Journal articles on the topic 'Meeting (2009 : Kampala, Uganda)'

This paper reports on a pilot project to develop a 32-acre site made available by the City of Kampala for housing with the express purpose of promoting urban agriculture. Started in 2004 under the leadership of a city agronomist, with the aid of research teams from McGill University, Montreal, Makerere University, Kampala, and financial support from IDRC, the project is still ongoing. The process is one of participatory planning with the future residents, a group of mixed ethnicity and religions from all parts of the city, and includes training in house construction and agricultural techniques. Project implementation has been slower than anticipated due to unforeseen hazards such as mislaid title deeds, unavailability of government resources, communication shut-downs, the time required to transact business, acquire permissions, permits and the like, and most recently by the threat of a major power line from the Bujagali Falls to serve Kampala being thrust through the site. We nevertheless remain optimistic of ultimate success.

ABSTRACTThis article investigates practices of speech and sociability in open radio debates in Kampala to decipher imaginaries of citizenship in contemporary Uganda. In these ebimeeza (‘round tables’ in Luganda, also called ‘people's parliaments’) orators are engaged in practices of social distinction when compared to those they call the ‘common men’. These spaces of discussion reflect the importance of education in local representations of legitimacy and morality, whether in Buganda ‘neotraditional’ mobilizations or Museveni's modernist vision of politics. The ebimeeza and the government ban imposed on them in 2009 reveal the entrenchment of the vision of a ‘bifurcated’ public sphere, the separation of a sphere of ‘development’ and a sphere of ‘politics’, the latter being only accessible to educated ‘enlightened’ individuals – despite the revolutionary discourse and the institutionalization of the Movementist ‘grassroots democracy’ model in 1986.

Background: Cancer is relatively rare in childhood compared with later in life. In high-income countries, hematologic malignancies are the most common, then brain tumors and solid tumors. World age-standardized incidence rates in Ireland averaged 142 cases per million children per year, higher than European average and lower than US average. In Africa, distribution of childhood cancers is quite similar, commonest being Kaposi sarcoma (KS), Burkitt's lymphoma, retinoblastoma, leukemia and Hodgkin lymphomas (HL). Among adolescent in Zimbabwe, leukemia has highest incidence rates then osteosarcoma, non-Hodgkin lymphoma (NHL) and KS. Aim: To describe the incidence of cancer among children and adolescents in Kyadondo County, Uganda from 2009 to 2014 which is necessary for planning of cancer control programs. Methods: Descriptive cross-sectional study which involved review of data from Kampala Cancer Registry that gathers information on cancers diagnosed within Kyadondo County (formed by Kampala and Wakiso districts) and analyzed using STATA 13. From 2014 Uganda population census, Kyadondo County had a population of 3,523,910 (32.2% children and 10% adolescents). Study population was children (0-14 years) and adolescents (15-19 years) diagnosed with cancer from January 2009 to December 2014. Results: The spectrum of cancers in adolescents reflects a transition. Carcinomas which are so prevalent in adults occur but at lower frequencies in adolescents. Study results are comparable to others studies indicating that nephroblastoma and retinoblastoma were common among children and not adolescents. Leukaemia and lymphomas cut across both children and adolescents. Conclusion: The spectrum of cancers in adolescents reflects a transition. Carcinomas which are so prevalent in adults occur but at lower frequencies in adolescents. Study results indicate that nephroblastoma and retinoblastoma were common among children and not adolescents. New prospective studies should be done on children and adolescent cancers covering a wide population size. Leukaemia and lymphomas cut across both children and adolescents. National cancer registries should be set up.

BackgroundDespite significant progress made by many countries towards meeting the millennium development goals and now sustainable development goals, there has been little improvement in access to essential medicines in developing countries.ObjectivesThe main aim of this study is to assess the factors influencing annual procurement planning of medicines and medical supplies in the public health facilities in Kampala district.MethodsThis study targeted respondents from government Health facilities in Kampala with a total population of 424 employees and applied simple random sampling to select 206 health workers. The researcher adopted mixed research approach with application of descriptive statistics, correlational and explanatory research designs that were used to maximize reliability and validity of findings. While the qualitative data was gathered through reviewing logistics tools, a physical count of the 30% purposively selected stock cards and interview of the staffs was carried out in health facilities in Kampala district, a Statistical Package for Social Science (SPSS) version 20 was used to analyze the quantitative data. Accordingly, a chi-square was used to determine the association between independent and dependent variables.ResultsThe findings indicated that 37.8% of the staff responded positively about the availability of annual procurement plan while the rest were from various health facilities. A significant association was observed between knowledge and availability of annual Procurement planning (X2 = 34.7; p value =.0001), as well as management support and Annual Procurement Planning (X2 = 9.87; P value = .008).ConclusionIn conclusion, the finding generated from analysis of quantitative and qualitative data revealed that a majority of the factors influencing annual procurement planning had a positive effect on medical supplies in public health facilities in Uganda although the capacity and capability of health workers, quality of logistics management information systems, and management support desires improvement. Rwanda J Med Health Sci 2021;4(2): 292-309

Background: HIV/AIDS is a hallmark of immune suppression. Micronutrient deficiencies in diet and recurrent opportunistic infections play major roles in the lives of people living with HIV. Although benefits of providing adequate diet to HIV positive persons are well documented, the demand for key elements still remain unclear in particular settings, especially in low and middle-income countries. Methods: This was a cross sectional analysis of baseline data collected from HIV-infected adults initiating antiretroviral therapy, and who were enrolled in a multivitamin supplementation trial. A food frequency questionnaire was used and intake were obtained as a product of quantities consumed. Adequacy was calculated as the proportion of Recommended Dietary Allowances (RDA). A chi square test and logistic regression analysis were used at p-value 0.05 to show significant associations. Results: Mean intakes were above minimum requirements for analyzed micronutrients with the exception of Calcium and Iron. Participants who met RDA intakes were as follows: highest (? 80%) for Magnesium, Selenium, Zinc and Vitamins B2, B6, B9, C and E; moderate (50% to <80%) for Vitamins B3, and A; and lowest (?50%) for Iron (30%), Calcium (14.9%), Vitamins B12 and B1. Gender differences in met RDA were observed for Iron, Selenium, Zinc, Vitamins A, B1, B3 and E. In multivariable analyses, nutritional status and CD4 count had no influence on meeting RDA for majority of micronutrients such as magnesium, Selenium, B class vitamins (B1, B2, B3, B6, B9, B12), vitamin (A, C, and E), Zinc and Calcium, but not including iron. Conclusion and Global Health Implications: Diets consumed by the study participants were low in most protective nutrients (Iron, Calcium, Zinc, Vitamin A, B1, B3, and B12). This deficiency was more common among females than males, and irrespective of BMI or CD 4 count. Findings warrant further investigation on the impact and cost implications for suplementation interventions that target the elements lacking in the diets of people living with HIV in similar low-resourced settings. Key words: • Recommended Dietary Allowances • Micronutrients • Dietary intakes • Body Mass Index • CD4 cell count • HIV/AIDS • Uganda Copyright © 2020 Isabirye et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

The Democratic Republic of the Congo (DRC), an important role player within the international community, has not escaped the widespread trend relating to the abuse of the terrorist concept. Whether it is about the rebels of the Movement of 23 March (M23) or the combatants of the Allied Democratic Forces / National Army for the Liberation of Uganda (ADF/NALU), the Congolese government has made use of the terrorist concept to describe these peace spoilers in eastern DRC. Furthermore, the government spokesperson qualified the civic movements known as Lucha and Filimbi as terrorist organizations. Yet, such extreme positions taken by government did not prevent the latter from entering into direct peace talks with the M23 leadership in Kampala (Uganda). Nor did it discourage the President from personally meeting with a delegation of Lucha and Filimbi in Goma. This article analyses the contradictions surrounding the phenomenon of terrorism: an abused concept describing a real contemporary societal threat. It subsequently applies this concept to the DRC's case. The central argument of the article is that the exploitation of the terrorist concept by Congolese political and media actors is likely to contribute towards impeding a full understanding of a phenomenon that, otherwise, represents a real security threat to the fragile Congolese state. In so doing, this exploitation prevents the formulation of relevant strategies designed to eradicate this phenomenon. In terms of methodology, observation and documentary investigation involving the content analysis were mobilized for this study.

Background: According to UWOCASO's research “Assessment of clinical and psychological needs of metastatic breast cancer patients, challenges and gaps in meeting their needs in Uganda” metastatic breast cancer (MBC) is not well understood, patients often feel isolated, invisible and stigmatized, have limited access to targeted treatment, specialized and comprehensive supportive services. Provision of information for available services and options for their care including open communication with health care providers, access to psychosocial services, pain control, financial support and cost of the treatment were important needs during the study. Patients end into depression, drop out of care thus compromising their quality of life. This project was designed as an intervention to address the unmet needs and barriers that limit access to supportive services. Aim: To improve access to supportive services for ABC patients and their families in Kampala and Wakiso districts. Methods: Fifteen (15) patients with advanced and metastatic breast cancer who were not respondents for the SAPRC research were recruited from the patients who sought psychosocial support from UWOCASO for a systematic follow-up. Using a bio-psycho-social (BPS) tool baseline data were collected to assess their psychosocial situation before our intervention and after 12 months. Baseline data were compared with the outcome. Results: At seven months more than 70% of patients had restored hope, pain kept under control, resumed treatment, reunited with families and some received in-kind and financial support. 30% of the patients passed on with no pain and legally supported. 2 patients were enrolled into a compassionate program for a targeted therapy. Conclusion: Patients living with advanced breast cancer have various needs that can only be met by a well-coordinated team of experts. UWOCASO's patient navigation program is important to bridge the gap between experts and improve access to supportive services.

10070 Background: Although many childhood cancers respond well to chemotherapy, survival among children with cancer in sub-Saharan Africa is poor. Little is known about children’s access to specialized cancer care in SSA or factors contributing to poor early outcomes. We aimed: 1) To estimate the proportion of childhood cancer patients without access to chemotherapy in Uganda; 2) To describe 30-day survival rates and predictors of mortality post diagnosis among children with lymphoma or Kaposi sarcoma (KS), the two most common pediatric cancers in Uganda. Methods: A retrospective study of incident childhood (age< 20 years) cancers diagnosed in Kyandondo County, Uganda from 2006-2009. We compared records of the population-based Kampala Cancer Registry (KCR) and patient records at the Uganda Cancer Institute (UCI), Uganda’s sole dedicated cancer treatment center. Patient characteristics were compared using Mann-Whitney and Pearson’s chi-square tests. Kaplan-Meier method and Cox regression models were used to describe mortality. Results: Of the 658 pediatric cases recorded in the KCR, only 238 (36%) presented to UCI. Patients identified in the KCR who did not present for care were more likely to be female, diagnosed in earlier years of the study, and to have a cancer other than KS or lymphoma. Of the 177 lymphoma and KS cases at UCI, 43.7% were Burkitt lymphoma (BL), 32.5% KS, and 23.8% other lymphomas. The post diagnosis 30-day overall survival rate was 77%. In multivariate analysis, age, gender, HIV status, platelets, and stage of cancer did not impact mortality. An increased risk of death at 30 days was predicted by presence of B-symptoms (HR=10.3, p=0.05), a diagnosis of BL compared to other lymphomas (HR=14.8, p=0.007), poor performance status (Karnofsky score <70, HR=14.7, p<0.001), and anemia (HR 1.5-fold per 1g/dL decrease in hemoglobin, p=0.002). Conclusions: Childhood cancer patients in Uganda have limited access to comprehensive care. Among those presenting to the UCI, a significant proportion die before they can benefit from chemotherapy. BL diagnosis, B-symptoms, performance status and hemoglobin level may be important predictors of early mortality among childhood cancer patients in sub-Saharan Africa.

Abstract Each year approximately 100 million units of blood are transfused worldwide. Current regulations allow RBCs to be stored in approved solutions for up to five or six weeks. Regulatory agencies use cell survival studies and in vitro markers of hemolysis, rather than measures of oxygen delivery, to establish the maximal duration of blood storage. During storage, RBCs undergo cumulative structural, biochemical, and enzymatic changes that collectively might impair the ability of erythrocytes to deliver oxygen to tissues and contribute to adverse patient outcomes. Study design and Methods: We conducted a prospective, randomized, controlled, clinical trial comparing short-storage versus longer-storage RBCs for tissue oxygen delivery as measured by reduction in blood lactate levels in severe anemia. We studied 290 patients presenting to a university hospital urgent care facility with a hemoglobin ≤5g/dL and lactate ≥5mM. Patients were children, age 6 to 60 months, whose lactic acidosis was due to severe anemia and who did not have shock, trauma, impaired cardiac function, refractory hypoxia, need for pressors, liver disease or tissue injury. Subjects were randomly assigned to receive leukoreduced RBCs stored 1-10 days (n=145) versus 25-35 days (n=145). All patients received 10mL/kg of RBCs during hours 0-2; and, if indicated per protocol, an additional 10mL/kg during hours 4-6. The study was conducted in Kampala, Uganda and registered as #NCT01586923 at clinicaltrials.gov. Results: Hour 0 was the start of transfusion.We measured blood lactate levels at time 0, 2, 4, 6, 8 and 24 hours following transfusion. The primary outcome was the proportion of patients achieving a lactate ≤3mM at 8 hours. Other measures included cerebral tissue oxygen saturation measured non-invasively, clinical and laboratory changes following transfusion, survival, and 30-day follow-up. At presentation, the mean hemoglobin was 3.7 ±1.3g/dL and mean lactate was 9.3 ±3.4mM. RBC storage averaged 7.8 ±2.1 days in the shorter-storage arm and 31.6 ±2.8 days in the longer-storage arm without overlap. See Fig 1A. The proportion achieving a lactate ≤3mM at 8 hours was 0.58 (95% CI, 0.49-0.66, shorter-storage) versus 0.61 (95% CI, 0.52-0.69, longer-storage), p=0.72, a result meeting the pre-specified margin of non-inferiority. Mean lactate levels were not statistically different between the two arms at 2, 4, 6, 8 or 24 hours. See Fig 1B. Kaplan-Meier analysis and global non-linear regression revealed no difference in lactate clearance between the shorter-storage and longer-storage groups. Clinical assessment, serial measurements of hemoglobin concentration, cerebral tissue oxygen saturation, and electrolyte abnormalities improved to the same degree in the two groups following transfusion. Adverse events, survival, and 30-day recovery were not significantly different between the two groups. Pre-specified sub-group analysis among patients receiving 20mL/kg of RBCs revealed no significant differences in outcomes. Given the severity of anemia, transfusions represented 60% to 90% of the patients' pre-transfusion red cell mass. Conclusion and Relevance: This is the first major randomized trial specifically testing whether prolonged storage RBCs deliver oxygen as well as short-storage RBCs. We tested the two extremes of blood storage duration and found that longer-storage RBCs were not inferior to shorter-storage RBCs for oxygen delivery as measured by reduction of elevated blood lactate levels, improved cerebral oxygen saturation, clinical outcomes, laboratory results, or adverse events. The results carry relevance for health policy decisions regarding the acceptable duration of RBC storage worldwide. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

Abstract Background Country-wide urbanization in Uganda has continued amidst institutional challenges. Previous interventions in the water and sanitation sector have not addressed the underlying issues of a poorly managed urbanization processes. Poor urbanisation is linked to low productivity, urban poverty, unemployment, limited capacity to plan and offer basic services as well as a failure to enforce urban standards. Methods This ethnographic study was carried out in three urban centres of Gulu, Mbarara and Kampala. We explored relationships between urban livelihoods and sustainable urban sanitation, using the economic sociology of urban sanitation framework. This framework locates the urbanization narrative within a complex system entailing demand, supply, access, use and sustainability of slum sanitation. We used both inductive and deductive thematic analysis. Results More than any other city in Uganda, Kampala was plagued with poor sanitation services characterized by a mismatch between demand and the available capacity for service provision. Poor slum sanitation was driven by; the need to escape rural poverty through urban migration, urban governance deficits, corruption and the survival imperative, poor service delivery and lack of capacity, pervasive (urban) informality, lack of standards: ‘to whom it may concern’ attitudes and the normalization of risk as a way of life. Amidst a general lack of affordability, there was a critical lack of public good conscience. Most urbanites were trapped in poverty, whereby economic survival trumped for the need for meeting desirable sanitation standards. Conclusions Providing sustainable urban livelihoods and meeting sanitation demands is nested within sustainable livelihoods. Previous interventions have labored to fix the sanitation problem in slums without considering the drivers of this problem. Sustainable urban livelihoods are critical in reducing slums, improving slum living and curtailing the onset of slumification. Urban authorities need to make urban centres economically vibrant as an integral strategy for attaining better sanitation standards.

While the importance of encouraging students to read and seek information is undisputed, it is an area of frustration for most school librarians. There are specific, practical principles that can help school librarians design activities that will motivate students to read and seek information on their own. This paper presents a theoretical framework for fostering intrinsic motivation, reports on current research on fostering motivation in students of individualistic (Colorado Springs, U.S.), collectivist (Kampala, Uganda), and individualistic/collectivist cultures (Mysore, India), and presents recommendations for designing instruction and programs using these best practices. The theoretical framework consists of the principles of self-determination theory (Ryan & Deci, 2017), building a growth mindset (Dweck, 1999, 2006), and using extrinsic motivators effectively (Deci & Ryan, 2002; Crow & Small, 2011; Small, 2009). Areas for further study are included.

Abstract Background Globally, school-going children spend most of their days at school, sitting in lessons and unable to achieve the daily WHO recommendations for Physical Activity (PA) of at least 60 minutes per day. Limited studies have assessed the opportunities schools provide for PA to help the children achieve their daily recommended PA. We determined the level of and the factors associated with PA offered in primary schools in Makindye Division in Kampala during the school term. Methods This cross-sectional study was conducted in 36 selected government and private primary schools in Makindye Division, Kampala. PA was defined as the amount of time in minutes available for PA as per WHO recommendations – sufficient (60 minutes or more of PA) or insufficient (less than 60 minutes of PA) and assessed for any factors associated with provision of time for PA in schools. Data were collected by interview administered questionnaires and analysed descriptively. Factors associated with PA were assessed using a logistic regression model. Results Of the 36 schools, 3 were government and 33 were private schools. The proportion of schools offering sufficient time for PA among Primary schools in the Makindye Division was (8/36) 22%. The average time for PA for all schools per week was 197 minutes (SD 70.7). Sufficient PA was associated with the provision of PE lessons after a break or after lunch (p-value 0.038). Sufficient PA was more likely in schools that offered volleyball (OR 8.69), had space in the school for PA (OR 13.27), provided athletics (OR 2.26) and whose fees were Ushs 700,000 (USD 187) or more (OR 1.30). Conclusions Only 22% of sampled schools offered sufficient time for PA among Primary schools in Kampala per WHO guidelines. Provision of sufficient time for PA was associated with PE scheduled either after break or lunch. Sufficient PA was more likely with schools that had space for PA, schools which offered volleyball and athletics, and whose fees were 700,000/= or more. Schools should consider scheduling PE lessons after break or after lunch to increase the likelihood of meeting the targeted time for PA. Primary schools need to be supported to establish facilities and to increase diversity in available activities to ensure children achieve their recommended PA.

Abstract Background While open hemorrhoidectomy under local anesthesia has been shown to be more cost-effective with shorter operation times and lower complication rates, local anesthesia is still not considered as a first-line technique in low-income countries like Uganda. The objective of this trial is to compare open hemorrhoidectomy using local anesthesia versus saddle block among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids in western Uganda. Methods The protocol for a prospective equivalence randomized, double-blind controlled trial was conducted among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids. Recruitment was started in December 2021 and is expected to end in May 2022. Consenting participants who require open hemorrhoidectomy indicated at Kampala International Teaching Hospital, Uganda, will be randomized into two groups of 29 patients per arm. Discussion The primary outcome of this study is to compare the occurrences of postoperative pain following open hemorrhoidectomy using the visual analog scale in an interval of 2, 4, and 6 h and 7 days postoperatively. Furthermore, the mean operative time from the induction of anesthesia to the end of the surgical procedure as well as the cost-effectiveness of the 2 techniques will be assessed in both groups. Open hemorrhoidectomy under local anesthesia has the potential to offer benefits to patients but most importantly expediting return to baseline and functional status, shorter hospital stay by meeting the faster discharge criteria, and reduction in costs associated with reduced length of stay and complications. Trial registration Pan African Clinical Trials Registry PACTR202110667430356. Registered on 8 October 2021

Abstract Background Occupation groups like police officers and fire fighters are exposed to a number of traumatic events which put them at a risk of developing post-traumatic stress disorder (PTSD). Previous studies have found the prevalence of PTSD in police officers to vary between 7 and 19%. However, most of these studies have been undertaken in western setting with little research having been undertaken in sub-Saharan Africa including Uganda. Objective To determine the prevalence and factors associated with post-traumatic stress disorder among field police patrol officers serving in Kampala Metropolitan Police (KMP) North Region. Methods This was a cross sectional study that was conducted on 392 field police patrol officers serving in KMP North Region. Diagnosis of PTSD was undertaken using the Clinician Administered PTSD Scale for DSM-5. In order to assess for psychiatric comorbidities, the study used the Mini International Neuropsychiatric Interview (M.I.N.I.) Results In this study, the prevalence of PTSD was 7.4%. An additional 62.5% had sub-threshold PTSD, which was defined as, the presence of at least one PTSD symptom but not meeting full criteria for PTSD diagnosis. The factors found to be significantly associated with PTSD were all related to the presence of psychiatric comorbidities, namely the presence of: a current major depressive episode (aOR = 4.7; 95% CI: 1.5- 14.8; p = .009); an alcohol use disorder (aOR = 5.1; 95% CI: 2.0–13.0; p = .001); and presence of dissociation symptoms (aOR = 6.7; 95% CI: 2.0–22.2; p = .002). Conclusion PTSD is one of the common psychiatric disorders experienced by serving police officers in Uganda. The tendency of PTSD in this group to co-occur with other psychiatric disorders means that any treatment program to address it should be part of a comprehensive multi-disorder mental health treatment programme in the police office.

Background: The realisation of patients’ rights in resource-constrained and patient-burdened public health care settings in Uganda remains an obstacle towards quality health care delivery, health care seeking behaviour and health outcomes. Although the Uganda Patients’ Charter of 2009 empowers patients to demand quality care, inequitable access and abuse remain common. Aim: The study aimed to assess level of awareness of, responsiveness to and practice of patients’ rights amongst patients and health workers (HWs) at Uganda’s national referral hospital, Mulago Hospital in Kampala. Methods: A three-phase cross-sectional questionnaire-based descriptive survey was conducted amongst 211 patients, 98 HWs and 16 key informants using qualitative and quantitative data collection methods. The study was conducted in May–June 2012, 2.5 years after the launch of the Uganda Patients’ Charter. Results: At least 36.5% of patients faced a challenge regarding their rights whilst seeking health care. Most of the patients (79%) who met a challenge never attempted to demand their rights. Most patients (81.5%) and HWs (69.4%) had never heard of the Uganda Patients’ Charter. Awareness of patients’ rights was significantly higher amongst HWs (70%) than patients (40%) (p < 0.01). Patients’ awareness was associated with education level (x2 = 42.4,p < 0.001), employment status (x2 = 33.6, p < 0.001) and hospital visits (x2 = 3.9, p = 0.048). For HWs it was associated with education level (x2 = 155.6, p < 0.001) and length of service (x2 = 154.5, p <0.001).Patients feel powerless to negotiate for their rights and fear being discriminated against based on their ability to bribe HWs with money to access care, and political, socio-economic and tribal status. Conclusion and recommendations: Awareness of, responsiveness to and practice of patients’ rights remains limited at Mulago Hospital. There is a need for urgent implementation of an integrated multilevel, multichannel, patient-centred approach that incorporates social services and addresses intrinsic patient, HW and health system factors to strengthen patients’ rights issues at the hospital.

Abstract Background The rate at which informal urban settlements (slums) are developing in Low and Middle Income. Countries (LMICs) like Uganda is high. With this, comes the growing intersection between urbanization and the reproductive health of key populations. Currently, a number of interventions are being implemented to improve the Reproductive Health (RH) of adolescents in Kisenyi, the largest informal urban settlement in Kampala, the capital of Uganda. Despite these efforts, adolescent RH indicators have persistently remained poor in Kisenyi. This could be indicative of a gap between the provided and needed adolescent RH interventions. We assessed the fit between the available interventions and the RH needs of adolescents living in Kisenyi. Methods We conducted a qualitative study in July 2019–February 2020 in Kisenyi. The methodology was guided by the Word Health Organization global standards for quality-health care services for adolescents, the “For whom? Where? By whom? and What?” Framework of sexual RH service delivery and the realist evaluation approach. Eight focus group discussions were conducted with adolescents 15–19 years to explore their RH needs. The design and implementation of the available adolescent RH interventions were assessed by conducting Key Informant interviews with 10 RH service providers in Kisenyi. Validation meetings were held with adolescents and they scored the extent to which the various design features of the existing interventions fit the adolescents’ RH needs. Results The available RH interventions focused on meeting the sexual RH needs like providing family planning services but less on social needs like livelihood and sanitation which the adolescents identified as equally important. While the providers designed intervention to target 10-24 year olds, the adolescents preferred to have interventions that specifically targeted the study population 15-19 years. Most interventions were facility-based while, the adolescents desired community based outreaches. Conclusion The packaging and mode of delivery of interventions were perceived less holistic to meet the adolescents’ needs. Most interventions were designed to address the sexual and family planning needs while ignoring the wider social and livelihood needs. More holistic and outreach-based programming that addresses RH within the broader context of livelihood and sanitation requirements are more likely to be effective.

Abstract Background. Amphotericin B is the preferred treatment for cryptococcal meningitis, but it has cumulative severe side effects, including nephrotoxicity, hypokalemia, and hypomagnesemia. Amphotericin-induced severe hypokalemia may predispose the patient to cardiac arrhythmias and death, and there is very little data available regarding these toxicities in resource-limited settings. We hypothesized that standardized electrolyte management during amphotericin therapy is essential to minimize toxicity and optimize survival in sub-Saharan Africa. Methods. Human immunodeficiency virus-infected, antiretroviral therapy naive adults with cryptococcal meningitis were prospectively enrolled at Mulago Hospital in Kampala, Uganda in 3 sequential cohorts with amphotericin B deoxycholate induction treatment. Intravenous fluid use was intermittent in 2001–2002, and universal in 2006–2012. In 2001–2009, serum potassium (K+) was monitored on days 1, 7, and 14 of treatment with replacement (K+, Mg2+) per clinician discretion. In 2011–2012, K+ was measured on days 1, 5, and approximately every 48 hours thereafter with universal electrolyte (K+, Mg2+) supplementation and standardized replacement. Clinical outcomes were retrospectively compared between fluid and electrolyte management strategies. Results. With limited intravenous fluids, the 14-day survival was 49% in 2001–2002. With universal intravenous fluids, the 30-day survival improved to 62% in 2006–2010 (P = .003). In 2011–2012, with universal supplementation of fluids and electrolytes, 30-day cumulative survival improved to 78% (P = .021 vs 2006–2010 cohort). The cumulative incidence of severe hypokalemia (&lt;2.5 mEq/L) decreased from 38% in 2010 to 8.5% in 2011–2012 with universal supplementation (P &lt; .001). Conclusions. Improved survival was seen in a resource-limited setting with proactive fluid and electrolyte management (K+, Mg2+), as part of comprehensive amphotericin-based cryptococcal therapy.

Background: Update and utilization of modern contraceptives has public health benefits including reduction of unintended pregnancies, unsafe abortions, and related maternal mortality. However, paucity of evidence on key indicators of family planning in the informal settlements abounds. Data are usually collapsed within the larger urban communities that tend to mask peculiarities of informal settlements. This study determined the proportion of women using modern contraceptives, the unmet need for modern contraceptives and the total demand in informal settlements of an urban municipality.Methods: A cross-sectional study conducted among 626 women in the reproductive age (15–49 years) in the informal settlements of Kira municipality (part of metropolitan Kampala). Multi-stage sampling was applied in the selection of the respondents. Descriptive and log-binomial regression analysis were conducted to determine percentage of women using modern contraceptives, unmet need, and total demand with their associated factors. All analyses were conducted using STATA version 15.0.Results: The total demand for modern contraceptives was 84.9%, modern contraceptive prevalence was 47.4% nearly meeting the national target of 50%, however the unmet need was 37.3%, which much higher than the national target of 10%. Lower total demand for contraceptives was associated with higher women's education status and preference to have another child, while higher total demand was associated with having at least one living child. Higher modern contraceptives use was associated with older age, having at least one living child and high decision-making power, while lower modern contraceptives use was associated with higher education and undetermined fertility preference. Lower unmet need for modern contraceptives was associated with older age (PR 0.68, 95% CI: 0.48–0.97) and high decision-making power (PR 0.64, 95% CI: 0.50–0.81), while higher unmet need was found among those who having at least one living child (PR 1.40, 95% CI: 1.01–1.93) and undetermined fertility preference (PR 1.70, 95% CI: 1.24–2.34).Conclusions: Total demand and contraceptive use were found to be higher in the informal settlements of Kira municipality, however, the unmet need was much higher among this population as compared to the national urban estimates. This indicates a much higher demand for contraceptives and the need to consider the diverse socio-demographic characteristics of urban spaces. Development of Interventions need to critically consider the diverse urban space, associated explanatory variables and a collaborative systems lens to achieve sustained improvements.

Introduction Documentary film has grown significantly in the past decade, with high profile films such as Fahrenheit 9/11, Supersize Me, and An Inconvenient Truth garnering increased attention both at the box office and in the news media. In addition, the rising prominence of web-based media has provided new opportunities for documentary to create social impact. Films are now typically released with websites, Facebook pages, twitter feeds, and web videos to increase both reach and impact. This combination of technology and broader audience appeal has given rise to a current landscape in which documentary films are imbedded within coordinated multi-media campaigns. New media have not only opened up new avenues for communicating with audiences, they have also created new opportunities for data collection and analysis of film impacts. A recent report by McKinsey and Company highlighted this potential, introducing and discussing the implications of increasing consumer information being recorded on the Internet as well as through networked sensors in the physical world. As they found: "Big data—large pools of data that can be captured, communicated, aggregated, stored, and analyzed—is now part of every sector and function of the global economy" (Manyika et al. iv). This data can be mined to learn a great deal about both individual and cultural response to documentary films and the issues they represent. Although film has a rich history in humanities research, this new set of tools enables an empirical approach grounded in the social sciences. However, several researchers across disciplines have noted that limited investigation has been conducted in this area. Although there has always been an emphasis on social impact in film and many filmmakers and scholars have made legitimate (and possibly illegitimate) claims of impact, few have attempted to empirically justify these claims. Over fifteen years ago, noted film scholar Brian Winston commented that "the underlying assumption of most social documentaries—that they shall act as agents of reform and change—is almost never demonstrated" (236). A decade later, Political Scientist David Whiteman repeated this sentiment, arguing that, "despite widespread speculation about the impact of documentaries, the topic has received relatively little systematic attention" ("Evolving"). And earlier this year, the introduction to a special issue of Mass Communication and Society on documentary film stated, "documentary film, despite its growing influence and many impacts, has mostly been overlooked by social scientists studying the media and communication" (Nisbet and Aufderheide 451). Film has been studied extensively as entertainment, as narrative, and as cultural event, but the study of film as an agent of social change is still in its infancy. This paper introduces a systematic approach to measuring the social impact of documentary film aiming to: (1) discuss the context of documentary film and its potential impact; and (2) argue for a social science approach, discussing key issues about conducting such research. Changes in Documentary Practice Documentary film has been used as a tool for promoting social change throughout its history. John Grierson, who coined the term "documentary" in 1926, believed it could be used to influence the ideas and actions of people in ways once reserved for church and school. He presented his thoughts on this emerging genre in his 1932 essay, First Principles of Documentary, saying, "We believe that the cinema's capacity for getting around, for observing and selecting from life itself, can be exploited in a new and vital art form" (97). Richard Barsam further specified the definition of documentary, distinguishing it from non-fiction film, such that all documentaries are non-fiction films but not all non-fiction films are documentaries. He distinguishes documentary from other forms of non-fiction film (i.e. travel films, educational films, newsreels) by its purpose; it is a film with an opinion and a specific message that aims to persuade or influence the audience. And Bill Nichols writes that the definition of documentary may even expand beyond the film itself, defining it as a "filmmaking practice, a cinematic tradition, and mode of audience reception" (12). Documentary film has undergone many significant changes since its inception, from the heavily staged romanticism movement of the 1920s to the propagandist tradition of governments using film to persuade individuals to support national agendas to the introduction of cinéma vérité in the 1960s and historical documentary in the 1980s (cf. Barnouw). However, the recent upsurge in popularity of documentary media, combined with technological advances of internet and computers have opened up a whole new set of opportunities for film to serve as both art and agent for social change. One such opportunity is in the creation of film-based social action campaigns. Over the past decade, filmmakers have taken a more active role in promoting social change by coordinating film releases with action campaigns. Companies such as Participant Media (An Inconvenient Truth, Food Inc., etc.) now create "specific social action campaigns for each film and documentary designed to give a voice to issues that resonate in the films" (Participant Media). In addition, a new sector of "social media" consultants are now offering services, including "consultation, strategic planning for alternative distribution, website and social media development, and complete campaign management services to filmmakers to ensure the content of nonfiction media truly meets the intention for change" (Working Films). The emergence of new forms of media and technology are changing our conceptions of both documentary film and social action. Technologies such as podcasts, video blogs, internet radio, social media and network applications, and collaborative web editing "both unsettle and extend concepts and assumptions at the heart of 'documentary' as a practice and as an idea" (Ellsworth). In the past decade, we have seen new forms of documentary creation, distribution, marketing, and engagement. Likewise, film campaigns are utilizing a broad array of strategies to engage audience members, including "action kits, screening programs, educational curriculums and classes, house parties, seminars, panels" that often turn into "ongoing 'legacy' programs that are updated and revised to continue beyond the film's domestic and international theatrical, DVD and television windows" (Participant Media). This move towards multi-media documentary film is becoming not only commonplace, but expected as a part of filmmaking. NYU film professor and documentary film pioneer George Stoney recently noted, "50 percent of the documentary filmmaker's job is making the movie, and 50 percent is figuring out what its impact can be and how it can move audiences to action" (qtd. in Nisbet, "Gasland"). In his book Convergence Culture, Henry Jenkins, coined the term "transmedia storytelling", which he later defined as "a process where integral elements of a fiction get dispersed systematically across multiple delivery channels for the purpose of creating a unified and coordinated entertainment experience" ("Transmedia"). When applied to documentary film, it is the elements of the "issue" raised by the film that get dispersed across these channels, coordinating, not just an entertainment experience, but a social action campaign. Dimensions of Evaluation It is not unreasonable to assume that such film campaigns, just like any policy or program, have the possibility to influence viewers' knowledge, attitudes, and behavior. Measuring this impact has become increasingly important, as funders of documentary and issue-based films want look to understand the "return on investment" of films in terms of social impact so that they can compare them with other projects, including non-media, direct service projects. Although we "feel" like films make a difference to the individuals who also see them in the broader cultures in which they are embedded, measurement and empirical analysis of this impact are vitally important for both providing feedback to filmmakers and funders as well as informing future efforts attempting to leverage film for social change. This type of systematic assessment, or program evaluation, is often discussed in terms of two primary goals—formative (or process) and summative (or impact) evaluation (cf. Muraskin; Trochim and Donnelly). Formative evaluation studies program materials and activities to strengthen a program, and summative evaluation examines program outcomes. In terms of documentary film, these two goals can be described as follows: Formative Evaluation: Informing the Process As programs (broadly defined as an intentional set of activities with the aim of having some specific impact), the people who interact with them, and the cultures they are situated in are constantly changing, program development and evaluation is an ongoing learning cycle. Film campaigns, which are an intentional set of activities with the aim of impacting individual viewers and broader cultures, fit squarely within this purview. Without formulating hypotheses about the relationships between program activities and goals and then collecting and analyzing data during implementation to test them, it is difficult to learn ways to improve programs (or continue doing what works best in the most efficient manner). Attention to this process enables those involved to learn more about, not only what works, but how and why it works and even gain insights about how program outcomes may be affected by changes to resource availability, potential audiences, or infrastructure. Filmmakers are constantly learning and honing their craft and realizing the impact of their practice can help the artistic process. Often faced with tight budgets and timelines, they are forced to confront tradeoffs all the time, in the writing, production and post-production process. Understanding where they are having impact can improve their decision-making, which can help both the individual project and the overall field. Summative Evaluation: Quantifying Impacts Evaluation is used in many different fields to determine whether programs are achieving their intended goals and objectives. It became popular in the 1960s as a way of understanding the impact of the Great Society programs and has continued to grow since that time (Madaus and Stufflebeam). A recent White House memo stated that "rigorous, independent program evaluations can be a key resource in determining whether government programs are achieving their intended outcomes as well as possible and at the lowest possible cost" and the United States Office of Management and Budget (OMB) launched an initiative to increase the practice of "impact evaluations, or evaluations aimed at determining the causal effects of programs" (Orszag 1). Documentary films, like government programs, generally target a national audience, aim to serve a social purpose, and often do not provide a return on their investment. Participant Media, the most visible and arguably most successful documentary production company in the film industry, made recent headlines for its difficulty in making a profit during its seven-year history (Cieply). Owner and founder Jeff Skoll reported investing hundreds of millions of dollars into the company and CEO James Berk added that the company sometimes measures success, not by profit, but by "whether Mr. Skoll could have exerted more impact simply by spending his money philanthropically" (Cieply). Because of this, documentary projects often rely on grant funding, and are starting to approach funders beyond traditional arts and media sources. "Filmmakers are finding new fiscal and non-fiscal partners, in constituencies that would not traditionally be considered—or consider themselves—media funders or partners" (BRITDOC 6). And funders increasingly expect tangible data about their return on investment. Says Luis Ubiñas, president of Ford Foundation, which recently launched the Just Films Initiative: In these times of global economic uncertainty, with increasing demand for limited philanthropic dollars, assessing our effectiveness is more important than ever. Today, staying on the frontlines of social change means gauging, with thoughtfulness and rigor, the immediate and distant outcomes of our funding. Establishing the need for evaluation is not enough—attention to methodology is also critical. Valid research methodology is a critical component of understanding around the role entertainment can play in impacting social and environmental issues. The following issues are vital to measuring impact. Defining the Project Though this may seem like an obvious step, it is essential to determine the nature of the project so one can create research questions and hypotheses based on a complete understanding of the "treatment". One organization that provides a great example of the integration of documentary film imbedded into a larger campaign or movement is Invisible Children. Founded in 2005, Invisible Children is both a media-based organization as well as an economic development NGO with the goal of raising awareness and meeting the needs of child soldiers and other youth suffering as a result of the ongoing war in northern Uganda. Although Invisible Children began as a documentary film, it has grown into a large non-profit organization with an operating budget of over $8 million and a staff of over a hundred employees and interns throughout the year as well as volunteers in all 50 states and several countries. Invisible Children programming includes films, events, fundraising campaigns, contests, social media platforms, blogs, videos, two national "tours" per year, merchandise, and even a 650-person three-day youth summit in August 2011 called The Fourth Estate. Individually, each of these components might lead to specific outcomes; collectively, they might lead to others. In order to properly assess impacts of the film "project", it is important to take all of these components into consideration and think about who they may impact and how. This informs the research questions, hypotheses, and methods used in evaluation. Film campaigns may even include partnerships with existing social movements and non-profit organizations targeting social change. The American University Center for Social Media concluded in a case study of three issue-based documentary film campaigns: Digital technologies do not replace, but are closely entwined with, longstanding on-the-ground activities of stakeholders and citizens working for social change. Projects like these forge new tools, pipelines, and circuits of circulation in a multiplatform media environment. They help to create sustainable network infrastructures for participatory public media that extend from local communities to transnational circuits and from grassroots communities to policy makers. (Abrash) Expanding the Focus of Impact beyond the Individual A recent focus has shifted the dialogue on film impact. Whiteman ("Theaters") argues that traditional metrics of film "success" tend to focus on studio economic indicators that are far more relevant to large budget films. Current efforts focused on box office receipts and audience size, the author claims, are really measures of successful film marketing or promotion, missing the mark when it comes to understanding social impact. He instead stresses the importance of developing a more comprehensive model. His "coalition model" broadens the range and types of impact of film beyond traditional metrics to include the entire filmmaking process, from production to distribution. Whiteman (“Theaters”) argues that a narrow focus on the size of the audience for a film, its box office receipts, and viewers' attitudes does not incorporate the potential reach of a documentary film. Impacts within the coalition model include both individual and policy levels. Individual impacts (with an emphasis on activist groups) include educating members, mobilizing for action, and raising group status; policy includes altering both agenda for and the substance of policy deliberations. The Fledgling Fund (Barrett and Leddy) expanded on this concept and identified five distinct impacts of documentary film campaigns. These potential impacts expand from individual viewers to groups, movements, and eventually to what they call the "ultimate goal" of social change. Each is introduced briefly below. Quality Film. The film itself can be presented as a quality film or media project, creating enjoyment or evoking emotion in the part of audiences. "By this we mean a film that has a compelling narrative that draws viewers in and can engage them in the issue and illustrate complex problems in ways that statistics cannot" (Barrett and Leddy, 6). Public Awareness. Film can increase public awareness by bringing light to issues and stories that may have otherwise been unknown or not often thought about. This is the level of impact that has received the most attention, as films are often discussed in terms of their "educational" value. "A project's ability to raise awareness around a particular issue, since awareness is a critical building block for both individual change and broader social change" (Barrett and Leddy, 6). Public Engagement. Impact, however, need not stop at simply raising public awareness. Engagement "indicates a shift from simply being aware of an issue to acting on this awareness. Were a film and its outreach campaign able to provide an answer to the question 'What can I do?' and more importantly mobilize that individual to act?" (Barrett and Leddy, 7). This is where an associated film campaign becomes increasingly important, as transmedia outlets such as Facebook, websites, blogs, etc. can build off the interest and awareness developed through watching a film and provide outlets for viewers channel their constructive efforts. Social Movement. In addition to impacts on individuals, films can also serve to mobilize groups focused on a particular problem. The filmmaker can create a campaign around the film to promote its goals and/or work with existing groups focused on a particular issue, so that the film can be used as a tool for mobilization and collaboration. "Moving beyond measures of impact as they relate to individual awareness and engagement, we look at the project's impact as it relates to the broader social movement … if a project can strengthen the work of key advocacy organizations that have strong commitment to the issues raised in the film" (Barrett and Leddy, 7). Social Change. The final level of impact and "ultimate goal" of an issue-based film is long-term and systemic social change. "While we understand that realizing social change is often a long and complex process, we do believe it is possible and that for some projects and issues there are key indicators of success" (Barrett and Leddy, 7). This can take the form of policy or legislative change, passed through film-based lobbying efforts, or shifts in public dialogue and behavior. Legislative change typically takes place beyond the social movement stage, when there is enough support to pressure legislators to change or create policy. Film-inspired activism has been seen in issues ranging from environmental causes such as agriculture (Food Inc.) and toxic products (Blue Vinyl) to social causes such as foreign conflict (Invisible Children) and education (Waiting for Superman). Documentary films can also have a strong influence as media agenda-setters, as films provide dramatic "news pegs" for journalists seeking to either sustain or generation new coverage of an issue (Nisbet "Introduction" 5), such as the media coverage of climate change in conjunction with An Inconvenient Truth. Barrett and Leddy, however, note that not all films target all five impacts and that different films may lead to different impacts. "In some cases we could look to key legislative or policy changes that were driven by, or at least supported by the project... In other cases, we can point to shifts in public dialogue and how issues are framed and discussed" (7). It is possible that specific film and/or campaign characteristics may lead to different impacts; this is a nascent area for research and one with great promise for both practical and theoretical utility. Innovations in Tools and Methods Finally, the selection of tools is a vital component for assessing impact and the new media landscape is enabling innovations in the methods and strategies for program evaluation. Whereas the traditional domain of film impact measurement included box office statistics, focus groups, and exit surveys, innovations in data collection and analysis have expanded the reach of what questions we can ask and how we are able to answer them. For example, press coverage can assist in understanding and measuring the increase in awareness about an issue post-release. Looking directly at web-traffic changes "enables the creation of an information-seeking curve that can define the parameters of a teachable moment" (Hart and Leiserowitz 360). Audience reception can be measured, not only via interviews and focus groups, but also through content and sentiment analysis of web content and online analytics. "Sophisticated analytics can substantially improve decision making, minimize risks, and unearth valuable insights that would otherwise remain hidden" (Manyika et al. 5). These new tools are significantly changing evaluation, expanding what we can learn about the social impacts of film through triangulation of self-report data with measurement of actual behavior in virtual environments. Conclusion The changing media landscape both allows and impels evaluation of film impacts on individual viewers and the broader culture in which they are imbedded. Although such analysis may have previously been limited to box office numbers, critics' reviews, and theater exit surveys, the rise of new media provides both the ability to connect filmmakers, activists, and viewers in new ways and the data in which to study the process. This capability, combined with significant growth in the documentary landscape, suggests a great potential for documentary film to contribute to some of our most pressing social and environmental needs. A social scientific approach, that combines empirical analysis with theory applied from basic science, ensures that impact can be measured and leveraged in a way that is useful for both filmmakers as well as funders. In the end, this attention to impact ensures a continued thriving marketplace for issue-based documentary films in our social landscape. References Abrash, Barbara. "Social Issue Documentary: The Evolution of Public Engagement." American University Center for Social Media 21 Apr. 2010. 26 Sep. 2011 ‹http://www.centerforsocialmedia.org/›. Aufderheide, Patricia. "The Changing Documentary Marketplace." Cineaste 30.3 (2005): 24-28. Barnouw, Eric. Documentary: A History of the Non-Fiction Film. New York: Oxford UP, 1993. Barrett, Diana and Sheila Leddy. "Assessing Creative Media's Social Impact." The Fledgling Fund, Dec. 2008. 15 Sep. 2011 ‹http://www.thefledglingfund.org/media/research.html›. Barsam, Richard M. Nonfiction Film: A Critical History. Bloomington: Indiana UP. 1992. BRITDOC Foundation. The End of the Line: A Social Impact Evaluation. London: Channel 4, 2011. 12 Oct. 2011 ‹http://britdoc.org/news_details/the_social_impact_of_the_end_of_the_line/›. Cieply, Michael. "Uneven Growth for Film Studio with a Message." New York Times 5 Jun. 2011: B1. Ellsworth, Elizabeth. "Emerging Media and Documentary Practice." The New School Graduate Program in International Affairs. Aug. 2008. 22 Sep. 2011. ‹http://www.gpia.info/node/911›. Grierson, John. "First Principles of Documentary (1932)." Imagining Reality: The Faber Book of Documentary. Eds. Kevin Macdonald and Mark Cousins. London: Faber and Faber, 1996. 97-102. Hart, Philip Solomon and Anthony Leiserowitz. "Finding the Teachable Moment: An Analysis of Information-Seeking Behavior on Global Warming Related Websites during the Release of The Day After Tomorrow." Environmental Communication: A Journal of Nature and Culture 3.3 (2009): 355-66. Jenkins, Henry. Convergence Culture: Where Old and New Media Collide. New York: New York UP, 2006. ———. "Transmedia Storytelling 101." Confessions of an Aca-Fan. The Official Weblog of Henry Jenkins. 22 Mar. 2007. 10 Oct. 2011 ‹http://www.henryjenkins.org/2007/03/transmedia_storytelling_101.html›. Madaus, George, and Daniel Stufflebeam. "Program Evaluation: A Historical Overview." Evaluation in Education and Human Services 49.1 (2002): 3-18. Manyika, James, Michael Chui, Jacques Bughin, Brad Brown, Richard Dobbs, Charles Roxburgh, and Angela Hung Byers. Big Data: The Next Frontier for Innovation, Competition, and Productivity. McKinsey Global Institute. May 2011 ‹http://www.mckinsey.com/mgi/publications/big_data/›. Muraskin, Lana. Understanding Evaluation: The Way to Better Prevention Programs. Washington: U.S. Department of Education, 1993. 8 Oct. 2011 ‹http://www2.ed.gov/PDFDocs/handbook.pdf›. Nichols, Bill. "Foreword." Documenting the Documentary: Close Readings of Documentary Film and Video. Eds. Barry Keith Grant and Jeannette Sloniowski. Detroit: Wayne State UP, 1997. 11-13. Nisbet, Matthew. "Gasland and Dirty Business: Documentary Films Shape Debate on Energy Policy." Big Think, 9 May 2011. 1 Oct. 2011 ‹http://bigthink.com/ideas/38345›. ———. "Introduction: Understanding the Social Impact of a Documentary Film." Documentaries on a Mission: How Nonprofits Are Making Movies for Public Engagement. Ed. Karen Hirsch, Center for Social Media. Mar. 2007. 10 Sep. 2011 ‹http://aladinrc.wrlc.org/bitstream/1961/4634/1/docs_on_a_mission.pdf›. Nisbet, Matthew, and Patricia Aufderheide. "Documentary Film: Towards a Research Agenda on Forms, Functions, and Impacts." Mass Communication and Society 12.4 (2011): 450-56. Orszag, Peter. Increased Emphasis on Program Evaluation. Washington: Office of Management and Budget. 7 Oct. 2009. 10 Oct. 2011 ‹http://www.whitehouse.gov/sites/default/files/omb/assets/memoranda_2010/m10-01.pdf›. Participant Media. "Our Mission." 2011. 2 Apr. 2011 ‹http://www.participantmedia.com/company/about_us.php.›. Plantinga, Carl. Rhetoric and Representation in Nonfiction Film. Cambridge: Cambridge UP, 1997. Trochim, William, and James Donnelly. Research Methods Knowledge Base. 3rd ed. Mason: Atomic Dogs, 2007. Ubiñas, Luis. "President's Message." 2009 Annual Report. Ford Foundation, Sep. 2010. 10 Oct. 2011 ‹http://www.fordfoundation.org/about-us/2009-annual-report/presidents-message›. Vladica, Florin, and Charles Davis. "Business Innovation and New Media Practices in Documentary Film Production and Distribution: Conceptual Framework and Review of Evidence." The Media as a Driver of the Information Society. Eds. Ed Albarran, Paulo Faustino, and R. Santos. Lisbon, Portugal: Media XXI / Formal, 2009. 299-319. Whiteman, David. "Out of the Theaters and into the Streets: A Coalition Model of the Political Impact of Documentary Film and Video." Political Communication 21.1 (2004): 51-69. ———. "The Evolving Impact of Documentary Film: Sacrifice and the Rise of Issue-Centered Outreach." Post Script 22 Jun. 2007. 10 Sep. 2011 ‹http://www.allbusiness.com/media-telecommunications/movies-sound-recording/5517496-1.html›. Winston, Brian. Claiming the Real: The Documentary Film Revisited. London: British Film Institute, 1995. Working Films. "Nonprofits: Working Films." Foundation Source Access 31 May 2011. 5 Oct. 2011 ‹http://access.foundationsource.com/nonprofit/working-films/›.

“Human beings are not born once and for all on the day their mothers give birth to them [...] life obliges them over and over again to give birth to themselves.” (Garcia Marquez 165) Introduction The refugee experience is, at heart, one of rebirth. Just as becoming a new, distinctive being—biological birth—necessarily involves the physical separation of mother and infant, so becoming a refugee entails separation from a "mother country." This mother country may or may not be a recognised nation state; the point is that the refugee transitions from physical connectedness to separation, from insider to outsider, from endemic to alien. Like babies, refugees may have little control over the timing and conditions of their expulsion. Successful resettlement requires not one rebirth but multiple rebirths—resettlement is a lifelong process (Layton)—which in turn require hope, imagination, and energy. In rebirthing themselves over and over again, people who have fled or been forced from their homelands become both mother and child. They do not go through this rebirthing alone. A range of agencies and individuals may be there to assist, including immigration officials, settlement services, schools and teachers, employment agencies and employers, English as a Second Language (ESL) resources and instructors, health-care providers, counsellors, diasporic networks, neighbours, church groups, and other community organisations. The nature, intensity, and duration of these “midwives’” interventions—and when they occur and in what combinations—vary hugely from place to place and from person to person, but there is clear evidence that post-migration experiences have a significant impact on settlement outcomes (Fozdar and Hartley). This paper draws on qualitative research I did in 2012 in a regional town in New South Wales to illuminate some of the ways in which settlement aides ease, or impede, refugees’ rebirth as fully recognised and participating Australians. I begin by considering what it means to be resilient before tracing some of the dimensions of the resettlement process. In doing so, I draw on data from interviews and focus groups with former refugees, service providers, and other residents of the town I shall call Easthaven. First, though, a word about Easthaven. As is the case in many rural and regional parts of Australia, Easthaven’s population is strongly dominated by Anglo Celtic and Saxon ancestries: 2011 Census data show that more than 80 per cent of residents were born in Australia (compared with a national figure of 69.8 per cent) and about 90 per cent speak only English at home (76.8 per cent). Almost twice as many people identify as Aboriginal or Torres Strait Islander as the national figure of 2.5 per cent (Australian Bureau of Statistics). For several years Easthaven has been an official “Refugee Welcome Zone”, welcoming hundreds of refugees from diverse countries in Africa and the Middle East as well as from Myanmar. This reflects the Department of Immigration and Citizenship’s drive to settle a fifth of Australia’s 13,750 humanitarian entrants a year directly in regional areas. In Easthaven’s schools—which is where I focused my research—almost all of the ESL students are from refugee backgrounds. Defining Resilience Much of the research on human resilience is grounded in psychology, with a capacity to “bounce back” from adverse experiences cited in many definitions of resilience (e.g. American Psychological Association). Bouncing back implies a relatively quick process, and a return to a state or form similar to that which existed before the encounter with adversity. Yet resilience often requires sustained effort and significant changes in identity. As Jerome Rugaruza, a former UNHCR refugee, says of his journey from the Democratic Republic of Congo to Australia: All the steps begin in the burning village: you run with nothing to eat, no clothes. You just go. Then you get to the refugee camp […] You have a little bread and you thank god you are safe. Then after a few years in the camp, you think about a future for your children. You arrive in Australia and then you learn a new language, you learn to drive. There are so many steps and not everyone can do it. (Milsom) Not everyone can do it, but a large majority do. Research by Graeme Hugo, for example, shows that although humanitarian settlers in Australia face substantial barriers to employment and initially have much higher unemployment rates than other immigrants, for most nationality groups this difference has disappeared by the second generation: “This is consistent with the sacrifice (or investment) of the first generation and the efforts extended to attain higher levels of education and English proficiency, thereby reducing the barriers over time.” (Hugo 35). Ingrid Poulson writes that “resilience is not just about bouncing. Bouncing […] is only a reaction. Resilience is about rising—you rise above it, you rise to the occasion, you rise to the challenge. Rising is an active choice” (47; my emphasis) I see resilience as involving mental and physical grit, coupled with creativity, aspiration and, crucially, agency. Dimensions of Resettlement To return to the story of 41-year-old Jerome Rugaruza, as related in a recent newspaper article: He [Mr Rugaruza] describes the experience of being a newly arrived refugee as being like that of a newborn baby. “You need special care; you have to learn to speak [English], eat the different food, create relationships, connections”. (Milsom) This is a key dimension of resettlement: the adult becomes like an infant again, shifting from someone who knows how things work and how to get by to someone who is likely to be, for a while, dependent on others for even the most basic things—communication, food, shelter, clothing, and social contact. The “special care” that most refugee arrivals need initially (and sometimes for a long time) often results in their being seen as deficient—in knowledge, skills, dispositions, and capacities as well as material goods (Keddie; Uptin, Wright and Harwood). As Fozdar and Hartley note: “The tendency to use a deficit model in refugee resettlement devalues people and reinforces the view of the mainstream population that refugees are a liability” (27). Yet unlike newborns, humanitarian settlers come to their new countries with rich social networks and extensive histories of experience and learning—resources that are in fact vital to their rebirth. Sisay (all names are pseudonyms), a year 11 student of Ethiopian heritage who was born in Kenya, told me with feeling: I had a life back in Africa [her emphasis]. It was good. Well, I would go back there if there’s no problems, which—is a fact. And I came here for a better life—yeah, I have a better life, there’s good health care, free school, and good environment and all that. But what’s that without friends? A fellow student, Celine, who came to Australia five years ago from Burundi via Uganda, told me in a focus group: Some teachers are really good but I think some other teachers could be a little bit more encouraging and understanding of what we’ve gone through, because [they] just look at you like “You’re year 11 now, you should know this” […] It’s really discouraging when [the teachers say] in front of the class, “Oh, you shouldn’t do this subject because you haven’t done this this this this” […] It’s like they’re on purpose to tell you “you don’t have what it takes; just give up and do something else.” As Uptin, Wright and Harwood note, “schools not only have the power to position who is included in schooling (in culture and pedagogy) but also have the power to determine whether there is room and appreciation for diversity” (126). Both Sisay and Celine were disheartened by the fact they felt some of their teachers, and many of their peers, had little interest in or understanding of their lives before they came to Australia. The teachers’ low expectations of refugee-background students (Keddie, Uptin, Wright and Harwood) contrasted with the students’ and their families’ high expectations of themselves (Brown, Miller and Mitchell; Harris and Marlowe). When I asked Sisay about her post-school ambitions, she said: “I have a good idea of my future […] write a documentary. And I’m working on it.” Celine’s response was: “I know I’m gonna do medicine, be a doctor.” A third girl, Lily, who came to Australia from Myanmar three years ago, told me she wanted to be an accountant and had studied accounting at the local TAFE last year. Joseph, a father of three who resettled from South Sudan seven years ago, stressed how important getting a job was to successful settlement: [But] you have to get a certificate first to get a job. Even the job of cleaning—when I came here I was told that somebody has to go to have training in cleaning, to use the different chemicals to clean the ground and all that. But that is just sweeping and cleaning with water—you don’t need the [higher-level] skills. Simple jobs like this, we are not able to get them. In regional Australia, employment opportunities tend to be limited (Fozdar and Hartley); the unemployment rate in Easthaven is twice the national average. Opportunities to study are also more limited than in urban centres, and would-be students are not always eligible for financial assistance to gain or upgrade qualifications. Even when people do have appropriate qualifications, work experience, and language proficiency, the colour of their skin may still mean they miss out on a job. Tilbury and Colic-Peisker have documented the various ways in which employers deflect responsibility for racial discrimination, including the “common” strategy (658) of arguing that while the employer or organisation is not prejudiced, they have to discriminate because of their clients’ needs or expectations. I heard this strategy deployed in an interview with a local businesswoman, Catriona: We were advertising for a new technician. And one of the African refugees came to us and he’d had a lot of IT experience. And this is awful, but we felt we couldn't give him the job, because we send our technicians into people's houses, and we knew that if a black African guy rocked up at someone’s house to try and fix their computer, they would not always be welcomed in all—look, it would not be something that [Easthaven] was ready for yet. Colic-Peisker and Tilbury (Refugees and Employment) note that while Australia has strict anti-discrimination legislation, this legislation may be of little use to the people who, because of the way they look and sound (skin colour, dress, accent), are most likely to face prejudice and discrimination. The researchers found that perceived discrimination in the labour market affected humanitarian settlers’ sense of satisfaction with their new lives far more than, for example, racist remarks, which were generally shrugged off; the students I interviewed spoke of racism as “expected,” but “quite rare.” Most of the people Colic-Peisker and Tilbury surveyed reported finding Australians “friendly and accepting” (33). Even if there is no active discrimination on the basis of skin colour in employment, education, or housing, or overt racism in social situations, visible difference can still affect a person’s sense of belonging, as Joseph recounts: I think of myself as Australian, but my colour doesn’t [laughs] […] Unfortunately many, many Australians are expecting that Australia is a country of Europeans … There is no need for somebody to ask “Where do you come from?” and “Do you find Australia here safe?” and “Do you enjoy it?” Those kind of questions doesn’t encourage that we are together. This highlights another dimension of resettlement: the journey from feeling “at home” to feeling “foreign” to, eventually, feeling at home again in the host country (Colic-Peisker and Tilbury, Refugees and Employment). In the case of visibly different settlers, however, this last stage may never be completed. Whether the questions asked of Joseph are well intentioned or not, their effect may be the same: they position him as a “forever foreigner” (Park). A further dimension of resettlement—one already touched on—is the degree to which humanitarian settlers actively manage their “rebirth,” and are allowed and encouraged to do so. A key factor will be their mastery of English, and Easthaven’s ESL teachers are thus pivotal in the resettlement process. There is little doubt that many of these teachers have gone to great lengths to help this cohort of students, not only in terms of language acquisition but also social inclusion. However, in some cases what is initially supportive can, with time, begin to undermine refugees’ maturity into independent citizens. Sharon, an ESL teacher at one of the schools, told me how she and her colleagues would give their refugee-background students lifts to social events: But then maybe three years down the track they have a car and their dad can drive, but they still won’t take them […] We arrive to pick them up and they’re not ready, or there’s five fantastic cars in the driveway, and you pick up the student and they say “My dad’s car’s much bigger and better than yours” [laughs]. So there’s an expectation that we’ll do stuff for them, but we’ve created that [my emphasis]. Other support services may have more complex interests in keeping refugee settlers dependent. The more clients an agency has, the more services it provides, and the longer clients stay on its books, the more lucrative the contract for the agency. Thus financial and employment imperatives promote competition rather than collaboration between service providers (Fozdar and Hartley; Sidhu and Taylor) and may encourage assumptions about what sorts of services different individuals and groups want and need. Colic-Peisker and Tilbury (“‘Active’ and ‘Passive’ Resettlement”) have developed a typology of resettlement styles—“achievers,” “consumers,” “endurers,” and “victims”—but stress that a person’s style, while influenced by personality and pre-migration factors, is also shaped by the institutions and individuals they come into contact with: “The structure of settlement and welfare services may produce a victim mentality, leaving members of refugee communities inert and unable to see themselves as agents of change” (76). The prevailing narrative of “the traumatised refugee” is a key aspect of this dynamic (Colic-Peisker and Tilbury, “‘Active’ and ‘Passive’ Resettlement”; Fozdar and Hartley; Keddie). Service providers may make assumptions about what humanitarian settlers have gone through before arriving in Australia, how they have been affected by their experiences, and what must be done to “fix” them. Norah, a long-time caseworker, told me: I think you get some [providers] who go, “How could you have gone through something like that and not suffered? There must be—you must have to talk about this stuff” […] Where some [refugees] just come with the [attitude] “We’re all born into a situation; that was my situation, but I’m here now and now my focus is this.” She cited failure to consider cultural sensitivities around mental illness and to recognise that stress and anxiety during early resettlement are normal (Tilbury) as other problems in the sector: [Newly arrived refugees] go through the “happy to be here” [phase] and now “hang on, I’ve thumped to the bottom and I’m missing my own foods and smells and cultures and experiences”. I think sometimes we’re just too quick to try and slot people into a box. One factor that appears to be vital in fostering and sustaining resilience is social connection. Norah said her clients were “very good on the mobile phone” and had links “everywhere,” including to family and friends in their countries of birth, transition countries, and other parts of Australia. A 2011 report for DIAC, Settlement Outcomes of New Arrivals, found that humanitarian entrants to Australia were significantly more likely to be members of cultural and/or religious groups than other categories of immigrants (Australian Survey Research). I found many examples of efforts to build both bonding and bridging capital (Putnam) in Easthaven, and I offer two examples below. Several people told me about a dinner-dance that had been held a few weeks before one of my visits. The event was organised by an African women’s group, which had been formed—with funding assistance—several years before. The dinner-dance was advertised in the local newspaper and attracted strong interest from a broad cross-section of Easthaveners. To Debbie, a counsellor, the response signified a “real turnaround” in community relations and was a big boon to the women’s sense of belonging. Erica, a teacher, told me about a cultural exchange day she had organised between her bush school—where almost all of the children are Anglo Australian—and ESL students from one of the town schools: At the start of the day, my kids were looking at [the refugee-background students] and they were scared, they were saying to me, "I feel scared." And we shoved them all into this tiny little room […] and they had no choice but to sit practically on top of each other. And by the end of the day, they were hugging each other and braiding their hair and jumping and playing together. Like Uptin, Wright and Harwood, I found that the refugee-background students placed great importance on the social aspects of school. Sisay, the girl I introduced earlier in this paper, said: “It’s just all about friendship and someone to be there for you […] We try to be friends with them [the non-refugee students] sometimes but sometimes it just seems they don’t want it.” Conclusion A 2012 report on refugee settlement services in NSW concludes that the state “is not meeting its responsibility to humanitarian entrants as well as it could” (Audit Office of New South Wales 2); moreover, humanitarian settlers in NSW are doing less well on indicators such as housing and health than humanitarian settlers in other states (3). Evaluating the effectiveness of formal refugee-centred programs was not part of my research and is beyond the scope of this paper. Rather, I have sought to reveal some of the ways in which the attitudes, assumptions, and everyday practices of service providers and members of the broader community impact on refugees' settlement experience. What I heard repeatedly in the interviews I conducted was that it was emotional and practical support (Matthews; Tilbury), and being asked as well as told (about their hopes, needs, desires), that helped Easthaven’s refugee settlers bear themselves into fulfilling new lives. References Audit Office of New South Wales. Settling Humanitarian Entrants in New South Wales—Executive Summary. May 2012. 15 Aug. 2013 ‹http://www.audit.nsw.gov.au/ArticleDocuments/245/02_Humanitarian_Entrants_2012_Executive_Summary.pdf.aspx?Embed=Y>. Australian Bureau of Statistics. 2011 Census QuickStats. Mar. 2013. 11 Aug. 2013 ‹http://www.censusdata.abs.gov.au/census_services/getproduct/census/2011/quickstat/0>. Australian Survey Research. Settlement Outcomes of New Arrivals—Report of Findings. Apr. 2011. 15 Aug. 2013 ‹http://www.immi.gov.au/media/publications/research/_pdf/settlement-outcomes-new-arrivals.pdf>. Brown, Jill, Jenny Miller, and Jane Mitchell. “Interrupted Schooling and the Acquisition of Literacy: Experiences of Sudanese Refugees in Victorian Secondary Schools.” Australian Journal of Language and Literacy 29.2 (2006): 150-62. Colic-Peisker, Val, and Farida Tilbury. “‘Active’ and ‘Passive’ Resettlement: The Influence of Supporting Services and Refugees’ Own Resources on Resettlement Style.” International Migration 41.5 (2004): 61-91. ———. Refugees and Employment: The Effect of Visible Difference on Discrimination—Final Report. Perth: Centre for Social and Community Research, Murdoch University, 2007. Fozdar, Farida, and Lisa Hartley. “Refugee Resettlement in Australia: What We Know and Need To Know.” Refugee Survey Quarterly 4 Jun. 2013. 12 Aug. 2013 ‹http://rsq.oxfordjournals.org/search?fulltext=fozdar&submit=yes&x=0&y=0>. Garcia Marquez, Gabriel. Love in the Time of Cholera. London: Penguin Books, 1989. Harris, Vandra, and Jay Marlowe. “Hard Yards and High Hopes: The Educational Challenges of African Refugee University Students in Australia.” International Journal of Teaching and Learning in Higher Education 23.2 (2011): 186-96. Hugo, Graeme. A Significant Contribution: The Economic, Social and Civic Contributions of First and Second Generation Humanitarian Entrants—Summary of Findings. Canberra: Department of Immigration and Citizenship, 2011. Keddie, Amanda. “Pursuing Justice for Refugee Students: Addressing Issues of Cultural (Mis)recognition.” International Journal of Inclusive Education 16.12 (2012): 1295-1310. Layton, Robyn. "Building Capacity to Ensure the Inclusion of Vulnerable Groups." Creating Our Future conference, Adelaide, 28 Jul. 2012. Milsom, Rosemarie. “From Hard Luck Life to the Lucky Country.” Sydney Morning Herald 20 Jun. 2013. 12 Aug. 2013 ‹http://www.smh.com.au/national/from-hard-luck-life-to-the-lucky-country-20130619-2oixl.html>. Park, Gilbert C. “’Are We Real Americans?’: Cultural Production of Forever Foreigners at a Diversity Event.” Education and Urban Society 43.4 (2011): 451-67. Poulson, Ingrid. Rise. Sydney: Pan Macmillan Australia, 2008. Putnam, Robert D. Bowling Alone: The Collapse and Revival of American Community. New York: Simon & Schuster, 2000. Sidhu, Ravinder K., and Sandra Taylor. “The Trials and Tribulations of Partnerships in Refugee Settlement Services in Australia.” Journal of Education Policy 24.6 (2009): 655-72. Tilbury, Farida. “‘I Feel I Am a Bird without Wings’: Discourses of Sadness and Loss among East Africans in Western Australia.” Identities: Global Studies in Culture and Power 14.4 (2007): 433-58. ———, and Val Colic-Peisker. “Deflecting Responsibility in Employer Talk about Race Discrimination.” Discourse & Society 17.5 (2006): 651-76. Uptin, Jonnell, Jan Wright, and Valerie Harwood. “It Felt Like I Was a Black Dot on White Paper: Examining Young Former Refugees’ Experience of Entering Australian High Schools.” The Australian Educational Researcher 40.1 (2013): 125-37.