning, like 6 months and above and the importance of exclusive breast feeding from birth to 6 months and we brought here the ones that are HIV positive. We told them if they come to the hospital their baby will be born HIV negati ve. And these babies will be the ones that help them when they are very sick. But if they infect their babies they will not have this. So we have the medicine for negative babies. We also talk about the conditions that lead to diarrhea, especially poor hygiene, eating the wrong food, wrong balance. So we also taught to feed the babies a good diet and in case of diarrhea we taught them community how to make this ORS At least they have this information but they have to been reminded of this. They always forget like children. You have to keep talking the same thing every time. At that We also taught of the but they then knew the dangers. And then the number of deliveries in the hospital increased. I: About what was the cost of the two day programs? R: The budget is in the acco travel fees. I was in charge of the education, there was a coordinator and one man was distributing this plumpy nut and the supplementary plumpy nut to moderately mal nourished children. He was the one who went around to distribute in sub counties. These womens groups with village health team were nourished, these children were giv en supplementary plumpy nut and collecting the data. I: Would this be easy to carry out again? R: Yes I: Would it always take two day workshops? R: Yes the two day program works good. I: Do you have personal here to carry it out again? R: Yes, there are enough and we can introduce and train nurse in the skills to nurse to be able to carry it out. I had the information from my school training so these nurses would have to be trained to carry it out. When I came here I took training twice on how to prepar e locally available food. This time I was

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70 also the one training on how to mix this food. Correct measurements is important. We make a local available thick juice with popo and orange and papaya. I was the one training this. You have to take time thoug h cause some of them are not used to learning. Some are drunkards some are typical villagers. Cause after teaching you have get them to demonstrate putting these food into groups. The energy foods, the protective foods. You have to encourage each one t o put foods in the groups or they will not understand. You have to be very patient with them. So all of one day is theories of food groups and when to eat them. How do you clean utensils, how do you clean after latrine. When we started only 30% had lat rines but at the end of the project up to 70% of them had latrines and rubbish heaps. So that was also good. We talk about immunizations and mal nutrision. We say do you know them do you have them in your villages. If they are there you make you tell t hem the signs of malnutrition and what are the dangers to our children, to you the mother, to the community and to the world at large. It is a very good. The second day we start with preparing food. We teach them how to make 3 different foods and make a varity with the 3 food nutrients. Then we prepare and the thickness matters if you can pour easily it is not good. If it is thick it contains a lot of nutrients. It is better than the other. The all over the second day is preparing these food and then w e do the recap of the whole thing. What has been learned these two days. All of them were able to tell us what we discussed when we returned. All of them could mention the food groups and what is there in the first cooking and second cooking and the thi rd.

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71 Annex 7 Example MoU from AVSI Memorandum of Understanding between AVSI Foundation and The present MoU concerns the implementation of the nutritional component under the De Agostini project (F4A6), particulars follow: Title Country : Uganda Donor : Foundation for Africa Area of intervention: Lagoro, Namokora and Omiya Anyima (Kitgum District); Schools involved: Alel Primary School Aloto Primary School, Deite Hill primary school, Oryebo primary school and Guda primary school General Objective of the Project To consolidate and expand the JFF&LS approach to benefit primary school children and their communities. In particular, AVSI will provide a total of: 8,040,000 UGX (Eight Million Fourty Thousand Shillings only) to St. Joseph Hospital, in order to allow the successful carrying out of the following Activities:

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72 Activity 1: Education on Nutrition topics in 5 schools Saint Joseph will train 12 mothers in each school,whose children are currently attending one of the schools under F4A6,in preparation of food, their conservation, the correct of diets for kids and pregnant mothers or brest feeding, hygene, sanitation and gardening. AVSI will then provide a kit for the distribu tion of the messages delivered at the training (to be prepared with the collaboration of Saint of 10 neighbouring families, whom she will represent. At the end of the training, the 12 women will form a group and will be given a kit to carry out more cooking demonstrations in their own villages. Activity 2: Cooking demonstrations in 5 schools Saint Joseph Hospital will hold 2extra pure cooking demonstratio ns per school, one in the month of August and two in the month of Septmeber. This activity aims to provide parents/tutors the competences to prepare and provide to their children food which will be prepared in a way that will benefit the body more.Each of the three food categories: Proteins (legumes, meat and fish), Carbohidrates (cereals) and Vitamins (fruits and vegetables) will need to be utilized during the demonstrations. The peer educators will have to be present for the activity and will facilitate t he diffusion of messages and techniques they also apprehended thanks to the course they followed.Invited to this demonstration, will be the mothers of o sensitize as many parents/guardian as possible. Expected Results: At the end of the collaboration, St. Joseph Hospital will ensure that the following results are achieved: A total of 60 mothers (12 per school) have attended and succesfully completed a 2 days training 2pure cooking demonstrations(apart from the training) took place in each of the 5 schools involved in the project, one in March,and one in A pril; At least 100 mothers/guardians have attended one cooking demonstration and are sensitized on value of nutrition and on cooking healthy food; The 5 groups of women are able, at the expiry of the MoU, to carry out a cooking demonstration on their own for the benefit of other women in their village;

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73 Inputs: St. Joseph Hospital will in order to achieve such goals provide the following inputs: Two staff assigned to the action; A car and a driver to ensure the mobility of the staff; Acquire the food items needed for each demonstration; AVSI will therefore provide the following inputs: A Daily Safari Allowance of 12,000 UGX each for the two nurses assigned to the action up to a maximum of 600,000 UGX (Code A.1). The funds will be released in cash to SJH in one installment upon request printed on SJH headed paper duly signed and stamped by the Medical Superintendent, or other authorized persons, to the AVSI Programme Manager ; A Daily Safari Allowance of 12,000 UGX for the St. Joseph driver assigned to the action up to a maximum of 300,000 UGX (Code A.2). The funds will be released in cash to SJH in one installment upon request printed on SJH headed paper duly signed and stamped by the Medical Superintendent, or other authorized persons, to the AVSI Programme Manager ; Payment oftwo months salary of a 2 Nurses assigned to the action, for a total maximum amount of 1,600,000 UGX (Code A.3) to be disbursed in cash by AVSI to SJH. T he contributions will be corresponded according to AVSI established procedure for requisition and reporting using the attached AVSI Staff contribution Form PER S5 and PER S6. Requests and reports will be addressed to the AVSI Program Manager. Provide funds for the acquisition of food items required for the two days Nutritional Training + Cooking Demonstration for a maximum amount of 110,000 UGX per training adding to a maximum amount of 550,000 UGX (Code B.1). The funds will be released in cash to SJH in o ne installment upon request printed on SJH headed paper duly signed and stamped by the Medical Superintendent, or other authorized persons, to the AVSI Programme Manager ; Provide funds for the acquisition of the food items required for the pure Cooking Dem onstrations up to 110,000 UGX per cooking demonstration, adding up to a maximum of 1,320,000 UGX (Code B.2). The funds will be released in cash to SJH in one installment upon request printed on SJH headed paper duly signed and stamped by the Medical Supe rintendent, or other authorized persons, to the AVSI Programme Manager ; Fuel for the activity and mobility of the St. Joseph staff, for a total maximum of 2,590,000 UGX (Code C.1) The Hospital will submit the orders/requisitions printed on SJH headed pape r duly signed and stamped by the Medical Superintendent or other authorized persons to the AVSI Programme Manager, who will afterwards forward the order to the AVSI Procurement Office concerned. The request will be verified and approved by the AVSI Program me Manager and or his delegate. AVSI will be responsible for the purchase, transport and delivery of the items to the Hospital; Lumpsum for coverage of administrative costs up to a total maximum of 1,300,000 UGX (Code C.2). The funds will be released in ca sh to SJH in one installment upon request printed on SJH

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74 headed paper duly signed and stamped by the Medical Superintendent, or other authorized persons, to the AVSI Programme Manager. ; List of mothers selected to be trained as peer educators in each schoo l (total of 60); Mobilization for the activities in the schools; A Nutrition Demonstration Package to be distributed in kind to the mothers in order to spread the messages acquired in the training; Provide one toolkit for cooking demonstrations per school (group of 12 mothers), in kind; Monitoring of the activities by the AVSI DEA PM and Project Officer; Release of Financial inputs and Accountability: Where applicable, AVSI will release the financial inputs as follows: Release of funds 1. Advance request printed on the SJH headed paper duly signed and stamped by the MS or other authorized persons, officially nominated in writing by him. The request should contain details of the items that will be procured. Accountability 2. Accountability in original accompan ied with the AVSI format ADM A6 summary sheet where nature of expenditures and related amount are indicated. 3. Accountability related to food must be accompanied by the list of beneficiaries who received the support. The list should contain details such as n ame and signature of the beneficiary, date, quantity and type of food received. 4. Accountability related to fuel consumption must be accompanied by list of trips adequately detailed (date location distance) 5. Accountability related to staff will be provided a ccording to AVSI established procedure for requisition and reporting using the attached AVSI Staff Contribution Form PER S5 and PER S6, duly signed and stamped by the Medical Superintendent (MS) and the health worker.

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75 Duration and Termination The present MoU is valid from the 1 st of March 2013 up to the 31 st May 2013. All project activities have to follow the objectives. Both Avsi and Saint Joseph can terminate this agreement, concluding their collaboration in the project implementation due to any moment sending a written notice at least three months before, stating the reasons for such a request. However the request will have to be accepted by both the partner and t he donor, Foundation for Africa. This MoU is made up of six (6) pages. Signed on:_______________________________________, in triplicate. For AVSI: __________________________________________ Fred Opok Kitgum Area Team Leader For Saint Joseph Hospital : _________________________________________ For AVSI (as witness): ___________________________________________ Fabio Beltramini F4A6 Project Manager

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76 Nutritional Activities under F4A6 Project (Fondazioni For Africa Project) From 1 st March 2013 to 31 st May 2013 MoU Breakdown Budget Breakdown: Budget for Nutritional Activities Code Activity # Amount Times Total A.1 Allowances Nurse (2) (DSA) 2 12,000 25 600,000 A.2 Allowance Driver (DSA) 1 12,000 25 300,000 A.3 Salary of staff assigned to the action (2 nurse for 2 months) 2 400,000 2 1,600,000 B.1 Nutritional Trainings (Theory + Cook Dem) (2 days) 5 110,000 1 550,000 B.2 Pure Cooking Demonstration (2 per school) 5 110,000 2 1,100,000 C.1 Fuel (lt) (lump sum) 600 3,700 1 2,220,000 C.2 Administrative Costs (lump sum) 1 1,300,000 1 1,300,000 Total 7,670,000

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77 Calendar of activities Activity 1: Education on Nutrition topics in 5 schools 2 days Nutrition Training + Cooking Demonstration Date Day School Activity 11 th March Monday Alel Primary School Theory 12 th March Tuesday Alel Primary School Cooking Demonstration 13 th March BREAK 14 th March Thursday Aloto Primary School Theory 15 th March Friday Aloto Primary School Cooking Demonstration WEEK END 18 th March Monday Deite Hill primary school Theory 19 th March Tuesday Deite Hill primary school Cooking Demonstration 20 th March BREAK 21 st March Thursday Oryebo primary school Theory 22 nd March Friday Oryebo primary school Cooking Demonstration WEEK END 25 th March Monday Guda primary school Theory 26 th March Tuesday Guda primary school Cooking Demonstration End Activity 2: Cooking demonstrations

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78 2 Cooking Demonstration per school Date Day School Activity 1 st April Monday Alel Primary School Cooking Demonstration 2 nd April Tuesday Aloto Primary School Cooking Demonstration 3 rd April Break 4 th April Thursday Deite Hill primary school Cooking Demonstration 5 th April Friday Oryebo primary school Cooking Demonstration BREAK 8 th April Monday Guda primary school Cooking Demonstration 9 th April Tuesday Alel Primary School Cooking Demonstration 10 th April Break 11 th April Thursday Aloto Primary School Cooking Demonstration 12 th April Friday Deite Hill primary school Cooking Demonstration BREAK 15 th April Monday Oryebo primary school Cooking Demonstration 16 th April Tuesday Guda primary school Cooking Demonstration 17 th April Break 18 th April Thursday EXTRA Cooking Demonstration 19 th April Friday EXTRA Cooking Demonstration BREAK St. Joseph Hospital will inform AVSI in advance in case any change is made on the calendar of implementation after the signing of this MoU. The EXTRA dates will accommodate any spill over training.

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79 Annex 8 Copy of final nutrition report REPORT ON NUTRITIONAL ACTIVITIES UNDER DEA2 PROJECT (DE AGOSTINI PROJECT) FROM 16 TH JULY, 2012 TO 30 TH OCTOBER, 2012 Implemented By: SUPPORTED WITH FUNDING FROM FOUNDAZIONE DE AGOSTINI/AVSI

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80 ACKNOWLEDGEMENT First of all, I wish to extend my heartfelt gratitude and thanks to AVSI for funding this program under DEA 2 Project on Nutrition activities. p roject which has greatly benefited the community I must also extend my appreciation to my colleague R/N Beatrice Aloyo Ochola and Drivers of the Hospital who actively participated towards this project which is worth remembering. You are intellectually res ourceful and profoundly knowledgeable. Lastly to all the staffs whose names may not be mentioned here. Thank you for all you have done towards this project. May the Mighty Father reward you abundantly. Compiled by: Sr. Amito Lilly Otim Medical Director, Dr Ojom Lawrence, I Y.C.F{Infant and Young Child Feeding supervisor} Mobile: 0772 845603. Mobile:0772 611929.

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81 E mail:lillyamito1970@gmail.com e mail:law_ojom@yayoo.co.uk. THE GENERAL OBJECTIVES world .THE SPECIFIC OBJECTIVES OF THE PROJECT. 1. To improve the state of food security and Nutrition o f vulnerable children and their families in Northern Uganda. 2. To promote a course on the theme of food security and the right to food to a group of schools in Uganda. Senegal and Italy. INTRODUCTION This report covers the period from 16/07/2012 to 30/10/2012, which is in line with The Uganda Clinical guide line on Nutrition especially Infant and Young Child Feeding of which they provided the frame work. This is mainly for ensuring the survival and Enh ancing Health, Growth and Development of Infant and young Children. They are also intended to strengthen care and support for parents and /or care takers to

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82 with AVSI under DEA2(De Agostini project) implemented a three months project to improve on Nutrition awareness and implementation. ACTIVITIES CARRIED OUT Health Education in 4 schools on Nutrition St.Joseph Hospital had trained 12 people from Lagoro s ubcounty Alel, 14 people from Oryebo Namukora subcounty, 12 people from kalongo and 12 from Lyelokwar. These people currently have their children attending one of the Schools under DEA, in preparation of food, their conservation, the correct diets, for inf ant and young children, pregnant mothers, Lactating mothers, and the sick. Hygiene and sanitation maintenance, and how to prepare and maintain kitchen able to train other people from the community THE FOLLOWING WERE PARTICIPANTS FROM LYELOKWAR OMIA ANYIMA SUB COUNTY. S/N NAMES ADDRESS 01 Okwong Gaitano Lyelokwar

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83 02 Akello Irene Lyelokwar 03 Oyella Irene Odongloo 04 Lalam Irene Lyelokwar 05 Akongo Matilda Lyelokwar 06 Alanyo Josphine Odongloo 07 Akwongo Doreen Lyelokwar 08 Abwola Patrick Odongloo 09 Aromo Margret Odongloo 10 Angeyo Ketty Lyelokwar 11 Amito Betty Odongloo 12 Achola Ventinora Odongloo LAGORO SUBCOUNTY AT ALEL THE FOLLOWING PARTICIPANTS WERE TRAINED.

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84 01.Mwaka Samson Oguda, 02. Lukwiya Richard Alel East, 03.Oyella Narasista Alel, 04. Aadoch Hellen Alel, 05. Duslina Akello Alel, 06. Ruphina Lalam Lagampit, 07. Anyeko Esterina Lel East, 08. Akwir Rose Al el East, 09. Adorina Layet Alel west, 10..Otim Benard Oguda, 11. Angeyo Atimayeta Alel West, 12. Olok Phibeto Alel East.

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85 ORYEBO NAMUKORA SUBCOUNTY TRAINED PARTICIPANTS ARE INDICATED BELOW: 10. Alok Anjelika Macece 02 Apoto Anjulina Macece 03 Anek Lilly Macece 04 Adwar Hellen Mcece 05 Acop Rose Oryebo 06 Akwero Christine Oryebo 07 Maracii Aneno Oryebo 08 Amony Mary Oryebo 09 Akwero Naracija Macece 10 Ajalo Margret Oryebo 11 Aciro Margret Oryebo 12 Lawoko Anjello Oryebo 13 Angee Pouline Macece 14 Okongo Vincent Oryebo PARTICIPANTS TRAINED FROM KALONGO NIMARO PRIMARY SCHOOL WERE:

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86 01. Ayoo Rebecca Kokil, 02. Atim Susan Kokil, 03. Akech Gulyelmina Pacer, 04. Auma Martha Pacer, 05. Ajok Mary Pacer, 06. Lanyero Beatrice Pakor, 07. Akello Santa Apil, 08. Akanyo Jenifer Apil, 09. Abwor Ida Apil, 10. Acan Agnes Pakor, 11. Ato Nighty Pakor, 12. Akello Florence Kamonojwir. SUMARY OF THE EXPECTED OUTCOME/ RESULTS A total of 50 participants were trained (12 per School except Oryebo were 14) All the groups were trained on dietary diversity and preparation of locally available food and successfully completed a 2days

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87 Food hygiene, recognition of signs of malnutrition in the community, and referrals of these cases to the nearby health facility Three pure big cooking demonstration were carried out in all these Schools and found out that all the groups were knowledgeable on what was taught which is a success from our side and the community

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88 The 4 groups are able to carry out cooking demonstration on their own for the benefit of other women in their villages, sensitized on the values of nutrition and cooking healthy food

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89 Children now enjoying nutritious well cooked food. CHALLENGES MET DURING THE PROJECT Bad roads Distance, some participants were coming from far away.

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90 Rainfall was troublesome from time to time especially during cooking demonstration. RECOMENDATIO N The project still need proper follow up by the team concerned. The group needs to be supported especially on valuable nutritious food items.

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91 jn COMMUNITY BASED SUPPLEMENTARY FEEDING PROGRAMME END OF PROJECT REPORT Community Based Supplementary Feeding Programme Kitgum and Lamwo District

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92

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93 Project Name: Community Based Supplementary Feeding Programme Project Location: KITGUM and LAMWO DISTRICTS Project Duration 2 Years 9 months ( 28 th /August, 2009 30 th April, 2012) Funding Requested Funds Disbursed Funds Utilized Available Balance 779,396,100 552,495,653 552,495,653 Nil Recipient Organization: Contact Person: Name: Address: Telephone No. E mail Address Dr.Lawrence Ojom Medical Superintendent 0772611929 Email: stjoseph@ucmb.co.ug

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94 Estimated population during the start of the programme (CBSFP) DISTRICTS TOTAL LAMWO KITGUM Total Population 136,798 200,380 337,178 Population Under 5 (20%) 27,360 40,076 67,436 Population under 1 (4.3%) 5,882 8,616 14,499 Estimated number of beneficiaries to be served. 2550 3708 6258 Estimated total amount of food to be distributed in M.T ( CSB, VEG. OIL, Sugar and MIXRUSF) 151.510 151.510 Introduction Districts Signed a memorandum of understanding in August 2009 to implement Community Based Supplementary Feeding Programme, the aim of the programme is to build the capacity of health workers, community groups and individuals to manage and sustain communi ty based supplementary feeding programme in the Districts to reduce morbidity, mortality and malnutrition rates among the displaced, resettled and returned populations according to Uganda guide line. t 3 kms North East of Kitgum Town, across Pager River and is under Chua HSD. It is a private not for profit hospital (PNFP). The owner is Gulu Catholic Archdiocese and is accredited to Uganda Catholic Medical Bureau. Background; Kitgum is one of the Distr ict in northern Uganda that has seriously been affected by the over 20 resistance army (LRA). The war displaced the greater population of Acholi into concentrated peopl other communicable diseases as a result of lack of proper immunization as well as sustainable curative and preventive interventions for diseases like malaria and diar rhoea. It also brought in acute poverty that led to severe malnutrition.

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95 With the relative peace enjoyed during the period; the return process has intensified and people were returning to their original homes; at the same time the humanitarian efforts that have over the past 20 years sustained service delivery in the district h as started to wane up. hospital with financial backing from WFP and support from MOH was officially given responsibility to implement community based supplementary feeding programme in Kitgum and Lamwo Districts. 1. Objective of the project; To contribute to the reduction in childhood Morbidity and Mortality in Kitgum and Lamwo District, Specific Objectives; To ensure that at least 100% of children with moderately acute malnutrition have access to supplementary feeding interventions through scale up of the CBSFP strategy to cover all hospitals, health centre IVs, health centre IIIs, health centre IIs and commu nity outreaches in Kitgum and Lamwo District. To strengthen the community based systems for screening and referral of children with severe acute malnutrition through establishment of a functional system in 90% of villages and 100% of health centre IIIs and IIs in Kitgum and Lamwo District. To prevent malnutrition by reaching at least 90% of households in Kitgum and Lamwo District through promotion of appropriate infant and young child feeding practices. To ensure that at least 90% of children in the targete d districts have access to appropriate treatment for malnutrition at facility and household level; To strengthen referrals and counter referral in IMAM for at least 90% of severely malnourished children in the community refer to or counter refer to targete d ITC, OTC and CBSFP. Expected Outputs Supplementary feeding programme coverage increased; Communities empowered to identify and refer cases of acute malnutrition for appropriate treatment; Communities empowered to promote adequate child care practices th rough improved knowledge, attitude and practice (KAP).

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96 CBSFP Activities Work closely with the District Health Office in implementation of the CBSFP according to the recommended guidelines. Follow up of malnourished individuals under treatment in communities Increase access to CBSFP services by the potential beneficiaries through reasonably establishing community outreach sites Screening of children in communities for identification, counseling and referral of malnourished individuals according to supplementary feeding admission criteria and protocols. Support the capacity strengthening of both district (DHT including health wo rkers) and community structures (including VHTs, CBOs, other community support groups etc) to in management for acute malnutrition. Ensure CBSFP beneficiaries services in addition to food including vaccination, de worming, supplementation, nutrition counse ling and others as recommended by the Integrated Management of Acute Malnutrition Guidelines Advocate for appropriate health and nutrition practices both at community and district levels. Mobilization of mothers and other child care givers for CBSFP serv ices. Sensitize district and target communities on Community Based Supplementary Feeding Programme Organize and Oversee training of the Village Health teams that will be involved in the Community Based Supplementary Feeding Programme Conduct Knowledge, a ttitude and Practice baseline and evaluation assessments Implementation and Actual Results 1. Community screening of children using MUAC by VHTs Accumulative figures of 150,924 children (6 59 months) (72,955 Males and 77,969 Females); were screened in th e community during monthly screening by VHTs in the districts of Kitgum and Lamwo from January 2011 to March 2012; with average numbers of children screened per month is 10,062. Out of 150,924,399 children screened 140,631 children (93%) their MUAC were in green colour, 8,612 (6%) their MUAC were in yellow and 1,681 children (1%) their MUAC were in red. 95% of children screened they were having child health cared 91% of children screened were vaccinated. 86% of children screened were given Vit A up to da te 65% of children were given de worming tablet. 2. Number of admission in CBSFP,

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97 12,707 moderately malnourished children were admitted in CBSFP since the Project inception. (5,716Males and 6,964 Females) Admission type Sept to Dec 2009 Jan to Dec 2010 Jan to Dec 2011 Jan to Mar 2012 TOTAL End of Aug 2009 1,664 1,664 Follow up from OTC/ITC 62 505 236 25 828 MAM Cases 1,393 4,373 3,885 393 10,044 Others 13 95 52 11 171 TOTAL 3,132 4,973 4,173 429 12,707 3. N o of Malnourished children Discharged i.e. Cured, died or defaulted from CBSFP; Out of 12,707 children admitted; 9,346 were cured, 52 died, 1,991 defaulted, 527 none responded, 212 transferred to OTC/ITC and 579 were admission error. Exit from CBSFP

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98 Type of exit Sept to Dec 2009 Jan to Dec 2010 Jan to Dec 2011 Jan to Mar 2012 Total Cured 875 4,356 3,126 989 9,346 Death 3 28 17 4 52 Defaulted 254 772 843 122 1,991 Non response 81 62 319 65 527 Transferred 60 37 109 6 212 Admission error 53 484 31 11 579 Total 1,326 5,739 4,445 1,197 12,707 4. Average Rate of weight Gain (RWG) and Average Length of Stay (LoS) Average RWG in CBSFP is = 3.1 and Average LoS in CBSFP is = 76 days 5. N o of facilities and outreaches created for CBSFP in the target area, A total of 19 health facilities and 52 outreaches were created as a distribution sites for CBSFP in Kitgum and Lamwo District since the Project inception. 6. Food distributed since the Project inception. (CSB, Vegetable Oil, Sugar and Supplementary plampy)

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99 Total of 246.942 MT Food Items distributed; Food Items Sept to Dec 2009 Jan to Dec 2010 Jan to Dec 2011 Jan to Mar 2012 Total CSB 20.901 101.787 62.086 6.829 191.603 Vegetable oil 2.655 17.228 6.843 0.792 27.518 Sugar 1.582 7.141 4.120 0.492 13.335 MIXSRF 0 0 10.691 3.795 14.486 TOTAL 25.138 126.156 83.740 11.908 246.942 7. N o of health workers who were trained in the management of CBSFP A total of 103 health workers were trained in the management of moderately acute malnutrition in the CBSFP. 8. N o of Village Health Teams who were trained in community screening. A total of 632 VHTs were trained in community screening and referral of of moderately acute malnutrition in the CBSFP. 9. N o of mothers groups identified and trained in the catchment area, A total of 44 women groups were identified and trained on nutrition interventions in 19 sub counties in Kitgum and Lamwo. 10. N o of community food demonstration conducted Community food demonstration was conducted in all the 99 parishes in the project area by women groups.

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100 Women group during community food demonstration; 11. Unanticipated benefits of the programme Enhanced service delivery Continuous professional training of the health unit staff has improved their capacity in care and management of undernourished children in the health facilities, Information sharing and disseminations There has been immense collaborations among the various institutions implementing health related interventions, best results emphasized and integra ted in the system. Combine support from WFP and UNICEF concurrently implement the nutrition project on a comprehensive basis covering all the four components of IMAM; Use of women groups The use of women groups in the training of the community and mothers on how to prepare balanced diet food has proven to be cost effective and sustainable. 12. Difficulties encountered;

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101 Inadequate knowledge In treating children with nodding diseases associated with malnutrition Pe rsonnel In some of the lower level health units staffing still remains the biggest challenge especially in HCII being run by only the Nursing Assistants. This has also affected the nutrition activity since they are barely involved in community outreach es as they are always pre occupied in the health unit, Overall there has been little involvement of the staffs in monitoring of project outcomes. Monitoring tool The register books, admission charts for both inpatient therapeutic rapeutic care are not available for data collection at the health facilities in the project area. Unavailability of essential drugs Routine medical treatment for children with malnutrition was not being given due to shortage of drugs in most of the health facilities. High default rate People were moving from satellite camp to their original village and Non response Most of the non responses are children with nodding diseases 13. Assets purchase under CBSFP and s upport through WFP funding 92 Bicycles 1 motorcycle YAMAH AG 100 1 Computer Laptop 1 Printer 1 Digital camera 1 Photocopier 1 Public address system Monitoring tools and equipments for CBSFP Food 14. WFP monitoring The frequent monitoring of WFP technical Staff in Project implementation was quiet Trainings, Meeting with hospital Management and Implementation team, frequent follow ups through email, and Phone calls. 15. B eneficiaries involved in the project implementation

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102 The target beneficiaries were involved in all aspects of Project implementation; The key local community structures were involved in mobilization and sensitization, i.e. The Local Councilors, women grou ps and the Village health teams, The beneficiaries were involved in community Food Demonstration, 16. lessons that could be applied to other projects Full community participation in planning, implementation and monitoring of project activities is efficien t in terms of accountability and delivery of outputs; this will also enforce the sense of ownership in the project outcomes. Integrations within the existing structures e.g. EPI, HIV/AIDS and Maternal health. With integration, information and ideologies are shared, best practices adopted for regular progress, Sharing and use of the available resources within the community and health facilities Local solutions Emphasis should be put on looking at local solutions to sustainably resolve local problems as a way of coping with a given situation. The adoption of integrating the VHTS, women groups and LCs in the mobilization and sensitization seems to be more effective, Continued use of the mothers group in the implementation of nutrition activities especially o n infant and young child feeding and identification and referral of children with acute malnutrition has proven to be cost effective in reaching household levels, Onsite training for the management of children with malnutrition and record keeping has been observed to be more effective than workshops. It is also less expensive. 6. Prepared by: Name: Acaye Terence Signature: _____________ __ Title: Project Coordinator (CBSFP) Date: 27 th /04 /2012 7. Reviewed by: Name: Dr. Lawrence Ojom Signature: ___________________ Title: Medical Superintendent Date: ____________________ KITGUM 8. Certified by: Head of Sub Office GULU

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103 Name: _______________ Signature: _____________________ Comments:_____________ _______________________________________________________ ______________________________________________________________________________ 9. Approved by: Head of Sub Office GULU Name: ______________________________ Signature: ____________________ Comments:____________________________________________________________________ ______________________________________________________________________________