1. Phumla Retreat Centre Ryenjoki Twimukie
Development Association
Community Health Needs Assessment
Kyangyenyi Sub-County
Sheema District, Uganda
January
2015

2.
1
Acknowledgements
This report was funded by Phillip J. and Frances A. Attwood of Phumla Retreat Centre.
The author of this report is the principal investigator of the study.
Principal investigator: Lore Herzer, MPH
Co-investigator: Grace Nahwera, United Nations High Commission for Refugees
(UNHCR)
This study was commissioned for Phumla Retreat Centre, Kampala Uganda, and
Ryenjoki Twimukie Development Association, Ryenjoki Uganda.
We wish to thank the following individuals who assisted with this project: Phillip J.
Attwood, Frances A. Attwood, Grace Nahwera, Dr. Able Kamukama, and Kato Nixon.
We also extend our sincere gratitude to all village chairpersons of Kyangyenyi sub-
county and all study participants.

3.
2

4.
3
Table of Contents
Figures & Tables _____________________________________________________ 4
Acronyms ___________________________________________________________4
Executive Summary ___________________________________________________5
Background _________________________________________________________ 6
Uganda and Sheema District ______________________________________ 6
The Ugandan Healthcare System ___________________________________7
Rationale for a Baseline Assessment ________________________________ 8
Methodology _________________________________________________________9
Study Design ___________________________________________________9
Study Location and Population _____________________________________ 9
Sampling Strategy and Sample Size _________________________________9
Study Outcomes ________________________________________________10
Data Collection _________________________________________________10
Data Analysis __________________________________________________11
Results ____________________________________________________________ 12
Overview of Present Conditions ____________________________________12
Family Level Prevalence of Common Illnesses ________________________ 22
Knowledge of Healthy Behavior ____________________________________ 24
Recommendations ____________________________________________________28
Bibliography _________________________________________________________31

5.
4
Figures and Tables
Figure 1: Map of Uganda
Figure 2: Ugandan Healthcare Structure
Table 1: Participant and Family Demographics
Table 2: Household Physical Condition
Table 3: Household Nutrition Status
Table 4: Household Health Status
Table 5: Village & Household Power
Table 6: Household Water & Sanitation
Table 7: Health Center Patient Experience
Table 8: Family Level Prevalence of Reported Childhood Illnesses
Table 9: Family Level Prevalence of Reported Adult Illnesses
Table 10: Healthiest Foods According to Participants
Table 11: Participant Disease Prevention Methods
Table 12: Participant Hand Washing Behavior
Acronyms
FP – Family Planning
HIV/AIDS – Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
MOH – Ministry of Health
PHPs – Private Health Practitioners
PNFPs – Private Not-For-Profits
PPH – Post-partum Hemorrhage
RTI – Respiratory Tract Infection
VIP – Ventilated Improved Pit

6.
5
Executive Summary
The health status of Uganda’s population has improved over the past several decades
according to many health indicators. Many of these improvements have been made
with the decentralization of the public healthcare system, the elimination of user fees,
and the increased utilization of the private sector. Although these developments have
brought about many improvements, there are still many rural communities experiencing
inadequate care as a result of health disparities.
This research was conducted in Kyangyenyi sub-county located in Sheema district,
Uganda. The purpose was to establish baseline health data for Kyangyenyi in order to
understand the prevalence of the population’s major health issues, assess the
population’s understanding of healthy behavior, identify health problems in need of
improvement through existing and future health programs, and to serve as baseline
data for future monitoring and evaluation efforts related to health programs in the sub-
county. A cross-sectional study design was used which utilized a family-level survey
containing both quantitative and qualitative elements. Six areas were assessed in order
to obtain a comprehensive view of family health including household demographic data,
household physical condition, family health and nutrition, access to power, water and
sanitation, and health center patient experience. A total of 269 participants were
interviewed across all six parishes in the sub-county using a multi-stage sampling
procedure.
The results of the survey were broken down by section. Participants identified access
to water, access to power, household cleanliness & organization, and access to quality
health services to be among their major concerns. Responses from the survey showed
a low community standard for home cleanliness, low village availability of food, limited
access to power, dissatisfaction with water cleanliness, and low monthly incomes
coupled with high expenditures related to food, health costs, and school fees. With
regard to knowledge of healthy behavior, the results showed a low level of knowledge
related to nutrition and disease prevention, but adequate knowledge related to hand
washing behavior. The prevalence of common childhood and adult illness were also
assessed with the most common childhood illnesses being malaria, RTI, skin infections,
and allergies and the most common adult illnesses being malaria, RTI, arthritis,
stomach pain, and allergies.
Based on the results of the survey, it is recommended that health education programs
be emphasized within the sub-county. The role of the government village health teams
in providing this service should be stressed and developed in order to provide education
in the areas of nutrition, crop production, disease prevention methods, family planning,
cleanliness and organization, and maternal & child health. In addition to health
education, existing government health centers should assess and address issues
related to timeliness, payment, and patient satisfaction, as well as private health centers
addressing community needs that are accessible by the current standard of living.
Future research should focus on the impact of current health services as well as assess
areas in need of improvement to support the overall health of the sub-county.

7.
6
Background
Over the past two decades Uganda has worked to improve its country’s health
indicators as a result of donor support and government policy changes. Although
several of Uganda’s health indicators have shown recent improvement, such as infant
mortality rate (76 deaths per 1000 live births in 2006 to 54 deaths per 1000 live births in
2010) and maternal mortality rate (435 deaths per 100,000 live births in 2006 to 328
deaths per 100,000 live births in 2010)1
, many health indicators continue to remain
stagnant or have increased. Uganda is currently experiencing wide health disparities,
with the most need among rural communities across the country1
. Factors contributing
to health disparities in Uganda include socioeconomic conditions, gender roles, climate
change, limited rural healthcare, and the availability of both government and external
resources1
. Despite government planning and decentralization efforts to meet these
challenges, rural healthcare continues to provide inadequate care across the country.
Uganda and Sheema District
Uganda is located in East Africa and is bordered by Kenya to the East, Tanzania to the
south, Rwanda to the southwest, Democratic Republic of the Congo to the west, and
South Sudan to the north. Uganda has a population of 38.85 million and an annual
GDP of $21 billion, classifying it as a low-income country2
. The country’s population
growth rate from 2002-2014 was 3.03%3
.
Uganda is divided into 112 districts. Sheema district is located in southwest Uganda
and is bordered by Buhweju district to the north, Mbarara district to the east, Ntungamo
district to the south, Mitooma district to the southwest, and Bushenyi district to the west.
Sheema district is comprised of ten sub-counties including Kyangyenyi, which was the
focus sub-county for this research. As of 2014, the population of Sheema district was
approximately 211,720 and the population of Kyangyenyi sub-county was 31,2633
.
Kyangyenyi sub-county is comprised of 6 parishes including Kitojo, Rushozi, Muzira,
Masyoro, Rwebaare, and Kangundu. The primary trading center of the sub-county is
Kakindo trading center, and the nearest town is Kabwohe. Kyangyenyi sub-county’s
largest health center is Kyangyenyi Health Center III, located in Kangundu parish.
Figure 1: Map of Uganda
4

8.
7
The Ugandan Healthcare System
The Ugandan National Health System is comprised of all public and private institutions
and systems that work to address health issues5
. The Ministry of Health (MOH) is in
charge of the public healthcare system, which has been decentralized at the district
level since 1993. The public healthcare system is categorized using a hierarchical
structure with three major levels including National Referral, Regional Referral, and
District/Rural Hospitals. District/Rural Hospitals are further categorized into health
center IV, health center III, health center II, and health center I (local village health
teams). Types of services offered at each level vary, with health center II providing
outpatient care and community outreach services, health center III providing laboratory
services for diagnosis and maternity care, health center IV adding simple surgery, blood
transfusion, and medical imaging, regional referrals adding specialist services and
higher level surgeries, and finally national referrals providing comprehensive specialist
services, health research, and teaching5
.
Figure 2: Ugandan Healthcare Structure
All public healthcare services have been provided at no cost since 2001 when the
government abolished user fees in order to provide increased access to services for the
most poor. As a result, the government finances its services using general taxes and
donor support6
. The government of Uganda also established a National Minimum
Healthcare Package to address the highest disease burdens among the population
which includes health promotion, environmental health, disease prevention and
community health initiatives; maternal and child health; prevention, management, and
National
Referral
Hospitals
Regional
Referral
Hospitals
Health
Center
IV
(Sub-­‐district
Level)
Health
Center
III
(Sub-­‐county
Level)
Health
Center
II
(Parish
Level)
Local
Village
Health
Teams
(Village
Level)

9.
8
control of communicable diseases; and prevention, management, and control of non-
communicable diseases.
The MOH oversees the private sector healthcare system, which is comprised of Private
Not-For-Profits (PNFPs), Private Health Practitioners (PHPs), and traditional healers.
PNFPs are traditionally more structured and more prominent in rural areas, while PHPs
are the fastest growing sector in the healthcare system5
. Since the private sector
covers approximately 50% of reported outputs, the government subsidizes PNFPs,
several private hospitals, and PNFP training institutions5
.
Rationale for a Baseline Assessment
Over the past two decades Kyangyenyi sub-county has seen major changes in climate,
food production, socioeconomic conditions, and availability of natural resources. As a
result, these changes have impacted the community in many ways including overall
health. For example, changes in climate have brought about longer dry seasons which
have impacted the availability of water, forcing many residents to walk long distances to
fetch water or to use dirty stagnant “ponds” and “wells” for household use. In addition,
the banana bacteria wilt disease has greatly affected crops in the area, creating food
shortages and decreasing the amount of money farmers can earn for their families.
These conditions not only increase the incidence of disease, but also families’ ability to
pay to access quality health services, whether in the private sector or transport to the
nearest government hospital. As a result of these conditions, the research team was
contracted to carry out a baseline assessment to assess the current health conditions
and the need for improved health services within Kyangyenyi sub-county.
The purpose of this research was to establish baseline health data for Kyangyenyi sub-
county in order to: 1. understand the prevalence of the population’s major health issues
2. assess the population’s understanding of healthy behavior 3. identify health problems
in need of improvement through existing and future health programs 4. serve as
baseline data for future monitoring and evaluation efforts related to health programs in
the sub-county.

10.
9
Methodology
It is commonly accepted that medical treatment and illness prevention are both equally
important in keeping a population healthy. The methods used in this analysis sought to
examine the current effectiveness of illness prevention with relation to health
knowledge, as well as disease prevalence in order to understand the current health
burden within Kyangyenyi. This section describes the methods used to obtain data on
the community’s overall health, including the prevalence of common health diagnoses,
and assessment of the population’s knowledge of healthy behavior.
Study Design
This study was conducted using a cross-sectional design in order to assess Kyangyenyi
sub-county’s current health status. Within this design a family-level survey was used
containing both quantitative and qualitative elements. As this study is intended to
gather information related to current conditions and serve as a baseline for future health
programs, a longitudinal design was not used. The family-level survey was divided into
six sections in order to obtain a comprehensive view of family health including
household demographic data, household physical condition, family health and nutrition,
access to power, water and sanitation, and health center patient experience. Within
each section a set of both quantitative and qualitative questions was asked, concluding
with a short discussion regarding the respondent’s major health concerns for the family
and community. Following the data collection phase of the study, data were assessed
to determine the prevalence of certain conditions and behaviors and common opinions
regarding the community’s health status. Based on the analysis, recommendations
were made in order to improve the community’s health in the most affected areas.
Study Location and Population
The study was carried out within Kyangyenyi sub-county, Sheema district, Uganda.
This location was selected based on a small pilot study carried out within the sub-
county, which indicated a high prevalence of disease, poor general nutrition status, and
poor general living conditions. In addition, a lack of beneficial health services was
indicated, implying that residents are not receiving optimal health care or health
education within the sub-county. The study population was comprised of all residents
within the six parishes of the sub-county. Inclusion criteria for the survey consisted of
any person age 17 or older that was a current member of the house being sampled.
Sampling Strategy and Sample Size
In order to identify study participants within Kyangyenyi sub-county, a multi-stage
sampling strategy was used. The sampling frame for stage one of the sample consisted
of all parishes and villages of the sub-county. Stratified sampling was used to divide the
sub-county into the six parishes of Kitojo, Muzira, Masyoro, Rwebaare, Kangundu, and
Rishozi. Each parish was then divided into a list of all villages within the parish. During
data collection, the sampling frame for stage two consisted of each family located within

11.
10
the present village. Data collectors began by traveling to the village chairperson of each
village. After explaining the scope of the survey and obtaining the chairperson’s
permission, the team then spun a plastic bottle to indicate a randomly chosen sampling
direction. Study participants were then randomly selected as the data collectors traveled
to every 5th
house along the sampling direction until the sampling number for that village
had been achieved. This process was repeated for every village within Kyangyenyi
sub-county in order to achieve the total sample size.
To calculate the sample size for the survey, the sample size calculator provided by
Raosoft®
was used. The sample size was calculated assuming a margin of error level
of 5% and a confidence level of 90%. Given the most recent population of Kyangyenyi
sub-county as 31,2634
, a total sample size of 269 was calculated. The total sample size
was then divided by six, resulting in a total of 44 or 45 surveys per parish. Each parish
was then divided by its respective number of villages to calculate the total sample for
each village. For parishes or villages with an uneven number, the larger sample was
allocated toward the parish or village with the larger population.
Study Outcomes
The outcomes of interest in this study were 1. an estimate of the prevalence of select
health diagnoses common within the region, and 2. an assessment of the population’s
knowledge of healthy behavior. In order to identify health diagnoses common within the
region a literature review was conducted which reviewed available surveys and results
previously used in the area as well as available health reports from local organizations.
A list of common health diagnoses was compiled and questions pertaining to each
diagnosis were formed within the survey in order to measure disease prevalence. In
order to understand the population’s knowledge of healthy behavior several open ended
questions related to diet and sanitation/hygiene were formed. The responses for these
questions were recorded qualitatively and were later categorized in order to quantify the
extent of the population’s knowledge of healthy behavior. In addition to these
quantitative assessments, each participant’s perceptions regarding health diagnoses
and healthy behavior within the family and population were obtained in order to
triangulate and provide a comprehensive view of the current health situation with
Kyangyenyi.
Data Collection
In order to obtain data to assess the study outcomes a comprehensive survey was used
which included both qualitative and quantitative elements. The data collection phase
took place from March to November 2014. Once a house was identified using the
sampling procedure, the data collectors confirmed participant eligibility, explained the
purpose, scope, and instructions of the survey, and received oral consent to participate
from the participant. The survey contained a total of 99 questions within the areas of
household demographics, household physical condition, family health and nutrition,
access to power, water and sanitation, and health center patient experience. Survey
questions were administered as an interview with one data collector asking questions

12.
11
and recording responses in English and a second data collector translating questions
and responses using the local language of Runyankole. Following the administration of
the survey, a short 5-minute open-ended discussion was held with each participant.
The purpose of this discussion was for the participant to verbalize their perceptions
regarding the overall health of the family and of the community, to clearly explain
problems faced by the family and community that have an effect on health, and to offer
any information not included in the survey that they felt related to the health status of
the family and community. Due to various limitations faced by the study team, formal
key informant interviews and focus groups were not possible. As a result, the interview
was used to obtain qualitative data in order to triangulate information obtained in the
survey.
Data Analysis
All data were entered into an Excel database during data collection, eliminating the
need for data assistants. This process not only saved time and resources, but also
allowed for minimal missing or incorrect data. Quantitative data analysis was performed
using R®
software. Given the cross-sectional design of this study, descriptive analyses
were performed using means, standard deviations, and percentages to describe the
population, calculate the prevalence of common diagnoses, and to quantify the
population’s knowledge of healthy behavior. Qualitative data obtained in the survey as
well as the interviews were coded by hand and assessed for common themes in order
to further assess the population’s knowledge of healthy behavior as well as describe
additional factors that affect family and population health.

13.
12
Results
This section describes the results from the survey and major issues discussed by
participants. The results from each section of the survey are discussed, followed by the
results related to the study outcomes.
Overview of Present Conditions
Demographics
Out of a total of 269 participants, 108 were male and 161 were female. The most
common age range of participants was from 31-50 years old and 80.3% of participants
reported that they were presently married. With regard to education level, men
accomplished a higher level than women with 4.2% more men finishing secondary
education compared to women, and 4.6% more men finishing tertiary. The majority of
both women and men had a primary education level, however 4.9% more women had
no education compared to men. At home, families produced an average of 6.06
children. The number of all people currently living in the house was an average of 6.10
with 4 children and 2 adults. The number of children currently living in the house was
largely comprised of both biological and non-biological children, and the majority of
houses had at least one child living outside the house. Income earned per month
ranged widely from zero to one million Ugandan shillings with a median income of fifty
thousand. The majority of participants shared that their total monthly income was not
enough to cover the monthly cost of food, school fees, medical fees, and other regular
costs, which frequently resulted in a need to borrow money or sell land when faced with
large essential expenditures.
Table
1:
Participant
and
Family
Demographics
Number
(n=269)
Relative
Frequency
(%)
Gender
Male
108
40.1
Female
161
59.9
Age
(years)
17-­‐30
63
23.4
31-­‐50
104
38.7
51-­‐70
79
29.4
70-­‐90
20
7.4
Unsure
3
1.1
Marital
Status
Single
10
3.7
Married
216
80.3
Widowed
38
14.1
Divorced
5
1.9
Religion

14.
13
Christian
255
94.8
Muslim
14
5.2
Husband’s
highest
level
of
education
None
32
12.4
Primary
146
55.9
Secondary
59
22.6
Tertiary
15
5.7
Unknown
9
3.4
Wife’s
highest
level
of
education
None
46
17.3
Primary
167
62.8
Secondary
49
18.4
Tertiary
3
1.1
Unknown
1
0.4
Mean(sd)
Median
Minimum
Maximum
Number
of
birth
children
6.06(3.69)
6
0
20
Number
of
people
in
house
6.10(2.89)
6
1
19
Number
of
all
children
in
house
4.29(2.65)
4
0
17
Amount
of
money
(UGX)
-­‐
50000
0
1000000
earned
per
month
Household Physical Condition
The physical condition of each household was included in the survey to assess living
conditions within the sub-county. The average number of buildings on a family’s land
was 2.3 with a range of 0 (renters) to 8. The average number of rooms per house was
4.09 with an average of 2.63 rooms used for sleeping by each family. Respondents
were asked to categorize the condition, organization, and cleanliness of their house
using a three point likert scale of poor, average, and good. Approximately 64.2% and
64.6% of houses were categorized as average condition and average organization
respectively, with 33.2% and 30.9% having a poor condition and organization
respectively. The general cleanliness of houses was comprised of 76.1% average,
17.5% poor, and 6.3% good. All of the houses interviewed used iron sheets as a roof
and 60.0% had mud floors compared to 40.0% cement. The majority of respondents
reported that they were not satisfied with the overall physical condition of their house,
and that the standard of the community was generally poor. Several participants also
stated that they would like to keep their homes better organized, but they were not sure
how to go about organizing their rooms.
Table
2:
Household
Physical
Condition
Mean
(sd)
Median
Minimum
Maximum

15.
14
Number
of
buildings
2.30(1.09)
2
0
8
Number
of
rooms
4.09(1.50)
4
1
10
Number
of
rooms
for
sleeping
2.63(1.06)
3
1
7
Number
(n=269)
Relative
Frequency
(%)
Condition
of
buildings
Poor
89
33.2
Average
172
64.2
Good
7
2.6
Organization
of
rooms
Poor
83
30.9
Average
173
64.6
Good
11
4.1
Unsure
1
0.4
Cleanliness
of
rooms
Poor
47
17.5
Average
204
76.1
Good
17
6.3
Type
of
roof
Iron
sheets
269
100
Banana
fibers
0
0
Type
of
floor
Mud
185
60.0
Cement
83
40.0
Health & Nutrition
In order to assess nutrition status across Kyangyenyi, questions related to eating habits
and food availability were asked to participants. When asked the number of times they
had eaten over the past 24 hours, participants responded with a mean number of 2.83
times. The most common foods eaten consisted of bananas, beans, posho, potatoes,
milk, millet, and cassava from most eaten to least eaten on a daily basis respectively.
Foods such as rice, eggplant, fruits, and bread were eaten sparingly on a daily basis.
Respondents reported that in 64.7% of families the man of the household was the one
to typically buy food, while 15.6% of families reported that the women bought food and
19.3% reported that another family member bought food. When purchasing food,
74.4% of participants reported that food availability in their village was low, while 24.9%
reported average and 0.7% reported a high availability of food. Reasons given for low
food availability included poor soil for growing, lack of understanding on how to grow
enough food on small land, crop diseases such as the banana bacteria wilt, and poor
crop yields during dry seasons. When asked the amount of money spent on food for
the family per month, the median response was 60,000 Ugandan shillings with a range
of zero to one million shillings. Those who spent a small amount of money on food per
month typically only ate food grown on their land while those who spent a large sum on
food typically had large families and typically sold the majority of food grown on their
land.

16.
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Table
3:
Household
Nutrition
Status
Mean(sd)
Median
Minimum
Maximum
Number
of
times
eaten
during
2.83(0.98)
3
1
6
the
past
24
hours
Amount
of
money
(UGX)
spent
on
-­‐
60000
0
1000000
food
per
month
Number
(n=269)
Relative
Frequency
(%)
Knowledge
of
foods
related
to
a
healthy
diet
Listed
3
foods
215
80.0
Unable
to
list
3
foods
54
20.0
Village
food
availability
Low
200
74.4
Average
67
24.9
High
2
0.7
Foods
Eaten
in
the
Past
24
Hours
Matooke
bananas
201
74.7
Beans
149
55.4
Posho
119
44.2
Potatoes
(sweet
&
Irish)
93
34.6
Milk
62
23.0
Millet
52
19.3
Cassava
41
15.2
Porridge
39
14.5
Tea
(dry)
22
8.2
Dodo
(greens)
21
7.8
G-­‐nuts
14
5.2
Meat
11
4.1
Eggs
11
4.1
Eggplant
7
2.6
Pumpkin
5
1.9
Maize
3
1.1
Rice
2
0.7
Bread
2
0.7
Cabbage
1
0.4
Fruits
1
0.4
Chapatti
1
0.4
With regard to overall health, questions related to maternal health, family planning,
malaria, HIV/AIDS, and common diseases were asked within the survey. Families
reported that 69.4% of mothers gave birth in a health center while 26% of mothers gave
birth at home. Approximately 4.6% of mothers gave birth to some children at home and
others at the health center. Similarly, 70.5% of families reported that women received

17.
16
assistance during child birth from a nurse, doctor, or health care worker while the
remaining 29.5% of families received assistance at home from either a family member,
midwife, traditional birth attendant, a neighbor, or with no assistance. Approximately
16.7% of those surveyed reported delivery complications consisting of C-section,
stillbirth, miscarriage, prolonged labor, or post-partum hemorrhage (PPH). Eighteen
families reported that the woman of the house did not receive prenatal or antenatal
care. Reasons for not obtaining care included lack of transport, far distance, and they
did not feel it was needed. After birth, mothers typically breastfed their babies for an
average of 18.4 months with a minimum of 3 and a maximum of 48 months, and first fed
their babies solid food at an average of 7.1 months with a minimum of 3 and a
maximum of 24 months. With regard to family planning, 46.5% of respondents reported
ever using any method. The most popular form of family planning was injection,
followed by contraceptive pills, no plant, hysterectomy, condoms, IUD, withdrawal,
vasectomy, and moon beads. Reasons for low use of family planning were most often
given as the side effects and the desire to produce many children. Several participants
reported that they had used family planning methods in the past, but had stopped due to
health care worker’s inability to manage the side effects. With regard to malaria,
respondents reported that children acquired malaria an average of 2.6 times per year,
and adults an average of 2.2 times per year. As a preventative measure for malaria,
97.4% of families currently owned at least one mosquito net, while 2.6% reported not
owning any nets. Mosquito nets were reported being used by 73.9% of children 5-7
nights per week, while 87.1% of adults used the nets 5-7 nights per week. Participants
shared that it was difficult to obtain mosquito nets; supplies of free nets from the
government quickly ran out before reaching all families in the sub-county, and many
families did not see a large enough need for nets to spend money from their monthly
incomes. Finally, out of those respondents with children, only 2 reported that their
children were not up to date on vaccinations. Reasons for this consisted of their
children being raised during a time when vaccination was not always available. Further
results related to common health diagnoses found across Kyangyenyi will be discussed
in later sections.
Table
4:
Household
Health
Status
Mean(sd)
Median
Minimum
Maximum
Age
(months)
that
children
18.4(7.1)
18
3
48
were
breastfed
Age
(months)
that
children
were
7.1(3.9)
6
3
24
first
fed
solid
foods
Number
of
times
per
year
that
2.6(3.1)
2
0
30
children
acquire
malaria
Number
of
children
that
have
had
0.4(0.7)
0
0
3
diarrhea
in
the
past
month
Number
of
children
that
have
had
1.7(1.5)
1
0
9
a
cough
in
the
past
month
Number
of
times
per
year
that
2.2(3.1)
2
0
30

18.
17
adults
acquire
malaria
Number
(n=269)
Relative
Frequency
(%)
Who
assisted
during
childbirth
Healthcare
worker
182
70.5
Family
member
(Mother/in
law)
33
13.2
Midwife
18
7.0
No
assistance
13
5.0
Traditional
birth
attendant
8
3.1
Neighbor
3
1.2
Where
children
were
born
Health
enter
179
69.4
Home
67
26.0
Some
home
&
health
center
12
4.6
Delivery
complications
C-­‐section
26
9.7
Post-­‐partum
hemorrhage
9
3.3
Stillbirth
4
1.5
Prolonged
labor
4
1.5
Miscarriage
2
0.7
Family
Planning
(FP)
Ever
heard
of
FP
264
98.1
Never
heard
of
FP
5
1.9
Ever
used
FP
125
46.5
Never
used
FP
144
53.5
Type
of
FP
used
(n=125)
Injection
70
56.0
Contraceptive
pills
28
22.4
No
plant
18
14.4
Hysterectomy
14
11.2
Condoms
8
6.4
IUD
4
3.2
Withdrawal
4
3.2
Vasectomy
3
2.4
Moon
beads
1
0.8
Mosquito
Nets
Family
currently
owns
at
262
97.4
least
1
net
Family
currently
owns
no
nets
7
2.6
Nights
per
week
that
children
use
nets
0
nights
18
7.2
1-­‐2
nights
14
5.6
3-­‐4
nights
33
13.3
5-­‐7
nights
184
73.9
Nights
per
week
that
adults
use
nets

19.
18
0
nights
14
5.3
1-­‐2
nights
7
2.7
3-­‐4
nights
13
4.9
5-­‐7
nights
230
87.1
HIV/AIDS
Participant
has
ever
tested
232
86.2
Participant
has
never
tested
37
13.8
Families
with
1
or
more
HIV+
42
15.7
member
Families
with
no
HIV+
members
221
82.8
Unsure
4
1.5
Access to Power
Access to power was defined as a home that had the physical possibility of using
hydroelectricity or solar power. According to respondents, 42.0% reported that their
village had access to power while 58.0% reported that their village did not have access
to power. Among all respondents who had possible access to either hydroelectricity or
solar, 32.2% were currently accessing power while 67.8% were not. Reasons for not
having power where accessible included lack of fees for initial connection and for
regular monthly access. Within villages that had no access to power, some
respondents were able to access solar through personal installation and maintenance.
Among all respondents with current access to power, 59.0% used hydroelectricity,
38.5% used solar, and 2.5% had access to both hydroelectricity and solar.
Respondents were also asked to rate the reliability of the power which was reported as
46.1% unreliable, 48.7% sometimes reliable, and 5.2% regularly reliable. Due to the
majority of respondents having no access to power within their village, power was
reported to be a major community problem by the majority of respondents. During the
final discussion section of the survey, many participants asked if future projects were
being planned to bring power to villages without access and how they could work to
obtain access for their villages in the near future. Respondents currently accessing
hydroelectricity voiced frustrations about frequent outages at certain times of day or
during inclement weather, which affected the overall reliability and user satisfaction.
Table
5:
Village
&
Household
Power
Number
Relative
Frequency
(%)
Village
access
to
power
(n=269)
Yes
113
42.0
No
156
58.0
Household
access
to
power*
(n=121)
Yes
39
32.2
No
82
67.8
Among
those
with
household
power:
Number
(n=39)
Relative
Frequency
(%)

20.
19
Type
of
power
Hydroelectric
23
59.0
Solar
15
38.5
Hydroelectric
&
solar
1
2.5
Power
reliability
Not
reliable
18
46.1
Sometimes
reliable
19
48.7
Regularly
reliable
2
5.2
*The
total
households
with
access
to
power
is
greater
than
the
number
of
villages
with
access
to
power
due
to
those
houses
with
access
to
solar
within
villages
that
do
not
access
power.
Water & Sanitation
Study respondents felt that access to water was one of the biggest challenges
throughout the sub-county. Approximately 32.3% of respondents felt that water
availability in their village was low, compared to 29.7% average and 37.9% high.
Although 64.6% of participants received their water by a government installed gravity
system, 35.4% of participants received their water by other methods such as streams,
springs, wells, ponds, and tanks. Those who did not use the gravity system shared that
they were not satisfied with the cleanliness of their water and felt that their current water
system caused some percentage of their family’s illnesses. When purifying water for
drinking 91.8% of families used the boiling method followed by 4.5% using no
purification method, 2.2% using both filtering and boiling, and 0.7% using both tablet
and boiling. Participants were also asked if community members and their containers
were generally clean or dirty when fetching water at their local water source.
Approximately 62.8% of respondents felt that others in the community were frequently
dirty when fetching water while 37.2% reported that others were generally clean. Given
that those who use stagnant water sources generally dip their hands and containers into
the water source to fill their containers, dirty hands and containers may add additional
contamination. When observing various water sources aside from gravity, stagnant
sources such as wells and ponds were observed to frequently have algae growing on
the surface, while streams and springs typically had a high number of mosquitos
present in the area.
With regard to sanitation, participants were asked questions related to their toilet
facilities, knowledge of illness prevention, and hand washing practices. Approximately
94.8% of families used a local pit latrine while 4.8% used ventilated improved pits (VIP)
and 0.4% used no toilet facilities. After using the toilet, 41.6% of families reported that
they had water for hand washing at the toilet, and 34.2% reported that soap was also
available at the toilet. According to respondents, the median number of times a person
washed their hands per day was 4. Participants shared that although water and soap
were not always available at the toilet, they were usually available at the house. Some
respondents shared that when they had kept water and soap at the toilet in the past

21.
20
they had been stolen, prompting them to keep them closer to the house. Further results
related to knowledge of sanitation practices will be discussed in later sections.
Table
6:
Household
Water
&
Sanitation
Number
(n=269)
Relative
Frequency
(%)
Village
water
availability
Low
87
32.3
Average
80
29.7
High
102
37.9
Source
of
water
Gravity
174
64.6
Stream/River
12
4.5
Spring
8
3.0
Well
67
24.9
Pond
1
0.4
Tank
7
2.6
Water
purification
methods
None
12
4.5
Boiling
247
91.8
Filtering
&
boiling
6
2.2
Tablet
&
boiling
2
0.7
Covering
water
1
0.4
Unsure
1
0.4
People
in
the
community
fetch
water
when
they
are
dirty
Yes
169
62.8
No
100
37.2
Toilet
facilities
Local
pit
latrine
255
94.8
Ventilated
Improved
Pit
13
4.8
None
1
0.4
Knowledge
of
illness
prevention
Listed
2
ways
to
prevent
illness
182
67.7
Unable
to
list
2
ways
to
prevent
85
31.6
illness
Missing
2
0.7
Knowledge
of
hand
washing
Listed
3
times
when
hands
219
81.4
should
be
washed
Unable
to
list
3
ways
when
50
18.6
hands
should
be
washed
Water
availability
for
hand
washing
Water
available
at
the
toilet
112
41.6
Water
not
available
at
the
toilet
157
58.4

22.
21
Soap
availability
for
hand
washing
Soap
available
at
the
toilet
92
34.2
Soap
not
available
at
the
toilet
177
65.8
Mean(sd)
Median
Minimum
Maximum
Average
number
of
times
participant
washes
hands
per
day
-­‐
4
1
100
Health Center Patient Experience
In order to assess participants’ experiences using local health centers, a series of
questions related to their use was asked. Approximately 61.0% of respondents
reported that local health centers typically operated on time, while 39.0% reported
frequent delays. During their visit to the health center, 60.2% of participants reported
that health center staff spared time for them by explaining the cause of their illness,
treatment, and prevention, while 39.8% of respondents reported that staff was
frequently too busy to speak to them and simply prescribed medication only. In
addition, 5.6% of participants reported that health center staff followed up with them
after their visit with a phone call or house visit, compared to 94.4% of respondents who
received no form of follow up. Those who received follow up were typically patients
recently diagnosed with HIV/AIDS. Of those who were prescribed medication at the
health center, 88.1% reported that the treatment prescribed was effective while 11.9%
reported that the prescribed treatment was ineffective. With regard to drug provider,
47.6% of respondents obtained their drugs from a government clinic, 36.8% obtained
their drugs from a private clinic, and 15.2% obtained drugs from both government and
private clinics. Survey participants spent a median of 50,000 Ugandan shillings per
month on their family’s health. Those families with major health problems and
complications spent up to one million shillings per month; for example those with
diabetes, hypertension, heart attacks, kidney disease, and other presently unknown
health problems. The majority of those who received services from government clinics
reported having to spend some amount of money either for timeliness or for certain
drugs. This was cause for frustration due to low income levels, high expenditures on
health and school, and the fact that government services are intended to operate at no
cost. Those respondents who used primarily private clinics explained that their
experience at government clinics has been one of untimeliness, regular stock outs,
ineffective medication, and the need to pay money to clinic staff when services should
be free. As a result of these experiences, those who use private clinics reported that if
they must spend money for health services, they would rather spend it to get quality,
timely service.
Table
7:
Health
Center
Patient
Experience
Number
(n=269)
Relative
Frequency
(%)
Timeliness
of
health
center
activities
On
time
164
61.0
Not
on
time
105
39.0

23.
22
Effectiveness
of
health
center
treatment
Effective
237
88.1
Not
effective
32
11.9
Staff
bedside
manner
Staff
spares
time
and
speaks
162
60.2
to
me
as
a
patient
Staff
does
not
spare
time
and
does
107
39.8
not
speak
to
me
as
a
patient
Health
center
follow
up
Staff
follows
up
with
me
after
my
15
5.6
visit
Staff
does
not
follow
up
with
me
254
94.4
after
my
visit
Drug
provider
Government
128
47.6
Private
99
36.8
Both
government
&
private
41
15.2
Unsure
1
0.4
Mean(sd)
Median
Minimum
Maximum
Amount
of
money
(UGX)
spent
-­‐
50000
0
1000000
on
family
health
per
month
Family Level Prevalence of Common Illnesses
Children
During the pilot study phase of this research, three common childhood illnesses became
evident that were included as questions in the research survey. These diagnoses
consisted of diarrhea, respiratory tract infection (RTI) or “cough”, and malaria. Within
the survey, respondents were asked how many children in the family had had diarrhea
and RTI in the past month, and how many times per year family children acquire
malaria. An average of 0.4 children per family were reported to have diarrhea per
month with a minimum of zero and a maximum of three. Although these numbers do
not demonstrate a major burden of diarrhea in the sub-county, it is possible that these
numbers are under reported out of embarrassment and shame of the disease. An
average of 1.7 children per family were reported to have RTI per month with a minimum
of zero and a maximum of nine. This suggests that the majority of families have at least
one child experiencing RTI per month. Finally, it was reported that children experience
malaria an average of 2.6 times per year. When asked which diseases and conditions
family children experience most frequently, the majority of respondents named at least
one of the above three conditions.

24.
23
Respondents were also asked which illnesses household children frequently acquire or
are diagnosed with. The most common illnesses reported within the sub-county consist
of malaria, RTI, skin infections, and allergies. For a complete list of reported childhood
illnesses and family level prevalence please refer to Table 8.
Table
8:
Family
Level
Prevalence
of
Reported
Childhood
Illnesses
Number
of
cases
Prevalence
(%)
(n=255*)
Malaria
187
73.3
RTI
152
59.6
Skin
infections
41
16.1
Allergies
15
5.9
Diarrhea
9
3.5
Worms
9
3.5
Stomach
pain
8
3.1
Typhoid
8
3.1
Pneumonia
8
3.1
Ulcers
4
1.6
Eye
problems
3
1.2
Nosebleed
3
1.2
Arthritis
2
0.8
Ear
problems
1
0.4
Measles
1
0.4
Cancer
1
0.4
No
illnesses
8
3.1
*n
represents
the
total
number
of
families
with
children.
The
number
of
cases
represents
the
number
of
families
that
have
one
or
more
children
frequently
diagnosed
with
the
given
condition.
Adults
After conducting the pilot study, two adult illnesses became apparent that were also
included within the research survey. These conditions consisted of malaria and
HIV/AIDS. Questions related to each condition were asked, as well as general illnesses
and conditions frequently experienced by family adults. Respondents reported that
family adults typically experienced malaria an average of 2.2 times per year, and
malaria was experienced regularly by 52.8% of respondent families. Out of all 269
respondents, only one reported that they had not heard of HIV/AIDS, and 86.6% of
study participants reported having ever tested for HIV/AIDS. The prevalence of
HIV/AIDS among at least one family member within respondent families was
approximately 15.7%. It is possible that this number could be under reported out of
shame and stigma associated with the disease.

25.
24
Respondents were also asked which illnesses household adults most frequently
experienced. The most common illnesses consisted of malaria, RTI, arthritis, stomach
pain, and allergies. For a complete list of reported household adult illnesses and family
level prevalence please refer to Table 9.
Table
9:
Family
Level
Prevalence
of
Reported
Adult
Illnesses
Number
of
cases
Prevalence
(%)
(n=269*)
Malaria
142
52.8
RTI
84
31.2
Arthritis
38
14.1
Stomach
pain
36
13.3
Allergies
33
12.3
Ulcers
24
8.9
Skin
infections
19
7.1
Chest
pain/heart
problems
16
5.9
Eye
problems
15
5.6
Sexually
transmitted
infection
13
4.8
HIV/AIDS
11
4.1
Diabetes
9
3.3
Kidney
problems
7
2.6
Worms
7
2.6
Typhoid
6
2.2
Hernia
5
1.9
High
blood
pressure
5
1.9
Cancer
4
1.5
Hypertension
3
1.1
Edema
3
1.1
Nosebleed
2
0.7
Pneumonia
2
0.7
Sleeplessness
2
0.7
Teeth
problems
2
0.7
Goiter
2
0.7
No
illnesses
14
5.2
*n
represents
the
total
number
of
families.
The
number
of
cases
represents
the
number
of
families
that
have
one
or
more
adult
frequently
diagnosed
with
the
given
condition.
Knowledge of Healthy Behavior
Nutrition
In order to assess knowledge of nutrition and healthy eating behavior, respondents
were asked to list the three healthiest foods available in the sub-county, regardless of

26.
25
availability or cost, according to their knowledge of nutrition. A total of 80.0% of
respondents were able to list three foods that they felt were healthy, while 20% were
unable to list three foods or responded that they did not know what made certain foods
healthy. Of those respondents who listed three foods, those listed as healthiest were
millet, matooke bananas, potatoes (sweet & Irish), and posho. These five foods are
eaten most often within the sub-county, however they are each high in carbohydrates
and do not contain some nutrients in quantities that are vital for growth, development,
and body maintenance. It was also observed that many children of respondents had
developed kwashiorkor, indicating low levels of protein in the body. Some parents of
these children were concerned about their child’s health, but did not know what the
condition was, what caused it, or how to treat it. The prevalence of kwashiorkor and
other types of observed malnutrition and the lack of general knowledge related to these
conditions indicate a low level of understanding of general nutrition among study
participants. For a complete list of foods listed by participants in order of healthiest
please refer to Table 10.
Table
10:
Healthiest
Foods
According
to
Participants
Number
(n=269*)
Relative
Frequency
(%)
Millet
125
46.5
Matooke
bananas
121
45.0
Potatoes
(sweet
&
Irish)
118
43.9
Posho
107
39.8
Rice
76
28.3
Cassava
66
24.5
Beans
35
13.0
Meat
(including
fish)
32
11.9
G-­‐nuts
13
4.8
Yams
12
4.5
Milk
10
3.7
Dodo
(greens)
8
3.0
Eggs
4
1.5
Fruits
3
1.1
Sugar
2
0.7
Carrots
2
0.7
Cabbage
2
0.7
Bread
2
0.7
Pumpkin
2
0.7
Maize
1
0.4
Did
not
know
2
0.7
*n
represents
the
total
number
of
participants.
The
number
for
each
food
represents
the
number
of
participants
who
stated
the
given
food
as
one
of
the
three
healthiest
foods
available
in
Kyangyenyi.

27.
26
Disease Prevention
In order to assess knowledge of disease prevention, participants were ask to list two
ways that they can prevent disease at home, and three times when they should wash
their hands during the day. A total of 67.7% of respondents were able to list two ways
they could prevent disease at home, while 81.4% were able to list three times when
they should wash their hands during the day. The most common ways participants
cited for preventing various diseases at home included boiling water, general cleaning,
and being clean, while the most often cited times for hand washing were before eating,
after using the toilet, after working, and after waking in the morning. These responses
illustrate that although respondents were able to list ways of preventing disease, the
majority of responses were very general and not distinct. Examples of hand washing
behavior were comprised of more specific examples implying that respondents had
better knowledge of hand washing behavior as opposed to disease prevention. For a
complete list of knowledge of disease prevention methods and hand washing behavior
please refer to Tables 11 & 12.
Table
11:
Participant
Disease
Prevention
Methods
Number
(n=269*)
Relative
Frequency
(%)
Boiling
water
82
30.5
General
cleaning
64
23.8
Being
clean
60
22.3
Sleeping
under
nets
35
13.0
Washing
hands
26
9.7
Sweeping
24
8.9
Washing
utensils
23
8.6
Cleaning
the
compound
20
7.4
Slashing
bushes
19
7.1
Good
sanitation
17
6.3
Having
a
toilet
16
5.9
Covering
food
8
3.0
Eating
healthy
foods
7
2.6
Destroying
stagnant
water
5
1.9
Abstinence
4
1.5
Covering
the
toilet
4
1.5
Closing
windows
&
doors
3
1.1
Proper
disposal
of
wastes
2
0.7
Having
a
high
income
2
0.7
Condoms
1
0.4
Stop
visiting
neighbors
1
0.4
Breastfeeding
1
0.4
Did
not
know
12
4.5

28.
27
*n
represents
the
total
number
of
participants.
The
number
for
each
method
represents
the
number
of
participants
who
stated
the
given
method
as
one
way
to
prevent
disease
at
home.
Table
12:
Participant
Hand
Washing
Behavior
Number
(n=269*)
Relative
Frequency
(%)
Before
eating
220
82.1
After
using
the
toilet
136
50.7
After
working
94
35.1
After
waking
in
the
morning
94
35.1
After
eating
53
19.8
Before
sleeping
17
6.3
Before
cooking
15
5.6
After
washing
utensils
11
4.1
Before
peeling
9
3.4
Before
breastfeeding
8
3.0
After
milking
7
2.6
After
touching
something
dirty
7
2.6
Before
bathing
6
2.2
Before
drinking
4
1.5
Before
praying
3
1.1
After
peeling
3
1.1
Before
serving
2
0.7
After
shaving
1
0.4
Before
taking
medicine
1
0.4
Before
brushing
teeth
1
0.4
Before
cleaning
1
0.4
After
cleaning
1
0.4
Did
not
know
1
0.4
*n
represents
the
total
number
of
participants.
The
number
for
each
situation
represents
the
number
of
participants
who
stated
the
given
situation
as
one
time
when
a
person
should
wash
his
or
her
hands.

29.
28
Recommendations
The results of this study demonstrate that the residents of Kyangyenyi sub-county must
improve certain aspects of their health and living conditions in order to improve their
overall health status. Based on current knowledge levels related to disease prevention
methods and nutrition, it is important that residents receive education in order to
improve overall knowledge and maintain behavior changes within these areas. It is also
important that education be used in order to teach the community how to improve their
standard of living in the home and on important health topics such as family planning
and maternal & child health. In addition to community education programs, it is
recommended that local government and private health organizations assess their
effectiveness and efficiency and address obstacles hindering the community from
receiving high quality medical care and patient satisfaction.
Participants of the survey frequently shared that they wished they could improve certain
areas such as the cleanliness and organization of their house, but they did not know
how to improve upon their current conditions. Similarly, after asking participants to list
ways they prevent illness at home and when they should wash their hands, the majority
of respondents asked to be educated in those areas. These responses as well as the
data from the survey show a need and desire for education in the sub-county related to
nutrition, crop production, disease prevention methods, family planning, cleanliness and
organization, and maternal & child health. Given that the government has established
local health teams at the village level, it should be their responsibility to regularly
implement these education topics. During discussions with survey participants, many
respondents shared that they had never been informed of any health education
programs and did not even know that village health teams existed in their area.
According to one participant who was also part of a village health team, the government
did not provide adequate training for the village health teams and they lacked
educational resources to help communities. The government also provides no financial
support or reimbursement, which creates a lack of motivation and interest for
community members to join. As a result, the teams are largely inactive and do not
provide the support needed by the community. Since local village health teams provide
a vital service and also serve as a valuable resource for the community, it is
recommended that the government work with the local village health teams to find a
way of increasing motivation so that the community regularly receives the health
education they need. Other countries have successfully used their village health teams
to make a difference in local community health by providing monetary compensation,
establishing a strong connection with local health centers, providing appropriate training
materials and training sessions, and uniformly coordinating teams across the nation7,8
.
In addition to improving government sponsored village health teams, it is recommended
that private health organizations in the area also address the need for health education.
While providing large health education programs provides the community with a wide
range of specific information, providing information at clinics or having one to one health
talks with patients also provides vital health information that can be shared by the
patient with family and friends in the community.

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Alongside health education, the support for behavior change is also important in order
to assist the community in adapting behaviors. For example, respondents reported
having a diet high in carbohydrate foods such as matooke bananas, cassava, posho,
beans, and potatoes. The addition of vegetables that are not as commonly eaten such
as tomatoes, cabbage, pumpkin, and eggplant that provide vital nutrients may be
difficult for families to implement in practice since they are used to eating their traditional
foods. Organizations that provide health education must be able to follow up with the
community and provide the support needed to help them change long standing
traditional behaviors.
It is essential that existing health services in the community operate efficiently and
effectively so that patients receive the highest quality care. Those study respondents
who reported using government health clinics shared experiences of long wait times,
frequent stock outs, and the need to pay to receive time with a doctor and quality
services. Those who used private clinics shared that although the doctor spent more
time with them and drugs were more readily available, the cost was much higher
making private services unaffordable or too costly. Respondents also shared a general
dissatisfaction with the way they are treated as patients in the sub-county, especially in
government clinics. As a result, it is recommended that local clinics assess their
standards and procedures and address areas that prevent quality care and a positive
patient experience.
One area that many participants shared was a major concern was their current and
future access to water. The fact that almost one-third of the sampled population
currently has low availability of water and that 35.4% obtain their water from stagnant or
polluted sources is cause for concern. In general, respondents who lived in
mountainous or very rural areas had the least access to regularly available water. One
positive solution that has been attempted has been the construction of high quality,
long-term durable rainwater tanks shared by a group of families. One village within
Rwebaare parish constructed three of these tanks and the result has been a more
consistent, reliable water source for those in the immediate area. As a result of this
success, it is recommended that local organizations helping with water access explore
the construction of these tanks for villages where water access is lowest. The
community is also encouraged to investigate grants available from large organizations
in order to provide funding for future tank construction.
As researchers we recognize that this study is subject to several limitations. As this
study was conducted using a cross-sectional design we are only able to measure the
prevalence of illness and are not able to make any inference regarding exposure related
to disease. Funding and time restrictions also limited our ability to assess valuable
qualitative data by holding focus group discussions and key informant interviews.
During data collection we also recognize the possibility of interviewer bias during
interpretation as well as recall bias resulting in respondent’s failure to report information
(such as HIV/AIDS) and fabricate information. In order to control for these different
types of limitations several methods were used in the design phase of this study. Clear,
specific questions were formed in the survey in order to account for response accuracy

31.
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and understanding. Specific interview techniques were used to form questions for
sensitive topics, such as HIV/AIDS and family planning. Local interpreters were also
trained in appropriate interview techniques in order to reduce interviewer bias. As one
purpose of this research is to serve as baseline data for future health projects and to
provide a clear picture of present conditions, it is recommended that more research be
conducted in order to assess the impact of current and future projects on the health
status of Kyangyenyi sub-county residents.
In conclusion, this research shows that the residents of Kyangyenyi sub-county are in
need of health education and behavior change support in order to improve conditions
having a negative impact on health in the home environment, and improved government
and private health services currently operating in the sub-county. Given that the
government has opted to provide medical services at no cost and has set up local
village health teams, these services should be utilized more effectively in order to have
a more positive impact in the community. Private organizations should also make sure
they are doing their part to offer the highest quality services needed by the community
that are accessible by the current standard of living. Future research should focus on
the impact of existing projects related to the community’s needs as well targeting areas
still in need of improvement in order to support the overall health of the Kyangyenyi sub-
county community.

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