Health
Dr. Achola’s PhD Study Uncovers Family Planning Barriers in Adjumani refugee hosting district
At precisely 10:53 AM, on 14th January 2025, the air in Freedom Square buzzed with anticipation as Dr. Crispus Kiyonga, Chancellor of Makerere University, delivered the life-changing words: “By virtue of the authority entrusted to me, I confer upon you a degree of Doctor of Philosophy of Makerere University.” In that moment, Miss Achola became Dr. Achola, a title that resonated deeply with her sister and father, Ms. Evelyn Nyafwono and Mr. Owino Vincent Olele, who stood nearby joyfully with open arms to receive her.
As Achola bagged her doctoral award, she walked majestically toward her excited lecturers and mentors, who eagerly queued to congratulate her. Her sister, Evelyne Nyafwono, and father, Mzee Owino, could hardly contain their excitement. The rhythmic beats of the cultural ensemble filled the air with celebration, while the vibrant melodies of ethnic music and dance, expertly crafted by Dr. Milton Wabyona and his talented team, wove around her. Each step she took was a heartfelt tribute to her journey, a celebration of hard work and achievement that enveloped her in warmth and joy.
Yet, as Dr. Achola reveled in her triumph, a bittersweet shadow hung over her heart. Her beloved mother, Veronica Abbo Owino (RIP), who had always been her greatest supporter, was not there to share in the joy, having passed away midway through her PhD journey.
In the beginning…
Back in time, 2015 was the year. Ms. Roselline Achola, while working with the United Nations Populations Fund as a Technical Specialist for Maternal Health and Reproductive Health Commodity Security/family planning, was charged with the responsibility of ensuring that there is increased access to voluntary information and services to both men and women who need family planning in Uganda and beyond. She was in charge of the Global Program for RHCS.
At the time, as a team leader, she was supervising an assignment that the UN had contracted an expert – Dr. Christopher Garimoi Orach, a Professor of Community Health, to undertake in developing the first family planning costed Implementation Plan for Uganda.
Achola found her motivation for pursuing a PhD, particularly in family planning, due to its cost-effectiveness in improving maternal and child health in resource-limited countries like Uganda.
“We began with the ambitious idea of evaluating the entire family planning program in Uganda, but that proved impossible at the time. I then went silent for two years, not mentioning anything. One day, Prof [Garimoi Orach] called to ask why I was quiet. I explained that I was overwhelmed with UN work and may not manage to juggle with academics. He fell silent too but continued to check on me and offered encouragement,” Achola recalls.
“Why family planning? It was my mandate to ensure the effective implementation of the family planning program in Uganda by supporting the Ministry of Health and implementing partners. I always felt a deep sadness reading about women dying in childbirth while having their 12th or 13th child, knowing that contraception could help them regulate their births and reduce the risk of dying from pregnancy-related complications associated with too many pregnancies,” recalls Achola.
In 2019, she officially enrolled in the PhD program at Makerere University hosted by the Department of Community Health and Behavioural Sciences at the School of Public Health (MakSPH). This was after submitting a concept that was quickly approved, granting her provisional admission. “It wasn’t an easy path though; I remember going nearly a year without progress until my lead supervisor encouraged me to continue working on my proposal. I had almost lost hope due to the demands of my job at the United Nations and had set aside my academic aspirations. This burden weighed heavily on me until I resumed my efforts, ultimately leading to the acceptance of my proposal.”
Inspired by the challenging conditions in Adjumani district in the West Nile region with several refugee settlements—where low family planning uptake and domestic violence related to its use were prevalent—Achola chose to study decision-making around the issue especially in Nyumanzi, Pagirinya and Mirieyi settlements including the surrounding host communities. Her goal was to develop recommendations to address the barriers faced by women and girls in these refugee-affected areas.
Uganda is a leading Africa’s largest refugee-hosting country with more than 1.6 million refugees residing in various settlements established in 12 districts within its borders, as per the latest National Population and Housing Census data from 2024. Adjumani is home to over 250,000 refugees, with more than half of them being female. Here, 1,310 respondents comprising both men and women were involved in the quantitative study.
The major highlight of her research was the low uptake of family planning methods in Adjumani, where only about one-third of the population utilizes modern contraceptives. She explored decision-making processes at individual, family, community, and institutional levels, identifying key factors influencing family planning use.
Her findings show that fear of harassment from family members and concerns about side effects deter many from using contraceptives, while motivations include limiting family size and financial constraints. To enhance family planning uptake, Dr. Achola recommends community outreach strategies to raise awareness about its benefits and promote couple counseling.
“I want to take this opportunity to once again thank SET SRHR for the scholarship that saw progress this far, the Tuition and initial research was supported by SET SRHR. The Mak-RIF support was equally timely because it supported the intervention and evaluation components of my PhD study. Both funds played a big role in enabling me to complete this study and have the achievement today,” says Achola.
While decision-making is a key part of everyday life, Dr. Achola found that it involves complex processes with four dynamic pathways: starting ideas, thinking them through, consulting others, and finally making a decision. Gender dynamics too play a definitive role in contraceptive use, as women often have less power and men typically dominate health decisions.
“I am so excited that my work has resulted in the development of a model for decision-making pathways. These include the idea inception, cognitive process, consultation, and making a decision I sincerely hope that this contribution will enhance the improvement of maternal and child health in humanitarian settings across Uganda and Sub-Saharan Africa, ultimately reducing pregnancy-related deaths associated with the non-use of family planning among both refugee and host populations,” says Achola.
At first, the language barrier stood in her way during her investigation with interpreters often sharing only what refugees wanted to hear instead of her intended messages. “Cultural norms favoring large families made it hard to communicate contraception information. Limited funding also slowed our progress in Adjumani. Although delays in getting my papers published affected my PhD requirements, I’m relieved that it’s finally complete and here we are,” she says.
How her PhD will impact family planning programs in Uganda
Dr. Achola’s research uncovered several key factors influencing contraception use, highlighting a pressing need for targeted solutions. To make a meaningful impact on family planning programs in Uganda, she advocates for community-based strategies that connect people with essential information and services to help them make informed decisions. She views community dialogues and outreach events as vital tools to spark conversations about the benefits of family planning and encourage couples to seek counseling together. “This approach will be instrumental in creating a supportive environment where families can make informed decisions about their health and future.”
With her background as a public health specialist and technical advisor to the Ministry of Health on family planning, she is eager to integrate the four decision-making pathways into all family planning efforts. She recognizes how influential significant others can be in shaping contraceptive choices, whether through encouragement or hesitation. By involving them in the planning process, she aims to develop more effective strategies and hopes her recommendations will be included in the Ministry of Health’s plans, thereby strengthening support for family planning initiatives at every level.
Achola firmly believes that family planning is a cost-effective way for the government of Uganda to reduce maternal and child mortality rates. And that by choosing to space births, mothers bond with their babies and allow themselves time to heal before the next pregnancy, thus allowing their bodies to heal and rejuvenate for the next pregnancy.
“When mothers space their childbirth for at least two years, their health improves, which reduces the risks of pregnancy-related challenges. Babies born with at least a two-year gap have a higher chance of survival than those born less than two years apart,” she stresses.
The next steps…
Achola resonates with the sentiment that “Research never ends.” She recognizes there’s still much to explore in her field and believes her work paves the way for others to examine how culture influences family planning perceptions and practices. This broader perspective can lead to more comprehensive results, with an emphasis on the role of family in decision-making. Achola also imagines future research that will dig deeper into these processes through longitudinal studies with key stakeholders. She also sees the importance of exploring decision-making pathways before applying her findings to larger populations, especially since her study focused on a refugee community in Adjumani, which may differ from other groups in Uganda. For her, the possibilities for further exploration are enormous and stresses that the journey of research is a shared and ongoing adventure. She is, therefore, set to continue with research in this area as a post-doctoral undertaking.
Upon achieving her PhD, Achola feels a renewed sense of determination and purpose in her field. “I will not look back,” she declares with conviction. “I will continue my work in sexual and reproductive health and rights (SRHR) and family planning, where I have developed passion, skills and expertise, positioning me as a leader in this area.”
She is committed to advising government bodies and engaging with the international community and development partners to advance this important field. Additionally, Achola plans to continue teaching in Public Health, nurturing the next generation of specialists and mentoring aspiring doctoral candidates. With her steadfast commitment, she is ready to make a lasting impact, inspiring others to embark on this important journey alongside her.
Health
Mak Staff Receive Prestigious International “Future of the Field” Recognition in Global Research Administration Class of 2026.
Prof. David Guwatudde, Principal Investigator (centre), and Dr. Justine Bukenya with researchers and stakeholders at the ARISE-NUTRINT dissemination meeting in Iganga, 1 October 2026.
Adolescence is a consequential period for health, when diets, behaviours and other risks can form and persist into adulthood. In Mayuge District, new evidence from Makerere University School of Public Health is showing how some of these early vulnerabilities could contribute to the later risk of non-communicable diseases (NCDs), and what can change when interventions begin early.
The evidence comes from the ARISE-NUTRINT project, a three-year EU-funded study led by Prof. David Guwatudde and Dr. Justine Bukenya. The project examines health and behavioural risks among adolescents and young adults, with a particular focus on nutrition-related NCD risks, and tests interventions designed to improve nutrition fluency and diet quality.
The work comes against a substantial NCD burden in a country where 73.2% of the population is below 30. WHO estimates that NCDs accounted for 42.2% of deaths in Uganda in 2023, while the country’s latest national NCD risk-factor survey found significant risk factors persisting in the population, with little overall change from the previous survey in 2014. Together, the evidence strengthens the case for prevention much earlier in life.
“There is strong evidence from literature demonstrating that most behavioral NCD risk factors, including nutrition-related, are established during childhood, persisting into adulthood. This may lead to development of actual NCDs if such risks are not reversed early,” Prof. Guwatudde said.
The study, he explained, linked assessment of young people’s health risks with developing responses suited to their circumstances. Since enrolling 1,206 participants aged 10–24 in Mayuge District in March 2024, the team has conducted three annual rounds of data collection, with young people and local stakeholders also helping evaluate interventions to reduce the risks identified.
A problem that starts early
The findings, shared with community and district stakeholders in Iganga on October 1, 2026, show that some vulnerabilities were already evident at baseline. Nearly one in three participants had anaemia, 49% had low nutrition literacy, while about one in ten reported symptoms of anxiety and a similar proportion reported depressive symptoms.
Anaemia, a condition in which the blood does not have enough healthy red blood cells or haemoglobin to carry adequate oxygen around the body, was highest among the youngest participants. Overall, 375, or 31%, had anaemia, rising to 35.7 per cent among 10–14-year-olds, compared with 18.9% among those aged 15–19 and 10.6 per cent among young adults aged 20–24.
Nutrition presented another challenge. At baseline, 49% of participants had low nutrition literacy and 13% had poor overall diet quality. Low nutrition literacy was associated with more than four times the odds of poor diet quality.
Gaps also emerged in sexual and reproductive health knowledge and behaviour. About 14 per cent of participants did not know that HIV cannot be transmitted by sharing food with a person living with HIV, 10% believed a condom could be used more than once, and 13 per cent did not know pregnancy could occur during first sexual intercourse. Among 168 participants who reported having had sex, more than half reported using no method to prevent pregnancy during their first or most recent sexual intercourse.
Mental health findings added another dimension. Anxiety symptoms were reported by 10 per cent of participants, depressive symptoms by 9.5% and loneliness by 6.3 per cent. Among 534 participants aged 13–24 assessed for suicidal ideation, 1.9% reported suicidal thoughts.
Together, the baseline findings show that vulnerabilities extended beyond any single health issue. For nutrition, the study went further to examine what shaped everyday food choices and whether those influences could be changed.
Nutrition literacy goes beyond knowing which foods are healthy. It includes understanding nutrition information and applying it to everyday choices. The study found those choices were also shaped by parents, peers, food vendors, culture, prices, seasons, and what was available locally. Improving diets, therefore, required reaching beyond individual knowledge to the households and communities where food choices are made.
What early action changed
The baseline evidence informed the Adolescent Nutrition Fluency Intervention. Working with adolescents and young adults, caregivers, Community Health Workers (CHWs), district teams and other stakeholders, the project adapted nutrition messages to local foods, language and household realities. Ten trained CHWs delivered nine monthly household sessions covering balanced diets, physical activity, vitamins and minerals, meal planning and anaemia prevention.
The household approach reached young people in and out of school. The nutrition literacy, diet-quality and intervention analyses form part of the PhD research of Mr. Thomas Buyinza, supported through ARISE-NUTRINT. At endline, participants who received the sessions recorded higher nutrition literacy and overall diet-quality scores.
“The improvement in nutrition literacy and diet quality suggests that practical education, grounded in local foods and household realities, can support healthier choices among adolescents and young adults. In addition, involving parents and caregivers is important because they influence what families buy, prepare, and eat,” Dr. Bukenya said.
She stressed that nutrition education needed to be complemented by better access to affordable, nutritious foods. Dr. Bukenya also called for continued follow-up, including the use of nutrition and dietary data from DHIS2, to assess whether improvements were maintained and guide district planning.
Changes in other outcomes were mixed. Participants reporting no physical activity fell from 22.6% to 7.4%, while those active on four to seven days a week increased from 46% to 54.8%. But activity duration did not improve: those reporting more than 60 minutes a day declined from 28.2% to 21.1%. Underweight fell modestly from 6.2% to 5%, while overweight and obesity did not change significantly.
Anaemia recorded the largest change, falling from 31.1% before the intervention to 9.9% afterwards. During the intervention period, participants received weekly iron and folic acid supplementation and deworming alongside nutrition education on iron-rich foods, dietary diversity and practices that improve iron absorption.
Mayuge District’s Assistant District Health Officer, Ms. Elizabeth Kawaala, said the findings reflected problems recognised locally and highlighted the need for a response involving families and other stakeholders.
“There is a serious challenge that needs to be tackled with many stakeholders, with parents at the centre because these are children. We also learnt that many parents, I think, lack the skills to communicate with their adolescents,” she said.
She said the findings had been shared with colleagues and described integrating health education and sensitisation into services. She also called for departments to use the evidence when planning activities in their workplans.
Beyond Mayuge
Seen alongside Uganda’s 2023 STEPS survey, the Mayuge findings add an earlier-life dimension to the national evidence. Makerere University School of Public Health contributed to both studies, with Prof. Guwatudde contributing to the national STEPS survey and now leading ARISE-NUTRINT. While STEPS found significant NCD risk factors persisting among adults, ARISE-NUTRINT shows that some behaviours and vulnerabilities relevant to later NCD risk are already evident during adolescence and young adulthood. The Mayuge research goes further by testing what can change when interventions begin during this period.
The findings leave Mayuge with more than a measure of the problem. They show where vulnerabilities are emerging, what changed when interventions were introduced and where challenges remain. For ARISE-NUTRINT, the evidence now turns attention to which approaches can be sustained and how lessons from Mayuge can inform efforts to support healthier transitions from adolescence into adulthood.
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