Health
An Indigenous Community-Led Model to Address Type 2 Diabetes: Through Evidence Informed Cross-Cultural Learning and Adaptation in Uganda
By Joseph Odoi
Globally, an estimated 462 million individuals are affected by type 2 diabetes, corresponding to 6.28% of the world’s population. 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 in various regions
Despite the increasing burden of Type 2 diabetes in the country, there is hardly any Community-led Behavioral Science oriented change model to address the risky factors that increase chances of developing Non-Communicable Diseases including Type 2 diabetes among Rural Population in Uganda.
To counter this implementation science – practice gap, researchers from Makerere University led by Dr Juliet Kiguli have embarked on a journey to develop and pilot-test a community-led Behavioral Change Model in Teso, Lango, Busoga and among the Samia cultural groups in Uganda. This Development follows a study by Makerere University researchers with funding from Government of Uganda and Makerere University Research and Innovations Fund (Mak-RIF) who sought to understand the patterns of socio-cultural norms in two high incidence districts namely, Busia and Bugiri, in Eastern Uganda.
While facilitating at the cross-cultural learning event in late July 2023, Ramadhan Kirunda one of the Co-Principal Investigators noted that addressing Type 2 Diabetes requires a cross-cultural approach where communities take lead in identifying drivers of T2D and also share what works in context to their areas.
Ramadhan noted that the team is developing a behavioral change approach for type 2 diabetes risky factors because this condition is a behavioral and lifestyle disease. We are planning to engage religious leaders, cultural leaders, local leaders (LC1s), health workers, para-social workers, VHTs, husbands, wives, and in-laws in co-designing and co-implementing this change behavioral change approach. This intervention is designed to look at the community and the affected people as implementers as opposed to looking at them as beneficiaries of the intervention – hence the potential for sustainable change is high. In addition, it targets some duty bearers and thus social accountability for healthy behaviours can be enhanced. This study started as an “exploratory to co-design to pilot testing to implementation” study, making it one of the few that directly link research and practice.
At this event, Dr. Gerald Mutungi, Assistant Commissioner of Non-Communicable Diseases (NCDs) at the Ministry of Health, emphasized the seriousness of Type 2 Diabetes and its significant consequences. He highlighted the urgent need to address this issue effectively.
Dr. Mutungi further noted that ‘’While there are established interventions recommended by the World Health Organization (WHO) and other advising agencies, it is encouraging to see efforts being made to find local solutions for Type 2 Diabetes’’. He added that this study is of great importance as it will provide us with valuable insights into the factors contributing to the increase of Type 2 Diabetes in our local communities. Furthermore, it will enable us to understand the perspectives of local stakeholders and leaders, informing us about effective strategies specific to our context, rather than simply adopting approaches from countries like Switzerland or the USA.
Regarding the factors contributing to the rise of Type 2 Diabetes, Dr. Mutungi said, “Ugandans are continuously eating poorly. They say they are eating well but eating badly by consuming processed foods, fried foods, and fast foods.” He also highlighted the issue of physical inactivity, stating, “Ugandans are becoming physically inactive because they are using motorized transport even where they could have walked. They spend a lot of time in offices and go to sleep.”
On the significance of the study, Dr. Gerald noted, report from the study will inform programming and action around Type 2 Diabetes in Uganda.
Andrew Ochole, the Deputy Prime Minister of the TESO Cultural Union, expressed his sincere appreciation to Makerere University and the Fidelitas Scientific Execution Facility for their pioneering efforts in conducting the first-ever Type 2 Diabetes Study in the Teso Region.
’Despite Type TWO Diabetes being a killer, No Type TWO Diabetes Research has never been done in TESO and no one has been coming up to find local ways of lowering even when we have peculiar and shared norms that facilitate Type 2 Diabetes, I’m happy that Makerere University has taken up this initiative and we are ready to take it up as a community’’ explained Ochole.
He further reaffirmed TESO’s commitment to collaborate with researchers and development partners, such as Fedelitas, who are working alongside Makerere University in this study adding that Teso Cultural Union is prepared to actively disseminate the study’s innovations to educate and raise awareness among its community members in an effort to address Type 2 Diabetes.
In his remarks, the District Health Officer (DHO) of Busia District, Dr. Fredrick Ouma, emphasized the importance of recognizing that the world is a global village, with norms that cut across boundaries adding that there is an alarming prevalence of non-communicable diseases (NCDs) in Uganda which can’t be ignored.
To address these health challenges, the DHO stressed the need to develop and disseminate messages that can effectively raise awareness and educate the community about Type 2 Diabetes.
Additionally, Dr. Ouma emphasized the importance of sharing original and accurate information as reliable data is crucial for making informed decisions and designing effective interventions to address the health needs in the community.
In terms of Lifestyle, He urged participants to be role models by engaging in continuous exercise and adopting healthy lifestyles. By embodying these behaviors, health workers can inspire others in the community to follow suit and become agents of change according to him
According to Dr Juliet Kiguli – the Principal investigator, notes that this study is intended to change the implementation landscape for NCD programs. She underlined the importance of connecting research with indigenous local organizations like Fidelitas Scientific Execution Facility (Fidelitas), who can support research uptake, further resource mobilization and support scale-up of the innovations developed by researchers.
In his closing remarks at the Workshop, Mr John King Odolon, the CEO Fidelitas Scientific Execution Facility, emphasized the importance of active participation from all participants to drive change in addressing Type 2 Diabetes – noting that the participation and zeal should continue upto field level. He urged them to play their respective roles effectively, recognizing that collective efforts are needed to make a significant impact.
Looking ahead, Odolon mentioned that the valuable lessons learned from the Workshop would be disseminated across the four regions. This dissemination aims to ensure that the insights gained from the study reach a wider audience and contribute to addressing Type 2 Diabetes on a broader scale.
As part of the study, researchers actively engaged with various health stakeholders. These stakeholders shared their experiences and insights regarding the behavioral factors influencing Type 2 Diabetes. Their input and expertise added valuable perspectives to the study, enhancing its comprehensiveness and applicability.
More about the study
In the next phase, the team working with Fidelitas is going to pilot test the intervention, through piloting and spreading the type 2 diabetes desired future state messages for social norms change. This will be done through a quasi-experimental implementation research intervention in the four regions of Busoga, Teso, Lango and the Samia cultural groups. Stay tuned for the results, learning brief and a publication!
Health
Mak Researchers Partner with Safe Bangle Technologies to Roll out a Real-Time Domestic Violence Reporting Bracelet
By Joseph Odoi
A Consortium of Researchers from Makerere University School of Public Health/Resilient Africa Network (MakSPH/RAN), Medical College of Wisconsin (MCW), Somero Uganda together with Safe Bangle Technologies have rolled out a real time domestic violence reporting bracelet.
This roll out was made possible with support from the United States Agency for International Development (USAID) under the PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER) program and the National Academies of Sciences.
Dr. Juliet Kiguli, the Principal Investigator from Makerere University, along with Dr. Roy Mayega, Deputy Chief of Party at RAN, and Dr. Agnes Nyabigambo, the study coordinator, initiated the PEER program to identify entry points for testing SafeBangle Technologies (a social enterprise based at Resilient Africa Network (RAN) with a mission to create a safer and more secure environment for women and children through innovative, affordable, and creative technology solutions to curb GBV in Africa.) wearable safety bracelet in the informal settlements. This decision stemmed from findings of increased intimate partner violence (IPV) and gender-based violence (GBV) in three informal settlements in Kampala, Uganda, following a longitudinal study, geospatial mapping, and interviews. The project, titled ‘The Impact of the COVID-19 Pandemic on Gender-Based Violence among Women and Girls in Informal Settlements in Kampala,’ highlighted the urgent need for affordable and immediate reporting mechanisms for violence.”
‘’While carrying out a study after the Covid-19 Pandemic, we identified gaps when it comes to reporting and response to Gender Based Violence (GBV) among women in informal settlements. Therefore, we used incorporated the SafeBangle intervention to solve the problem of lack of affordable and immediate reporting mechanisms for violence using a bracelet that reports violence in real time’’ explained Dr. Kiguli.
Innovation details
According to Saul Kabali and Messach Luminsa, the innovators behind SafeBangle from SafeBangle Technologies, hosted at the Resilient African Network Lab. ‘’The inspiration behind SafeBangle came from a deeply personal place. ‘’We heard countless stories of women who couldn’t call for help during moments of danger. We were deeply affected by the story of Aisha, a young woman in a rural village who was attacked while walking home alone at night. With no way to call for help, she felt helpless and vulnerable. This incident made us realize the critical need for immediate reporting alert tools, accessible to women like Aisha. We knew technology could play a crucial role and this incident awakened a strong desire in us to create a solution’’
“While developing SafeBangle, we tested with the users in both rural and urban contexts. We piloted the innovation around Kampala with support from Digital Human Righs Lab and Naguru Youth Health Network as well as it in five districts of Karamoja region with support from Save the Children and Response Innovation Lab. Right now it has become handy in Kamapala‘s informal settlements. We envision a future where SafeBangle becomes a standard tool in the fight against GBV, ensuring every woman feels safe and secure as it has the potential to transform how we respond to GBV in Africa” added Kabali.
HOW THE SAFEBANGLE TECHNOLOGY WORKS
The SafeBangle is wearable technology similar to a smartwatch that sends an alarm by SMS to people chosen by a woman herself if she feels threatened.
In terms of the acceptability of the SafeBangle innovation as a solution to GBV among at-risk women in informal settlements Of the 72 adolescent girls and women who received the SafeBangle, 22 activated the reporting button, resulting in 19 receiving immediate and appropriate support, including counseling, police intervention, and health services.
All adolescent girls and women who experienced GBV received a phone call from Somero Uganda to discuss the most appropriate intervention, including counseling, police cases being handled by the probation office, referral for health services, and post-exposure prophylaxis. All the GBV survivors received support and are still receiving continuous follow-up.
Researchers conducted a survey among 644 girls and women in Kinawataka (Nakawa Division) and Bwaise (Kawempe Division) to gain insights into awareness and understanding of sexual and gender-based violence among adolescent girls and women in informal settlements. The survey measured socioeconomic factors, mental health symptoms, and exposure to GBV. Focus group interviews were conducted with a separate sample of women over 18 in the settlements to explore responses to GBV.
A tabular representation of the key findings and lessons learned from your study on gender-based violence (GBV)
| Key Findings | Lessons learned |
| Prevalence of GBV. – Overall prevalence: 34.1% of women and girls reported experiencing GBV. – Among adolescents (15-19 years): Over 50% reported experiencing GBV. | – The pandemic highlighted the need for accessible and comprehensive support services for GBV survivors. – Schools emerged as crucial safe spaces for girls, emphasizing their well-being during crises. – Economic independence proved crucial, enabling women to leave abusive environments. – Involving men and boys as allies in GBV prevention efforts is essential. |
| Age-related trends | – GBV prevalence tends to decrease with increasing age. |
| Physical and health consequences. | – Women and girls suffered physical violence, injuries, and deaths, primarily from domestic violence and unsafe abortions due to limited healthcare access. – GBV resulted in unintended pregnancies, unsafe abortions, and increased risk of sexually transmitted diseases (STIs) like HIV/AIDS. |
| Social and economic impact. . | – GBV contributed to family breakups, strained marriages due to financial stress. – Economic hardships forced some women and girls into transactional sex, exposing them to further health risks and exploitation. – Pandemic-related job losses and economic constraints increased financial dependence on abusers, trapping women in violent situations. – School closures and increased household responsibilities limited women’s job opportunities and subjected them to sexual harassment. |
| Psychological effects | – Survivors experienced guilt, shame, anxiety, fear, and suicidal thoughts due to ongoing abuse. |
| Long-term effects | – Post-COVID-19, survivors faced disrupted education, early marriages, pregnancies, social stigma, and persistent mental health issues. |
Reproductive Health Consequences: GBV resulted in unintended pregnancies, unsafe abortions, and increased risk of sexually transmitted diseases (STIs) like HIV/AIDS.
Family Breakdown: The rise in GBV led to family breakups as women fled abusive relationships. Marriages were strained due to increased financial stress.
Transactional Sex for Survival: Desperate for basic needs due to job losses and economic hardship, some women and girls resorted to transactional sex, exposing them to further health risks and exploitation.
One study participant stated, “The time of COVID-19 was so terrible for some of us. We in fact got a lot of diseases from it because you would want to get food and didn’t have money. That way you would be forced to get a man who would use you and pay.” – (FGD_Girls_19–24years_Kinawataka).
Economic Effects: COVID-19 restrictions caused job losses and limited economic opportunities, particularly for women in the informal sector. This increased financial dependence on abusers and trapped women in violent situations.
Limited Access to Employment: School closures and increased household chores limited women’s ability to seek employment, perpetuating gender inequality in the workforce. Some faced sexual harassment from potential employers.
Psychological Effects: Survivors of GBV experienced guilt, shame, anxiety, fear, and even suicidal thoughts due to the constant threat and unpredictability of abuse.
Post-COVID Effects: GBV survivors faced long-term consequences, including disrupted education, early marriage, early pregnancy, social stigma, and persistent mental health issues.
Lessons learned
The pandemic highlighted the need for accessible and comprehensive support services for survivors of GBV, the significance of schools as safe spaces for girls, and the need to prioritize their well-being during crises. Economic empowerment emerged as a significant protective factor for women and girls. Those with greater economic independence were better equipped to leave abusive environments and secure their safety and well-being, while dependent ones suffered abuses. Engaging men and boys as allies in the fight against GBV and involving them in prevention efforts can help promote positive behavior change and foster more equitable relationships.
Recommendations
To address GBV against women and girls, the researchers recommend the following moving forward;
- There is need to integrate technology-driven solutions like SafeBangle into national GBV prevention and response strategies. SafeBangle can be a valuable tool for policymakers as cases of violence that would have gone unreported will be brought to light and the would-be victims will be able to get immediate help from trusted relatives and friends.
- Provide economic opportunities and vocational training for women and girls to enhance their financial independence and reduce vulnerability to violence. There is therefore a need to introduce education and training programs that empower women and girls, by providing them with skills, resources, and opportunities to start their own ventures and to participate fully in community affairs.
- Strengthen and enforce existing laws and policies related to GBV, including laws against domestic violence, child marriage, and sexual assault without discrimination be it for law enforcers, leaders, and employers where such cases were suffocated. Ensure that perpetrators are held accountable through swift and fair legal processes that have no room for corruption.
- Establish and promote effective, accessible, and confidential reporting mechanisms for GBV incidents that provide confidence and can be trusted by survivors to enhance reporting of such incidences of GBV. Community Engagement and Involvement: Involve community leaders, religious leaders, and elders in discussions about GBV to promote gender equality, change social norms, and reinforce the message that violence against women and girls is unacceptable.
- Launch extensive public awareness campaigns to challenge harmful gender norms, report cases of GBV, raise awareness about the consequences of GBV, and promote positive behaviors and attitudes towards women and girls.
- Implement comprehensive sexuality education in schools and communities, educating young people about healthy relationships, consent, and reproductive rights to be able to make informed decisions about their own lives and well-being.
- Engage men and boys as allies in the fight against GBV, encouraging them to challenge harmful masculinity norms and behaviors. This will help minimize GBV because mostly they are the perpetrators. Strengthening Support for Survivors: Provide ongoing support and follow-up services for survivors of GBV mostly counselling services to aid their recovery and facilitate their reintegration into society.
- Provide ongoing support and follow-up services for survivors of GBV, mostly counseling services to aid their recovery and facilitate their reintegration into society.
- Provide avenues to seek free or subsidized services by survivors of GBV medical services and legal processes by survivors of GBV to enhance reporting of GBV cases, access to medical care, counseling, legal support, and other essential services.
- Encourage and support more research and innovations like SafeBangle to curb incidents of GBV.
- A comprehensive and inclusive approach is required. The efforts should involve government institutions, civil society organizations, community leaders, and individuals working together to address the root causes and provide support to survivors.
- Involve media in GBV prevention activities and for enhancing campaigns against GBV mostly on radio and TV.
MORE ABOUT THE STUDY
The core project team, included researchers at Makerere University School of Public Health (MakSPH), Medical College of Wisconsin (MCW) led by Prof. Julia Dickson-Gomez, SafeBangle Technologies, and Somero Uganda, a community-focused NGO, began the project by designing their research protocol and taking a CITI Program course on human subjects social/behavioral research. Team members also met with the Ministry of Gender, Labour, and Social Development (MGLSG) in support of the gender-based violence policy process, Ministry of Health and local government. They also established relationships with the Kampala Capital City Authority (KCCA) and Nakawa and Kawempe probation offices to support legal processes for the GBV survivors. SafeBangle Team also received an award from Defenders Protection Initiative.
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