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Researchers Design Community-led Behavioural Change Model to Control Rate of Type 2 Diabetes among Rural Population

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By Joseph Odoi

Globally the proportion of undiagnosed diabetes is high, standing at 46.5%. In high-income regions like Europe, of all persons with Type 2 Diabetes Mellitus (T2DM), 39.3% are undiagnosed. Low-income countries in Africa have the highest prevalence of undiagnosed diabetes, estimated at 66.7%. In Uganda alone, a steady increase in the number of diabetes cases has been observed.

Despite the increasing burden of diabetes in the country, little is known about the socio-cultural norms influencing type 2 diabetes risky behaviors, especially in rural areas to inform action.

In the bid to contribute to data driven interventions, Makerere University researchers with funding from Government of Uganda and Makerere University Research and Innovations Fund (Mak-RIF) carried out a study to understand the patterns of socio-cultural norms in two high incidence districts namely, Busia and Bugiri, in Eastern Uganda.

As part of this study, researchers engaged various health stakeholders who shared their experiences about behaviors factors influencing type two diabetes.

It is upon that background that researchers co-designed a contextual strategy to ensure behavioral change to limit type two diabetes among the rural population under the project titled; “Socio-cultural norms influencing Type 2 Diabetes risks Behaviours – an exploratory to intervention co-design innovative study in two high incidence districts of eastern Uganda”. The strategy was developed by a team of researchers led by Dr. Juliet Kiguli, a Senior Lecturer in the Department of Community Health and Behavioural Sciences  at the School of Public Health, Makerere University.

According to Dr. Kiguli, despite evidence confirming a high rate of T2D in Uganda, there is hardly any innovation that speaks to the deep rooted causes of Type 2 Diabetes hence the justification for their new model.

‘’There is enough evidence in Uganda at the national and local/community level confirming a high rate of T2DM, compared to the measures/innovations that try to address the disease. We can argue with confidence that most of the research around T2DM in Uganda and Africa has been largely academic and hasn’t been translated into action at a comparable pace of disease incidence and prevalence. Additionally, since the T2DM is largely a lifestyle disease that is influenced by external factors, exposure and social constructs, the solution to T2DM needs to be socially constructed, and currently, there is no innovation that speaks to the deep rooted causes of T2DM – this is the reason why we designed an evidence based innovation that is socially constructed to address diabetes with prevention in mind too‘’she explained of the model

The Assistant Commissioner Non Communicable Diseases (NCDs) at Ministry  of Health, Dr. Gerald  Mutungi  who participated in the study’s innovation co-design  had this to say;

“This study is unique, I have learnt many things which I had never looked at from a perspective of social norms and I am glad that we are already designing an innovation together with the community stakeholders and influencers to mitigate and reduce T2DM”.

He also tasked researchers   to give answers on  why people doing their daily activities and living a normal lifestyle still get diabetes.

Approaches behind the model

As part of the behavioral change strategy, the research team came up with the following approaches to their community-led behavior change model.

  1. T2DM organized diffusion messaging and practices

This approach of the model will work through community-level social networks and will be used to conduct myths bursting sessions, building new positive social norms and spreading them using social networks related to the norm. This approach will be complemented by deliberation and reflection methodologies and the intent is to create shared commitments to change negative and/or maladaptive risky behaviors around T2DM.

  1. Community-leader-initiated behavior modeling for T2DM

Because of power, control and therefore influence, this approach will target political leaders, religious leaders, cultural leaders, informal community leaders and all individuals with influence to model, demonstrate and promote the recommended behaviors and practices. This will be the first level of establishing reference groups and this approach will complement other approaches.

  1. T2DM Non-conforming trendsetters and positive deviants.

In the co-design process, evidence shows the existence of trendsetters and positive deviants who are willing and able to be the first movers in initiating positive normative change around T2DM risky behaviors. Their nonconformity to the social norms around T2DM will contribute to the erosion of strong perceptions in favor of the negative gendered social norms that facilitate entrenchment of T2DM risky behaviors. This approach will be complemented by creation of new risky-behavior-specific reference groups that are able to enact alternative social sanctions against T2DM risky behaviors.

On timing of this model, Mr. Ramadhan Kirunda who was key in innovating the model  noted that evidence from the social-norms study revealed a disconnect between the health system and the social system constructs at community and family level, yet T2DM risky behaviors are gendered and influenced by power, control and sanction around submission.

‘’Social norms are responsible for the harmful constructions of dominant masculinity engineered by power and control over women, hence the social-cultural acceptance of inferiority on the part of women. Therefore, even on matters of diet, women have to submit and follow what men prefer, and can become violent in asserting their dominance if women don’t comply. It is important to note that while gender-injustice related consequences affect mostly women, gendered social norms undermine the health and wellbeing of all people, regardless of age, sex, gender, or income setting. Therefore, our proposed model is informed by this reality, it is inclusive by design since it was co-designed together with all community stakeholders/duty bearers and targets risky behaviors that accelerate T2DM, but also other health outcomes.

KEY FINDINGS FROM THE SOCIAL NORMS STUDY

The main behavioral factors influencing type 2 diabetes were a) consuming processed and added sugar products, b) consuming high cholesterol fatty foods, c) excessive alcoholism, d) smoking (traditional and contemporary), e) mental/psychosocial stress and f) lack of exercise. The analysis shows that dietary factors contribute the greatest threat to the fight against type 2 diabetes in Busia and Bugiri according to the researchers.

In terms of social norm strength around dietary factors, the two strongest norms were “people who don’t prepare fried food are poor people”, “taking tea without adding sugar is mistreatment to your husband” and “Bwita/kalo is our staple food, we eat it daily”. Some of the less strong norms included; “eating greens is mistreatment to your man/husband”, “fat people especially men are respected in the community”, and “A true Samia meal must contain meat or fish daily” said one of the study participants

The strongest social norms around alcoholism.The strongest social norms around alcoholism were “alcohol takes away negative thoughts and stress”, “when you take alcohol with your friends, they can’t abandon you”, “Waragi reduces diabetes because it is sour”, “religion does not allow us to take alcohol” explained one of the key informants.

The social norms around smoking included; “if you want to feel good, you have to smoke”, “most old people and our grandparents lived long and were smokers” and “traditional religion demands and allows smoking of pipes, it’s part of our culture”. Affirmed another study participant

The main social norm around physical exercise was that “men are expected to rest/lie down and wait to be served by women”. They have to sit and wait for food’’ added a participant

On drivers that support norm entrenchment, the researchers outlined easy access to alcohol, gender based violence, cultural set up, poverty, wrong peers, poor parenting, one sided food systems as areas that need serious attention.

MORE ABOUT THE STUDY

The study used Social Norms Exploration Tools (SNET). It was conducted in Eastern region in the districts of Bugiri and Busia in December, 2020. This study covered a total of 4 health facility catchment areas: Bugiri Hospital, Nakoma H/C IV, Masafu Hospital and Lumino H/C III.

A number of data collection methods were used including Focus Group Discussions. Key Informant Interviews, In-depth Interviews, Observation and Photography.

This study builds on previous studies funded by Swedish Embassy and conducted in Iganga and Mayuge by the School of Public Health’s Prof. Guwatudde David, Dr. Barbara Kirunda, Dr. Elizabeth Ekirapa, Dr. Roy Mayega and Prof. Buyinza Mukadasi (Research and Graduate Training, Makerere University)

The research team consisted  of the following researchers:  Dr. Juliet Kiguli (Principal Investigator), Dr. Roy William MayegaDr. Francis Xavier Kasujja,  Mr. Ramadhan Kirunda, Ms. Gloria Naggayi, Ms. Joyce Nabaliisa, Ms. Rita Kituyi, Sr. Nabwire Mary, and Sr. Nampewo Evarine Wabwire. The social norms study was made possible with funding by Mak-RIF (led by Prof. Bazeyo William) and Government of Uganda.

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Digital Mobile Technologies to Study Tuberculosis: A Multi-Discplinary Program

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An aerial view of the Makerere University School of Public Health construction site on the Main Campus. To the Right is the Infectious Diseases Institute (IDI) and in the background are Dag Hammaskjold Hall (Green roof) and University Hall (Brown tiles).

A TRAINING PROGRAM SPONSORED BY FOGARTY INTERNATIONAL CENTER NATIONAL INSTITUTES OF HEALTH, USA

INFORMATIONAL SESSION

Makerere University School of Public Health under D43 multi-disciplinary training program in digital mobile technologies to study tuberculosis that was recently funded by the NIH, through the University of Georgia (UGA) has an opportunity for funding of a masters’ research thesis. This is available to two (02) first year students of the Graduate programmes offered at Makerere University who have progressed to concept proposal development stage of their graduate program. These should be in good academic standing and have or are about to complete year 1 in Academic Year 2023/24. The support will start at the beginning of Academic Year 2024/25, i.e., end of August 2024 when the students are starting their year 2.  Students of geography and or digital health related courses are encouraged to apply, females too.  Students will be provided with secondary data to address the following, or similar, issues relating to tuberculosis (TB):

  1. Characterizing mobility patterns between urban and rural areas of Uganda using archived cell-phone (CDR) metadata
  2. Correlation between self-reported geolocated mobility patterns of TB patients and CDR data
  3. Differences in mobility patterns of TB patient’s pre-diagnosis and post-diagnosis
  4. Gender differences and relationship between IGRA and TST in a prospective cohort
  5. Patterns of change in serial IGRA test results by sex, age, HIV status
  6. Temporal changes in contact, mobility and geographic networks in TB converters and non-converters
  7. Ecological Momentary Assessment (EMA) of social contacts and location patterns of movement by residents at risk for TB infection

Interested students are encouraged to attend an information session on Wednesday 17th July 2024 at MakSPH Annex Kololo where details about the research questions and funding opportunity will be provided to prospective applicants. Prospective applicants will be required to work with their mentors and training grant personnel to develop a 2-5-page concept that will be vetted for possible funding by training faculty of the training program.

Interested students should register their attendance with the training Coordinator, Mr Ivan Mutyaba by sending an email expressing interest in attending the session to imutyaba@musph.ac.ug by close of business on Thursday, 11th July 2024.

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METS Newsletter June 2024

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Makerere University School of Public Health (MakSPH) Dean, Prof Rhoda Wanyenze (Left), MoH Director General, Dr. Henry Mwebesa (Right) and other stakeholders join Dr. Amy Boore (2nd Right) to cut cake at her farewell event. Golden Tulip Hotel, Kampala Uganda, East Africa.

The Monitoring and Evaluation Technical Support (METS) Program is a 5-year CDC-supported collaboration of Makerere University School of Public Health (MakSPH), the University of California San Francisco (UCSF) and Health Information Systems Program (HISP Uganda).

Highlights of the METS June 2024 Newsletter

  • Tracking Trends in HIV Outcomes: The Implementation of HIV Case-Based Surveillance
    • METS in partnership with the Ministry of Health (MoH) and various implementing partners, is spearheading the HIV Case-Based Surveillance (CBS) initiative across Uganda. By February 2024, CBS had been activated in 504 health facilities, with 349 sites (69%) actively transmitting data.
    • Trends of New HIV Diagnosis: An analysis trends over a 20-year period (2000-2022) revealed an increase in new HIV diagnosis over time, peaking in 2014 and 2018, before starting to decline. Diagnoses among females consistently exceeded those among males each year.
    • Case-Based Surveillance (CBS) complimenting other HIV surveillance programs: CBS provides valuable insights into infection patterns and highlights the need for targeted interventions, particularly among females. Next steps include continued scale up of CBS implementation to reach 80% of ART sites; improving data transmission from facility to the national repository to achieve at least 90% of the CBS activated sites; and strengthening data analytics and use of the data for program improvement.
  • Enhancing HIV Prevention Data Collection Through Bootcamps
    • METS in collaboration with HISP Uganda held a workshop in Mbarara to update the Health Management Information System (HMIS) tools for PrEP (Pre-Exposure Prophylaxis) in the HIV Prevention Tracker. The workshop focused on digitizing paper forms to efficiently collect data on key and priority populations.
  • Electronic Medical Records (EMR) upgrades in Eastern Uganda
    • The two-week activity kicked off with a week-long training session at Northeast Villa in Kumi focused on the enhancements of UgandaEMR+, including improved point-of-care (POC) functionalities and data visualization techniques.
    • The initiative successfully trained over 15 AIDS Information Centre (AIC) staff members, including M&E leads, IT personnel, data officers, and M&E managers, in the practical use of UgandaEMR+. Additionally, the two facilities, Ochero HCIII and Kapelebyong HCIV, were upgraded and their staff trained on the new system.
  • Tribute to Dr. Joshua Musinguzi (9/09/1963 – 7/06/2024)
    • Dr. Joshua Musinguzi’s efforts to minimize HIV incidence and death strategically focused on translating knowledge into policies and actions, which has helped Uganda manage the HIV epidemic.
  • Gallery
    • Bidding farewell to Dr. Amy Boore, Program Director, Division of Global Health Protection – CDC
    • Analysing the UgandaEMR Clinical Laboratory Module
    • UgandaEMR+ training for USAID SITES
    • Training for clinicians at Ruharo Mission Hospital on SARI and ILI
    • HIV Treatment Services (HTS) Implementers Meeting

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Job Opportunity at MakSBSREC: Assistant Administrative Officer

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The Davies Lecture Theatre (Right), School of Biomedical Sciences (Blue) and other buildings at the College of Health Sciences (CHS), Mulago Campus, Makerere University, Kampala Uganda, East Africa.

Makerere University is pleased to announce a vacancy for the position of Assistant Administrative Officer (REC Administrator) within the School of Biomedical Sciences Research Ethics Committee (MakSBSREC). This is an excellent opportunity for qualified individuals to contribute to the ethical oversight of research involving human participants.

Position Details:

  • Job Title: Assistant Administrative Officer (REC Administrator) – MakSBSREC
  • Reports to: Chairperson MakSBSREC
  • Engagement: Full-time
  • Duration: 1 Year, renewable upon satisfactory performance
  • Duty Station: Kampala

Qualifications, Desired Skills, and Experience:

  • Bachelor’s degree in Social Sciences and Humanities, Medicine and Surgery, Ethics and Human Rights, or any related field.
  • Master’s degree in Bioethics (an added advantage).
  • Up-to-date training in Human Subject Protection or Good Clinical Practice.
  • Proficiency in English (both spoken and written).
  • Prior experience in regulatory work in research studies or projects.
  • Excellent communication, organizational, and interpersonal skills.
  • Ability to work independently with minimal supervision and meet deadlines.

How to Apply:

Qualified and interested candidates are invited to submit a soft copy of their application documents and a motivation letter to deansbs.chs@mak.ac.ug with the subject line “Application for the position of Assistant Administrative Officer (REC Administrator)”. Address your application to the Dean, School of Biomedical Sciences.

Deadline for submission: July 2, 2024, by 5:00 pm Ugandan time.

Please provide a reliable 24-hour phone contact. Only short-listed candidates will be contacted for interviews.

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