Muni Repository (MR)
This repository contains open access publications of Muni University Library.
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Recent Submissions
Barriers and facilitators to community-based, peer-led sexual and reproductive health intervention for adolescent girls and young women in northeastern Uganda: A qualitative study
(PLOS (Public Library of Science), 2026-06-11) Komuhangi, Alimah; Kajabwangu, Rogers; Izudi, Jonathan
Peer-led interventions can effectively improve sexual and reproductive health (SRH) knowledge, promote safer sexual behaviors among adolescents and young people, especially where health system capacity is limited. To inform a planned pre-post study, we explored the barriers and facilitators to the implementation of a community-based, peer-led SRH intervention for adolescent girls and young women (AGYW) aged 15–24 years in northeastern Uganda. We designed a qualitative case study and collected data through focus group discussions across AGYW in six categories: in-school, out-of-school, ever given birth, and never given birth, aged 15–17 years, and aged ≥18 years. We also conducted key informant interviews with SRH officials in the district and at two health facilities. Data collection was guided by the socioecological model. We performed thematic analysis and reported findings using themes along with the participants’ quotes mapped onto the socioecological model. A total of 51 adolescent girls and young women, and five key informant interviews with the district and health facility level officials were conducted. Findings show that the anticipated barriers and facilitators to implementation occur across socioecological levels. At the individual level, stigma and fear of judgment hindered participation, whereas trust in peers supported engagement. Limited autonomy hindered access at the interpersonal level, but support from family and friends helped. Institutional barriers included judgmental provider attitudes and confidentiality concerns; existing youth-friendly services and school clubs were facilitators. At the community level, myths, misconceptions, and restrictive cultural norms posed challenges, while community dialogues and champions encouraged acceptance. No major policy barriers were noted; however, supportive SRH policies and existing partnerships were facilitators. The implementation of the intervention may be influenced by several factors across individual, interpersonal, institutional, community, and policy levels. Future implementation should consider addressing the barriers while leveraging the facilitators to enhance implementation outcomes among AGYW
Effect of prior TB preventive therapy on allcause mortality during TB treatment among people with HIV/TB in rural eastern Uganda: an observational causal analysis
(Springer Nature, 2026-06-08) Izudi, Jonathan; Bajunirwe, Francis; Ssentongo, Saadick Mugerwa; Appeli, Saidi; Cattamanchi, Adithya
Background
Tuberculosis preventive therapy (TPT) is the cornerstone for preventing TB disease. However, it is uncertain whether prior TPT completion improves survival once TB disease develops in people with human immunodeficiency virus (PWH) while on anti-retroviral therapy (ART). We evaluated the effect of prior TPT completion on all-cause mortality during TB treatment among PWH who developed TB disease while on ART in rural eastern Uganda. Prior TPT completion served as a marker of sustained engagement in HIV care.
Methods
We applied inverse probability of treatment weighting using propensity scores, a causal inference analysis approach, to mimic a randomized controlled trial using real-world retrospective cohort data. Inverse probability of treatment weighting addresses design flaws in observational studies, such as selection and confounding biases, providing less biased causal effect estimates. Individuals who had completed a full course of TPT before the start of the index TB treatment episode formed the intervention group, while the control group comprised those with no history of TPT before the index TB treatment initiation. Inverse probability of treatment weighting ensured balanced baseline covariates between the exposure groups. We estimated all-cause mortality rates using person-time methods and Kaplan-Meier curves and performed propensity-score weighted Cox proportional hazards analysis for cause-effect estimation. We reported adjusted hazard ratios (aHR) with 95% confidence intervals (CI).
Results
Of 719 participants, 296 (41.2%) had completed a full course of TPT before the start of the index TB treatment episode, and 83 (11.5%) had died. The mortality rate was 7.13 per 10,000 person-days, higher among participants without prior TPT than those with prior TPT completion (18.0% vs. 2.4%, log-rank χ²(1) = 35.3, p < 0.001). Median survival was 277 days (95% CI: 213–689). Prior TPT completion was associated with an 87% lower hazard of all-cause mortality (aHR 0.13, 95% CI: 0.06–0.29).
Conclusion
Prior TPT completion substantially reduced all-cause mortality among PWH who developed drug-susceptible TB disease while on ART. Therefore, there is a need to strengthen TPT completion and engagement in HIV care across HIV programs to lower all-cause mortality among PWH.
Risk factors for cryptococcal infection among people with HIV receiving care at a referral hospital in Uganda: a nested case–control study
(Springer Nature, 2026-04-27) Namuyanja, Sarah; Appeli, Saidi; Izudi, Jonathan
Background
Cryptococcal infection is a major cause of morbidity and mortality among people with HIV (PWH), particularly those with advanced immunosuppression. Cryptococcal infection, detected by a laboratory-confirmed positive serum cryptococcal antigen (CrAg) test (cryptococcal antigenemia), typically precedes cryptococcal meningitis and provides a critical window for prevention. However, recent data on its risk factors in Uganda are limited. We assessed the risk factors for cryptococcal infection among PWH with non-suppressed viral load and severe immunosuppression receiving care at a referral hospital in midwestern Uganda.
Methods
We conducted a facility-based nested case-control study among PWH with non-suppressed viral load (viral load ≥ 1,000 copies/mL) and severe immunosuppression (CD4 < 200 cells/µL) at the Fort Portal Regional Referral Hospital in midwestern Uganda. Cases were PWH with a positive serum CrAg test, and controls were those with a negative serum CrAg test in a 1:2 case-to-control ratio, respectively. Socio-demographic and clinical data were retrospectively extracted from routine records. Multivariable binary logistic regression analysis was used to identify factors independently associated with cryptococcal infection. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported.
Results
We included 89 cases and 178 controls, with comparable mean age between the groups: 40.3 ± 12.4 years vs. 40.4 ± 11.7 years, respectively; p = 0.952. In the multivariable analysis, PWH with advanced World Health Organization (WHO) clinical stages III/IV compared to WHO clinical stages I/II (aOR 3.45, 95% CI 1.28–9.97), and those with missed clinic visits within three months before the serum CrAg testing compared to those without any missed clinic visits (aOR 2.39, 95% CI 1.14–5.02) had higher odds of cryptococcal infection.
Conclusion
This study showed that among PWH with non-suppressed viral load and severe immunosuppression, cryptococcal infection is strongly associated with markers of advanced HIV disease and gaps in care engagement. Strengthening retention in care, improving clinic appointment tracking, and ensuring timely serum CrAg screening among PWH with non-suppressed viral load may reduce cryptococcal disease burden through early diagnosis and treatment.
Participants’ experiences of potential adverse effects of an intervention to improve critical thinking about health choices: a qualitative cross-trial process evaluation in Kenya, Rwanda and Uganda
(BMJ Publishing Group, 2025-09-29) Oxman, Matt; Chesire, Faith; Mugisha, Michael; Ssenyonga, Ronald; Nsangi, Allen; Oxman, Andrew D; Fretheim, Atle; Rosenbaum, Sarah; Kaseje, Margaret; Sewankambo, Nelson; Melby-Lervåg, Monica; Lewin, Simon
Objectives: To explore participants’ experiences of potential adverse effects of the Informed Health Choices secondary school intervention across three trial sites and to revise a framework of potential adverse effects of interventions to improve critical thinking about health choices.
Design: This was a qualitative study. We extracted and analysed relevant data from separate process evaluations in each country. Data came from surveying teachers, observing lessons and group and individual interviews with students, teachers and other stakeholders. We modified and applied framework analysis, including five stages: (1) development of an initial framework of potential adverse effects, (2) familiarisation with the data, (3) indexing, (4) abstraction and synthesis and (5) revising the framework. We applied reflexive strategies individually and as a team.
Setting: Lower secondary school in five randomly sampled subcounties of Kisumu County in Kenya, districts representing all five provinces in Rwanda, and six districts in the central region of Uganda, between 2022 and 2024.
Participants: Students and teachers in the intervention arms of the trials, parents of students in the intervention arms and administrators at intervention schools, as well as curriculum developers and policy-makers.
Intervention: The intervention involved providing teachers with a 2–3-day training workshop, and digital classroom resources, including lesson plans for 10 lessons to be delivered over the course of one semester.
Results: We generated findings about potential increases in adverse misunderstandings, anxiety related to transfer of learning, adversely experienced cognitive dissonance, work or schoolwork-related stress, inequity, conflicts and waste. The revised framework includes the same categories of potential adverse effects as our initial framework: decision-making harms, psychological harms, equity harms, group and social harms, waste and other harms. We revised other elements of the framework, including definitions of the categories and its structure.
Conclusions: This study provides insight into the potential adverse effects of interventions to improve critical thinking about health choices. The findings complement those of the trials and country-level process evaluations.
A two-decade review of human exposure to legacy and emerging organic pollutants in Sub-Saharan Africa: Current status, exposure pathways, challenges and recommendations
(Elsevier, 2026-06) Ssebugere, Patrick; Miiro, Ashirafu; Odongo, Silver; Muhwezi, Godfrey; Nabuuma, Josephine; Abayi, Juma John Moses; Matovu, Henry
Rapid urbanization, industrialization, and continued pesticide use have intensified human exposure to persistent organic pollutants (POPs) in Sub-Saharan Africa (SSA). POPs are highly stable, bioaccumulative, and toxic, posing chronic reproductive, endocrine, and developmental risks. This review synthesized studies (2005–2025) that assessed legacy and emerging POPs—including organochlorine pesticides (OCPs), polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs), and per- and polyfluoroalkyl substances (PFAS)—in human fluids and tissues across SSA. Blood and serum (⁓48%) and breast milk (⁓38%) were the most analyzed matrices, followed by urine, placenta, and cord blood (<10%). Total dichlorodiphenyltrichloroethane (∑DDT) in milk samples from South African mothers were in the range of 9500–140,000 ng/g lw—the highest globally—linked to malaria vector control. Mean total PCBs reached 160 ng/g lw in Ghanaian and Nigerian mothers, while ∑PBDEs were up to 786 ng/g lw in exposed Tanzanian populations. Dioxin toxic equivalents in Ghanaian serum (4.2 pg WHO 2005-TEQ/g lw) and South African milk (1.6–9.1 pg TEQ/g lw) were within global mid-range values. PFAS levels in South African and Ethiopian serum (0.6–2.5 ng/mL) confirmed emerging fluorinated exposure. Although health risk assessments were limited, some exceeded FAO/WHO thresholds, suggesting potential endocrine and developmental effects. Median POP levels in SSA populations were lower than the global averages but exhibited localized exceedances. Strengthened biomonitoring, harmonized QA/QC, and inclusion of short-chain PFAS, novel brominated flame retardants (NBFRs), and bisphenol analogues are essential to implement the Stockholm and Basel Conventions.