Rural households in South Asia’s coastal deltas face numerous livelihood challenges, including risks posed by climatic variability and extreme weather events. This study examines major climate risks, farmers’ adaptation strategies, and the factors affecting the choice of those strategies using data collected from 630 households in southwestern coastal Bangladesh. Farmers identified cyclones, excessive rain and flooding, and salinity as direct climate risks. Increased crop diseases/pests and livestock diseases were perceived as indirect risks resulting from climatic variability. Farmers used multiple adaptation strategies against those risks such as modifications in farm management, use of savings and borrowing funds from family and neighbors, and periodically reducing household food consumption. Off-farm employment and seeking assistance from governmental as well as non-governmental organizations (NGOs) were also common adaptation strategies. The results show that male-headed households are more likely to change farming practices and reduce consumption compared with female-headed households that conversely tended to take assistance from NGOs as an adaptation strategy. Ownership of land and livestock, as well as farmers’ prior exposure to climate change and educational training, also had a significant effect on the choice of adaptation strategy. Therefore, development interventions and policies that aimed at improving resource endowment and training to farmers on climatic risks and their adaptation strategies can help minimize the impact of climatic risks. Climate-related risks, including extreme events such as cyclones, excessive rainfall, and consequent flooding and waterlogging, soil salinity, and river bank erosion, have been widely acknowledged to negatively affect rural livelihoods in South Asia’s coastal regions Dastagir . The geoImpacts of these climatic risks are particularly severe for smallholder farmers that make up the bulk of the rural population in Bangladesh. As the agriculture sector contributes 13% of the country’s gross domestic product and employs 48% of the labor force  in 2013 as part of the CGIAR Research Program on Climate Change, Agriculture, and Food Security. A total of 630 farm households from three districts of Bangladesh were interviewed , economic and social capital related variables  or extension, and access to training) and perceptions of the major climate risks faced and the adaptation strategies applied by households were collected.In addition, four follow-up focus group discussions (FGDs) were carried out in two villages of Satkhira district to understand local gender norms, surveyed farmers’ perceptions of climate risks and adaptation strategies used in their communities. The FGD was carried out separately for men and women farmers to capture gender-differentiated perceptions of the impacts of climate risks and the use of adaptation strategies.Climate risks, including extreme weather events, can adversely affect agricultural production and hence, the livelihood of farm households  Households that experience a higher level of “damage,” in terms of the effects of climate risks on their livelihoods, are more likely to adopt adaptation strategies compared with other households. (ii) Households with more livelihood assets, when experience with a higher level of damage due to climate risks, are more likely to apply adaptation strategies compared with other households. (iii) Households that experience more damage from extreme climate events are more likely to undertake multiple adaptation strategies than those experiencing less damage. (iv) Finally, male-headed households are more likely to apply multiple adaptation strategies as compared with female-headed households.As noted in the fourth hypothesis, to adapt to the impact of climate change, a farm household may apply multiple strategies. In the cases when the severity of climate risks becomes very high, their own efforts may not be sufficient to effectively manage risks. Under such circumstances, farmers may seek external assistance from governmental or nongovernmental and civil society organizations. Once the adverse effect of climate risks on their livelihood crosses a self-determined threshold, changing farm practices, reducing consumption, or using savings and borrowings alone cannot improve their situation . Under these circumstances, in our conceptual framework, farmers can, therefore, opt to make use of both farming and nonfarming strategies.Y denotes the decision to adopt at least one climate adaptation strategy by the farmer, and thus, Y∈{0,1}, where Y = 1 if farm household adopts climate adaptation strategies and 0 otherwise. The probability of a farm household adopting climate risk mitigating strategies [Pr(Y = 1)] is consequently derived using Eq.  can be represented by Eq. :2\documeXK, the marginal effect is obtained from Eq. , therefore depends on a set of explanatory variables, Xi1, …….., Xik, as described in Eq.  and substitutability (negative correlation) between adaptation strategies employed by the farmers. From the survey data of the study area, we identify that farm households commonly adopt five major types of climate adaptation strategies, i.e. (i) changing farming practices, (ii) use of savings and borrowings, (iii) a reduction in household consumption, (iv) seek off-farm or other farm laborer employment options, (v) take assistance from government, and/or (vi) NGOs.ith farm household  facing a decision on whether to adopt the jth climate adaptation strategies (where j denotes a choice of: changing farming practices (F), using savings and borrowings (S), reducing household consumption (C), seeking off-farm or other farm laborer employment options (J), take assistance from government (G), and/or from NGOs (N)). Let U0and Uj represent the benefits to a farmer without and with the adoption of climate adaptation strategies. A farmer will decide to adopt the jth climate adaptation strategies if the net benefit Xij) and the error term (εij) as in Eq. (A farmer is more likely to adopt a particular climate adaptation strategy if the benefit from its adoption is higher than nonadoption. Consider the s in Eq. :5\documeEquation ω) is given by Eq.  and excessive rain and storms and flooding (26%). Of the indirect climatic risks, livestock diseases and epidemics and crop pests and diseases were reported by 23% and 22% of respondents, respectively. Farmers have used several agricultural, economic, and other measures to adapt to these climate risks  was developed by the Ministry of Environment and Forests in 2005 and revised in 2009 to acknowledge these issues. Alongside the Bangladesh Climate Change Strategy and Action Plan , including but not limited to farmers’ groups or associations. Similarly, the role of NGOs in enhancing the capacity of men and women farmers in climate change adaptation, and how to improve the coordination between governmental and NGOs to improve farm households’ capital assets so that climate adaptation is achieved.This study explored the major climatic risks in south-western coastal Bangladesh, farmers’ adaptation strategies, and determinants of the choice of those strategies. We found that the livelihood of smallholder farmers in the study area are affected by climatic risks such as cyclones, increasing soil and water salinity, storm surges and heavy rainfall that can result in flooding and waterlogging. Besides, farmers in the study area reported crop/livestock pests and diseases as indirect impacts of climate change.Major adaptation strategies to reduce the impact of climate change adopted by the farmers in the study area include changes in farming practices, use of savings and borrowing money from others, and reduced household food and goods consumption. In addition, farmers indicated that they may seek to take assistance from the government and/or NGOs, as well as seeking alternative forms of agricultural and nonagricultural employment and income generation.We found that the choice of adaptation strategy was affected by the gender of the household head, availability of household assets at their disposal, and level of awareness on climate change and its impact. This calls for future policy aimed at increasing the capacity of farmers in South Asia’s climate risk vulnerable coastal areas and should focus on enhancing the knowledge through educational programs, increase access to multiple livelihood opportunities, and information on adaptation strategies, while also working to improve poor and women’s access to resources.Despite robust results, one of the limitations of this study is that it is based on the cross-sectional data. Therefore, future study with panel data over a long period of time can help in understanding the dynamics of climate change and its impacts on farm households livelihood and also looking deeper into how adaptation strategies evolve over a period of time.


The GSA publications team sponsors this annual symposium to assist prospective authors to successfully publish their gerontological scholarship in GSA’s high impact and influential journals. The first part of the session will include five brief presentations from the Editors-in-chief of Journals of Gerontology-Series B, Social and Psychological Sciences, The Gerontologist, and Innovation in Aging, plus one of GSA’s managing editors. We will integrate practical tips with principles of publication ethics and scholarly integrity. The topics will be as follows: (1) preparing your manuscript, including how to choose the right journal; (2) strong and ethical scholarly writing for multidisciplinary audiences; (3) transparency, documentation, and Open Science; (4) successfully responding to reviews; and (5) working with Scholar One. Following these presentations, we will hold round table discussions with editors from the GSA journals portfolio. At these roundtables, editors will answer questions related to the podium presentations and other questions specific to each journal. Intended audiences include emerging and international scholars, and authors interested in learning more about best practices and tips for getting their scholarly work published.


Since the declaration of the 10th Ebola Virus Disease (EVD) outbreak in DRC on 1st Aug 2018, several neighboring countries have been developing and implementing preparedness efforts to prevent EVD cross-border transmission to enable timely detection, investigation, and response in the event of a confirmed EVD outbreak in the country. We describe Uganda’s experience in EVD preparedness.On 4 August 2018, the Uganda Ministry of Health (MoH) activated the Public Health Emergency Operations Centre (PHEOC) and the National Task Force (NTF) for public health emergencies to plan, guide, and coordinate EVD preparedness in the country. The NTF selected an Incident Management Team (IMT), constituting a National Rapid Response Team (NRRT) that supported activation of the District Task Forces (DTFs) and District Rapid Response Teams (DRRTs) that jointly assessed levels of preparedness in 30 designated high-risk districts representing category 1 (20 districts) and category 2 (10 districts). The MoH, with technical guidance from the World Health Organisation (WHO), led EVD preparedness activities and worked together with other ministries and partner organisations to enhance community-based surveillance systems, develop and disseminate risk communication messages, engage communities, reinforce EVD screening and infection prevention measures at Points of Entry (PoEs) and in high-risk health facilities, construct and equip EVD isolation and treatment units, and establish coordination and procurement mechanisms.As of 31 May 2019, there was no confirmed case of EVD as Uganda has continued to make significant and verifiable progress in EVD preparedness. There is a need to sustain these efforts, not only in EVD preparedness but also across the entire spectrum of a multi-hazard framework. These efforts strengthen country capacity and compel the country to avail resources for preparedness and management of incidents at the source while effectively cutting costs of using a “fire-fighting” approach during public health emergencies. A week after declaring the end of the 9th Ebola Virus Disease (EVD) outbreak in Equateur province of the Democratic Republic of Congo (DRC) on July 24th, 2018, the Ministry of Health of the DRC confirmed a new EVD outbreak in the Eastern DRC, North Kivu province on August 1, 2018 [EVD is a severe, often fatal illness in humans. Initial human infection with Ebola virus (EBOV) occurs through contact with an infected animal, such as a fruit bat or non-human primate . The virThe spread of Ebola Zaire strain can be effectively prevented through vaccination, as demonstrated by a ring vaccination trial held in Guinea during the 2014 West African EVD outbreak . Guinea EVD outbreaks have also occurred in the central African nations of Gabon , the Democratic Republic of Congo (DRC) , Sudan(2004), and Uganda  [The epidemic preparedness process constituted all the activities that were undertaken by MoH and its partners from national to health facility levels to enable readiness to effective response to EVD outbreak in Uganda from August 2018 when EVD outbreak was declared in the DRC to the time of writing this paper. The reports of the National Task Force (NTF) and its subcommittees were reviewed to inform the content of the paper.The preparedness efforts included activation of coordination mechanisms, functionalising subcommittees of the NTF, classifying districts by risk level and conducting risk assessment and mapping exercise which informed development of the national EVD response plan. To assess the country readiness, a major simulation exercise was conducted.The MoH activated the Public Health Emergency Operations Centre (PHEOC), NTF and District Task Forces (DTFs) for coordination of the EVD preparedness. The NTF is multi-sectoral and multi-disciplinary in nature and comprises key ministries, agencies, and departments as well as partners and relevant stakeholders and works through its subcommittees Fig. .Fig. 1SThe NTF which is chaired by the Director General of Health Services and co-chaired by WHO, held an urgent meeting on the 2nd of August 2018 to discuss EVD preparedness and prevention of spillover from DRC into Uganda. The NTF developed a multi-agency Incident Management System (IMS) to coordinate preparedness efforts and guide central and field EVD activities. The major IMS components are command and management of preparedness activities, resource management, communication, and information management. The NTF assigned an Incident Management Commander (IMC) and team, made of 6 technical subcommittee team leads encompassing the eleven key WHO EVD preparedness components, including: 1) epidemiological surveillance ; 2) case management and Infection Prevention and Control (IPC) including psycho-social support, waste management and safe and dignified burials; 3) risk communication and community engagement; 4) vaccination, therapeutics, and research; 5) emergency coordination including budgeting and resource mobilisation; and 6) logistics . The IMTAs a result of the complexity of the EVD situation in DRC, civil unrest and refugee influx, several national development partners became involved in EVD preparedness. The NTF, with support from WHO, developed a partners’ coordination matrix to avoid duplication of efforts, facilitate identification of preparedness gaps, support monitoring of implementation of the preparedness plan and realise the importance of impact on competing health interests. The matrix specified who should be doing what, where, and when , as well as the EVD preparedness goal, objectives, strategies, budget, funding sources, funding gaps, donors, and implementing agencies in the respective high-risk districts. Guided by this matrix, the MoH and partner institutions provided district-level financial and technical support for preparedness activities Figs.  and 3. FThe matrix was updated regularly based on feedback from NTF members. A dashboard was developed and updated promptly to display the financial and technical progress as well as the 4Ws.The NTF classified district EVD transmission risk into 3 categories. Category 1 included 20 high-risk districts that have physical borders, direct routes, and refugee influx from the affected provinces in DRC as well as the central business disticts of Kampala Capital City and Wakiso. Category 2 included 10 moderate-risk districts that have physical borders with DRC but no direct route to EVD-affected regions, and category 3 included low-risk districts in the rest of the country Fig. .Fig. 4GThe NTF deployed the NRRT to the districts to conduct rapid risk assessments and report within the first 12 h of deployment followed by subsequent updates as the outbreak situation evolved. The NTF adapted and used the WHO EVD preparedness checklist to assess the districts’ level of preparedness. The checklist is composed of 11 key components and core capacities and tasks for both districts and health facilities that are required for a district to be operationally ready . ThroughTo establish DRC population movements and patterns across the DRC-Uganda border, the Population Connectivity across Borders (Pop-CAB) tool developed by US CDC was used to document, record, analyze, and map risks associated with population movements across borders. The NRRT held key informant interviews with the District Health Team (DHT), which included the District Health Officers, Surveillance Focal Persons, Health Inspectors and Health Educators, and local leaders at known border PoEs and along priority porous borders. Several official and non-official high-risk crossing points for population movement from DRC across border districts were identified. Trained facilitators also interviewed Township Chairpersons, Town Clerks, Sub-county Chiefs, Mayors, and transport operatives in the high-risk locations. In addition, Focus Group Discussions (FGDs) with village leaders, community health workers in the cited high-risk locations for DRC population were held. The FGDs were guided by an adapted PopCAB FGD guide to gather information about the type of people crossing the border, their points of origin, congregation points, reasons for entering Uganda, duration of their stay and destinations. GPS coordinates for each of the locations were recorded. We developed summaries from key informant interviews and focus group discussions aided with sketch maps to track cross-border movements and indicate key locations for the DRC population. The facilitators integrated participatory mapping with spatially-accurate, printed maps in the key informant interviews and focus group discussions to identify location information for priority points of interest and travel routes. Respondents described population movement patterns associated with refugees who leave the Uganda settlements to visit their relatives in DRC and return back to Uganda. In addition, they described the patterns of persons newly-arriving from the DRC to established refugee reception centers and resettlements areas in Uganda such as Kyangwali in Hoima District or Kyaka II in Kyegegwa District, as well as DRC traders traveling across Lakes Albert and George to major markets in towns in the Ugandan border and non-border districts for business, and others who fly directly to Entebbe International Airport from Goma, Eastern DRC. The DRRT used the results to identify several official and non-official high-risk border locations with population movement from DRC into border districts. These exercises revealed multiple DRC travelers’ destinations to towns as far as Uganda’s capital city of Kampala.A mapping exercise was conducted by the International Organization for Migration (IOM) to establish the numbers, locations, and traveler flow of the numerous non-official border crossing points that exist between the DRC and Uganda through which people travel for social, business, and health reasons. This enabled selection of relevant PoEs for the establishment of screening, isolation and notification systems. Some of the busy border PoEs receive about 5000 people daily; however, the numbers increase tremendously and can reach over 20,000 people during market days, and this increases workload on screeners.With support from development partners and relevant stakeholders, the NTF developed the National EVD Contingency Plan to address the identified gaps in preparedness, and to support timely detection, response, and immediate containment of a potential EVD case in Uganda. This plan was developed in line with guidance provided in the International Health Regulations (IHR) 2005 for countries to develop core capacities to prevent, protect against, and rapidly respond to public health threats, including EVD. The plan was developed based on the rapid assessment preparedness reports, past experiences, and lessons learnt during the previous EVD outbreaks in Uganda . The plaAfter several cross-border contacts were made and points of entry coordination exchanges took place at local levels, the NTF and MoH engaged with the DRC Ministère de la Santé Publique  to convene a cross-border health meeting. Attendees included the East African countries at risk of introduction of EVD cases from the DRC in October 2018. Following this meeting, a bilateral ministerial meeting was held in Goma, DRC, in December 2018. The first meeting was designed to formalize cross-border collaboration and local-level exchange of information between affected countries, meanwhile the second meeting was meant to result in developing and signing of the Uganda-DRC Memorandum of Understanding (MoU) on cross-border collaboration for public health preparedness and response. The MoU enabled establishment of four surveillance zones between Uganda and the DRC.The NRRT trained DHTs, health and non-health frontline workers including members of security forces, Village Health Teams (VHTs) and political leaders on EVD case definitions and distributed copies of case investigation forms and contact tracing guidelines in assessed health facilities. Health facilities formed surveillance teams to heighten surveillance and active case search in order to detect any alert or suspect cases. Volunteers were trained on EVD screening at border PoEs and refugee reception centers with support from various partners. A PoE coordination committee developed a PoE toolkit which was approved by the NTF and adapted for use by MoH. The PoE teams screened everyone crossing into Uganda from DRC with infrared thermometers for body temperature, including all refugees at reception centers. Persons found with elevated body temperatures (> 38 degrees Celsius) were further screened for Ebola-like symptoms.The NRRT trained laboratory health workers on specimen collection from suspected EVD cases and triple packaging for transportation to the Uganda Virus Research Institute (UVRI) for testing. With support from partners, ambulances were stationed in each of the 20 category 1 high-risk districts for rapid transportation of specimens to the UVRI Viral Haemorrhagic Fever (VHF) Program laboratory in Entebbe, ensuring delivery of samples within 24 h of collection. In addition, the MoH conducted a pilot of an electronic system to track collected samples to improve the monitoring of laboratory results turnaround time. Other actions undertaken in the preparedness period include modifications of the specimen collection, sample chains of custody and packing list forms. These modifications aimed to strengthen the existing biosecurity mechanisms of the National Laboratory Services. By end of May 2019, 641 Ebola alerts were verified countrywide Fig. .Fig. 5MAlthough up through 9 June, no specimen collected from an alert tested Ebola positive, other VHF pathogens were detected in samples from 25 alert cases including Crimean Congo Haemorrhagic Fever  and RiftThe DTFs identified clinical staff including clinicians and community health workers whom the NRRT trained on EVD case definitions, transmission, clinical presentation, community surveillance, reporting, IPC, and case management including dignified safe burial. The trainings included simulation exercises such as donning and doffing of EVD PPE for case management and safe burial. During the trainings, the NRRT disseminated EVD guidelines and Standard Operating Procedures (SOPs) for patient management and, safe and dignified burial.The NRRT also helped the DTFs to designate and set-up EVD isolation units at specified hospitals and health facilities ready to provide care to EVD patients. With support from partners, MoH constructed ten Ebola Treatment Units (ETUs) at designated hospitals in high-risk districts.The NRRT conducted IPC assessments and instituted hand-washing and disinfection measures and positioned hand-washing stations at major health care facilities, official and high-risk unofficial PoEs, refugee transit and reception centers, and other relevant public places in the 30 high and moderate risk districts. With support from partners, MoH trained district-based IPC trainers who trained and mentored all relevant health facility workers on IPC practices in handling suspect, probable and confirmed EVD patients including safe waste management, and safe dignified burials.The NTF Logistics Sub-committee conducted logistics assessments in at least five of the high-risk districts to determine a baseline, and then used the data for forecasting and quantification for medical, IPC, PPE, and laboratory needs for the districts. With support from the NRRT, the DTFs developed emergency contingency plans and budgets to facilitate EVD preparedness activities, which were reviewed and approved by the NTF. The MoH with support from partner agencies purchased and distributed PPE and other relevant supplies to all designated district hospitals and health facilities for case management. A number of development partners and international agencies supported the MoH financially to avail the preparedness logistics and supplies to the districts.The NTF generated a press statement which was read by the Minister of Health on 3rd August 2018 to inform the public about the EVD outbreak in DRC and increase alertness for surveillance in the 30 high- and moderate-risk districts and the rest of the country. The NTF Risk Communication Subcommittee developed subsequent press releases for the Minister of Health, The committee also developed the risk communication plan, radio spot messages, reviewed, printed and translated IEC materials which were translated in fifteen most spoken local languages in the 30 high-and moderate-risk districts across the western border of Uganda to ensure reach to the general public. Information specified signs and symptoms of EVD, the need to seek urgent medical care in case symptoms arise, and the importance of safe burial of the dead. EVD information was disseminated regularly through local newspapers, popular radio, and television stations. In addition, the DTFs disseminated IEC on EVD through regular radio talk shows, spot messages, and posters in high-risk communities. They also supported trained community volunteers to carry out communal and door-to-door EVD health education.The NTF sought ethical and institutional approval for prophylactic use of the rVSV-ZEBOV vaccine currently used in the DRC based on its demonstrated protective efficacy against the Ebola virus-Zaire type. This particular vaccine was being administered in DRC and had demonstrated positive protective results and potency against the Ebola virus-Zaire type . The aimThe vaccination team in their wisdom selected health workers they considered more at risk compared to others and targeted those for vaccination rather than vaccinate all health workers. This was the first time Ebola vaccination was conducted as part of a country’s preparedness response.A WHO Joint Monitoring and Assessment of EVD preparedness in Uganda conducted in December 2018 showed significant progress, with up to 92% readiness nationally. The MoH therefore recommended a full-scale simulation exercise to test the operational capabilities of all components of the preparedness and response plan.A full-scale simulation exercise (FSX) was conducted in April 2019 to test the preparedness and response systems at three levels of operation: community, district, and national. The exercise was conducted in a highly stressful environment, simulating actual response conditions. The exercise simulated three suspected cases of EVD. The first case tested the response systems at a designated land PoE in Kasese District (Mpondwe Border Point), and referral to an Ebola Treatment Unit (ETU), while the second came through Entebbe International Airport. The third case tested community surveillance and reception of an EVD suspected case in a non-ETU facility in Kasese District, and subsequently safe and dignified burial when the patient died. The coordination structures at national and district levels were also tested.In all scenarios, detection of a suspected EVD case was timely, though reporting from the community to the national level was delayed. The simulation exercise identified strengths and gaps in the development and implementation of preparedness and response measures. The exercise also identified areas for improvement in coordination of the response at district level, safe referral of EVD suspected cases, infection prevention and control, and management of severely ill patients. It was recommended that preparedness efforts prioritize skilling health care providers through intensified supervision, mentorships and drills.The conflation of political instability and rebel activities coupled with community mistrust in the outbreak response in Eastern DRC have made it very difficult for the DRC and its partners to control what has now become the second-largest and -longest EVD outbreak recorded in history . As a reA day after the official declaration of the 10th EVD outbreak in the DRC, Uganda’s MoH initiated a quick EVD preparedness response by activating the NTF and PHEOC to a response level and mandating its members and partners to plan, mobilize resources and coordinate implementation of the full range of EVD preparedness pillar activities. With support from several partner organizations, Uganda was able to activate the NTF and create an active IMS and a partner coordination matrix, mobilize resources and carry out preparedness activities in 30 designated high- and moderate-risk districts on its western border with DRC as well as on adjacent borders with Rwanda and South Sudan and the central urban hubs of Kampala and Entebbe, linked to population movements from and to the DRC’s outbreak hotspots. In addition, Uganda has established multi-sectoral and multidisciplinary national and district task forces, and technical subcommittees for each preparedness pillar that advise the NTF and act as liaisons between the NTF and the high- and moderate-risk districts. These quick actions were most influenced by Uganda’s experiences with four previous EVD outbreaks . With thThe WHO recommends EVD preparedness activities in countries with close proximity to EVD epicenters to enable them respond should there be any importation of EVD cases. Uganda is among nine priority countries neighboring DRC since the present 10th EVD outbreak started . After tThe preparedness assessment found that all 30 high- and moderate-risk Ugandan districts had less than a 50% score for EVD readiness at baseline. It also found that the average score for EVD preparedness was highest in laboratory and lowest in budgets, safe burials, and contact tracing. These findings were similar to WHO’s initial assessments done across EVD African countries neighboring DRC during the 2018 EVD outbreak as well as what was found by WHO in the 2015 EVD preparedness assessment for west African countries (23). The UNHCR, IOM and Medical Teams International (MTI) that provide active health, border, and mobility care for refugees in the settlements had already put in place measures to strengthen EVD preparedness such as EVD trainings, EVD screening, IPC measures, and dissemination of EVD IEC materials.Following the IDSR guidelines, the national surveillance system was strengthened with training of all national and district surveillance focal persons and facilitation for timely detection, reporting, and investigation of EVD alerts with focus on cross-border surveillance and early patient triage at high-risk referral health care facilities. The EOC continues to provide timely information about disease epidemics while the NTF closely continues to guide, monitor, and supervise the preparedness activities. The country has built capacity and established a good laboratory network within districts, regional referral hospitals, and at the national level to collect, package, store and transport samples to the National VHF Program laboratory at UVRI. The VHF Program laboratory at UVRI is a regional diagnostic referral laboratory for VHF and routinely screens all suspect specimens for Ebola , Marburg, CCHF and RVF. There is also well-developed local capacity for social mobilisation during epidemics with engagement of political, local and religious leaders. Many health workers have been trained in EVD case management and provided with updated guidelines and SOPs with support from several partner agencies.Nine months after the declaration of the 10th EVD outbreak in the DRC, Uganda continues to conduct preparedness activities to prevent introduction and spread of EVD into the country. While WHO continues to support this effort, the duration and extent of this outbreak has come as a surprise to many. As a result, governments, donors, and partners have all been stretched to a point where the preparedness strategy needs to be revisited. Specifically, it is important to redefine strategies in order to both maintain the readiness momentum at a time where the risk of outbreak spillover has increased, as well as to plan for the human, technical, and financial resources needed to balance this protracted effort with the rest of the national health security agenda. This agenda requires at least equal time, efforts, and resources as EVD preparedness, yet the capacity of an at-risk country like Uganda is limited and cannot address both needs fully. A WHO meeting on Strengthening Partnership for Improving Ebola Preparedness and Readiness took place at the end of April 2019 and this issue was addressed.As the EVD outbreak continues in DRC, the risk of cross-border transmission remains imminent. Subsequently, the country has plans to expand and intensify preparedness activities to additional districts, with a special focus on the use of universal precautions and ways to strengthen and sustain IPC practices at all health facilities in high-risk districts. The broad EVD preparedness workgroup continues to strengthen cross-border collaboration and to engage the community in door-to-door risk communication and surveillance in all high-risk districts. There is also need to accelerate vaccination of at-risk frontline health workers in the other high-risk districts. The MoH, with support from partner agencies, has started to conduct drills and simulation exercises in the most at-risk districts bordering the DRC to evaluate preparedness and response capacity. The MoH also plans to improve sample transportation and re-establish a national border health unit that has been inactive for many years.Within the first month of declaration of the 10th EVD outbreak in DRC, Uganda’s MoH had established a strong coordination and surveillance system to effectively alert and respond to any EVD suspect case and to mitigate risk of importation of EVD into Uganda. With continued technical and financial support from many partners, the country has strengthened EVD preparedness and timely detection, investigation and response to EVD alerts. Sustained efforts are required to support refreshing of health workers, provision of infection control supplies, maintenance of infrastructure, provision of equipment for case referral and isolation, regular drills and simulation exercises in key technical areas, continued risk communication, community engagement, resource mapping as well as countrywide coordination.On June 10, Uganda detected its first cases of EVD as a result of a spillover event from the DRC. While the details of the cases will be presented in another paper, cases were quickly recognized, specimens safely collected and efficiently transported for diagnostic testing and confirmation at UVRI. Case patients were rapidly relocated to an ETU for isolation and care. As of 22 June 2019, no secondary transmission from these three cases have occurred in Uganda, a clear demonstration of the effectiveness of the Uganda preparedness program.


Effective implementation of nutrition and dietetics interventions necessitates professionals in these fields to possess the requisite competencies for health systems performance. This study explored the stakeholders’ perceptions of the community nutrition and dietetics needs, the nature of work done by graduates of the Bachelor’s degree in Human Nutrition/Human Nutrition and Dietetics (HN/HND), and the competencies required of Nutrition and Dietetics professionals in Uganda.A cross-sectional mixed methods design was used. Respondents included 132 graduates of the Bachelor’s degrees in HN/HND obtained from the Makerere and Kyambogo Universities in 2005–2016; 14 academic staff that train HN/HND in the two universities; and 11 HN/HND work/internship supervisors. Data from the graduates was collected through an email-based survey; data from other participants was through face to face interviews using researcher administered questionnaires.Most HN/HND respondents (84.8%) obtained their Bachelor’s degrees from Kyambogo University; 61.4% graduated in 2013–2016. Most (64.3%) academic staff respondents were females and the majority (57.1%) had doctorate training. All stakeholders viewed communities as facing a variety of nutrition and dietetics challenges cutting across different Sustainable Development Goals. The nutrition and dietetics interventions requested for, provided, and considered a priority for communities were both nutrition-specific and nutrition-sensitive. Work done by HN/HND graduates encompassed seven main competency domains; the dominant being organizational leadership and management; management of nutrition-related disease conditions; nutrition and health promotion; research; and advocacy, communication, and awareness creation.This study shows that nutrition and dietetics challenges in Uganda are multiple and multifaceted; HN/HND graduates are employed in different sectors, provide nutrition-specific and sensitive services in a multisectoral environment, and are expected to possess a variety of knowledge and skills. However, graduates have knowledge and skills gaps in some of the areas they are expected to exhibit competency. We recommend using these findings as a basis for obtaining stakeholder consensus on the key competencies that should be exhibited by all HN/HND graduates in Uganda; developing a HN/HND competency-based education model and a national HN/HND training and practice standard; and undertaking further research to understand the quality and relevancy of HN/HND curricula to Uganda’s job market requirements.The online version contains supplementary material available at 10.1186/s12913-021-06090-3. Malnutrition in its different forms: undernutrition; micronutrient deficiencies; and overweight, obesity, and the associated diet-related non-communicable disease remains a key global health challenge , 2 partlNutrition and Dietetics professionals are a key human resource for the delivery of nutrition-related services ; and shoThe government of Uganda embraced the multisectoral approach for the delivery of nutrition interventions in 2011 upon the adoption of a National Nutrition Action Plan and has since called upon all concerned ministries to integrate nutrition in their sector policies and plans , 15. SomThe purpose of this study was to explore the stakeholders’ perceptions of the community nutrition and dietetics needs, the nature of work done by HN/HND graduates, and the competencies required of Nutrition and Dietetics professionals in Uganda. The key questions answered by this study are: (1) What are the nutrition and dietetics related challenges facing different communities in Uganda?; (2) What nutrition and dietetic services are demanded by Ugandan communities?; (3) Which of the demanded nutrition and dietetic services are provided by the different agencies?; (4) What is the nature of work done by HN/HND graduates in Uganda?, (5) and What knowledge and skills are required of HN/HND professionals to perform effectively in Uganda’s varied healthy system’s settings?This study used a cross-sectional mixed methods design. The rationale for using this design was based on the need to triangulate data collection and analysis processes as well as obtain complementary data on the study objectives to strengthen the study conclusion , 30. TheGraduates who responded to the survey were not re-interviewed amongst the other categories of respondents. Data collection and analysis were done following an explanatory sequential design , 30; begA sampling frame for the graduates was developed from the graduation records of Kyambogo and Makerere University for the years 2005–2016. According to the available records, there were about 607 graduates for the reference period; 493 from Kyambogo University and 114 from Makerere University. The available email and phone contacts for the graduates were obtained from the respective university department records. Starting with these, other contacts were obtained by making phone calls to the known contacts, explaining to them the purpose of the research, the methods that were to be used for data collection and requesting them to provide the email and phone contacts of their fellow graduates. This process was repeated until no more contacts could be obtained; at which point 450 email and mobile phone contacts of the 607 graduates had been obtained. Given that the participants were widely geographically distributed and given the techniques that were to be used in reaching the participants, a decision was made to have an exhaustive sample of all the 450 graduates whose contacts had been established as the study sample and to invite all to participate in the study. The use of such a strategy is theoretically justifiable and meets the requirements for sampling when a study uses aspects of a qualitative descriptive approach in sampling  as was iTo collect data from the participants, a Google email-based group account comprised of emails identified while developing the sampling frame was created. A cross-sectional email-based survey was then undertaken amongst all the 450 contacts by emailing participants a consent form  obtained their HN/HND Bachelor’s degree from Kyambogo University and most (61.4%) completed their studies in the years 2013–2016. Close to half of the respondents (44.7%) had undertaken further training at different levels; post-graduate diploma/certificate (19.7%), master’s degree (23.5%), and Ph.D. (1.5%).In regards to places of internship, regional referral hospitals and the national referral hospital were the main places attended during the first internship at 42.5 and 20.5% respectively. On the contrary, non-government organizations and regional referral hospitals were mainly attended for the second internships at 30.2 and 16% respectively. As per the regions of Uganda where internships were undertaken, most respondents undertook their first internship in the central region (55.1%) followed by the western region (18.9%). The same trend was observed for the second internship with 60 and 20% of respondents respectively.As for current employment; the majority of the respondents (60.9%) were employed by non-governmental organizations and the minority by healthcare-related facilities (12.2%). The northern and central regions of Uganda had the most graduates employed at 34.8 and 33.9% respectively. A small percentage of graduates (9.1%) reportedly worked outside Uganda.A total of 14 academic staff and 11 work/internship supervisors were interviewed in this study as shown in Table As summarised in Table Based on the illustrative quotes by the academic staff and the work/internship supervisors as further summarised in Table Graduates’ responses were grouped under seven major domains as summarised in Table For the nutrition and dietetic services provided by employers, the majority of respondents (56%) mentioned nutrition awareness, education, and counselling services as being the main provided services; followed by integrated management of acute malnutrition (54%); food security and livelihood support (47%); nutrition screening (28%); management of non-communicable and communicable diseases (22.0%); maternal, infant, young child and adolescent nutrition (19%); and water, sanitation and hygiene (14%).When asked about their views on the would-be priority nutrition and dietetics services to provide, most graduates 64.3%) mentioned services under the domain of nutrition awareness, education, and counselling; followed by food security and livelihood support (41.8%); integrated management of acute malnutrition (31.6%); maternal, infant, young child, and adolescent nutrition (14.3%); management of non-communicable and communicable diseases (12.2%); and water, sanitation and hygiene (8.2%). Some illustrative quotes to justify the responses are summarised along with the responses in Table .3% mentiThe responses by the academic staff and the work/internship supervisors in regards to the nutrition and dietetic services provided in communities were coded under similar themes as those used for the HN/HND graduate as also summarised in Table Under the theme of food security and livelihood support; mention was made for the provision of nutrition livelihood programs, food relief, and cash for work interventions. Some of the services perceived to be provided under the theme of maternal, infant, young child, and adolescent nutrition included child health and nutrition services in clinics, antenatal nutrition education, food demonstrations in infant and young child feeding, and health education. Under the theme of nutrition screening, mention was made of nutrition assessment and routine community nutrition screening for children. Some of the services mentioned under the theme of nutrition awareness, education, and counselling included guidance and counselling and community nutrition education. Other mentioned services included water, sanitation, and hygiene; and product development and food processing under the themes of water, sanitation, and hygiene, and business and industry respectively.As per the graduates’ responses, the nature of work done by the practicing graduates was categorised under seven major domains ; project planning, management and implementation (53.8%); project monitoring and evaluation (30.4%); budgeting and accountability (22.5%); and human resources management (18.8%).For the respondents with job roles categorized under the domain of management of nutrition conditions at the health facility and community level, the main mentioned work roles included nutrition screening or assessment (76.1% of respondents); offering of inpatient and outpatient therapeutic care each at 58.2%; supplementary feeding (52.2%); nutrition education and counselling (39.4%), nutrition supplies management (20.9%); monitoring, supervision and quality improvement (19.4%); and community nutrition work (16.4%).The main work roles performed by graduates engaged in nutrition and health promotion included nutrition and health promotion (62.1%); capacity building (52.3%); offering technical support (18.5%); and growth monitoring and promotion (3%).For undergraduates engaged in research and documentation, all (100%) reportedly participated in dissemination; followed by 73.8% that undertook report writing, 45.9% that participating in carrying out nutrition surveys, 8.2% that did data entry and analysis, and 6.6% that contributed to proposal writing.For the undergraduates whose job roles were categorized as falling in the domain of advocacy, communications, and awareness, the majority (76.9%) mentioned carrying out community/stakeholder engagements. This was followed by undertaking stakeholder orientations and networking each at 7.7% and coordinating advocacy events (3.8%).Besides the feedback from the HN/HND graduates, this study also explored the views of academic staff and those of the work/internship supervisors on the types of employment in which the HN/HND graduates were engaged as well as the work/job roles they performed. From the responses, it was evident that employed graduates mainly worked as nutritionists in different positions; across different sectors; and in both government and non-government agencies. As per the following respondents’ narratives, the ministry of health, non-governmental organizations, academic institutions, private health facilities, United Nations agencies, hotels, district local governments, and special care homes included some of the mentioned employers.“They are employed in the public service as nutritionists at the national level, in the ministry of health, in regional referral hospitals, and at local government level …. [They] also work as nutrition specialists with various NGO’s and United Nations bodies.”“Nutritionists in humanitarian relief based organizations; nutrition program managers in NGOs; nutritionists and dieticians in the national referral hospital, district hospitals, and private hospitals; nutrition and diet consultants; lecturers; and researchers.”The graduates were regarded to be performing multiple cross-cutting roles in the different types of employment. For instance, one of the respondents noted the HN/HND job roles to involve “Conducting nutrition education for various groups; individual nutrition counselling sessions for various nutrition-related conditions; dietary assessment; conducting of food demonstration sessions in infant and young child feeding; and nutrition project planning and implementation.”The performed roles were however observed by one of the respondents to vary according to the job position, “Roles vary depending on the rank. Supervisory work is done as one grows in rank; other roles assigned depending on rank include nutrition assessment; … undertaking nutrition interventions for clients; giving food supplements, and client follow up.”From the multiple responses by the HN/HND graduates, 20 knowledge and skills themes were identified. Based on these themes; an evaluation of the respondents’ perceptions in regards to knowledge and skills expected of HN/HND graduates; knowledge and skills gaps amongst individual graduates; knowledge and skills inadequately attained while at university; and the knowledge and skills recommended as a training minimum for HN/HND was done as summarised in Table In regards to the knowledge and skills expected of HN/HND graduates, responses were received from 132 respondents. The top six mentioned themes were integrated management of acute malnutrition (75.8%); communication, education, and counselling (62.1%); medical/clinical nutrition therapy (56.8%); research, proposal, and report writing (52.3%); nutrition screening and assessment (47.7%); and leadership and management (47%).For the knowledge and skills gaps amongst individual graduates; responses were received from 120 graduates. The top six mentioned gaps included medical/clinical nutrition therapy (61.7%); project planning, management, monitoring and evaluation (38.3%); integrated management of acute malnutrition (31.7%); communication, education, and counselling (18.3%); leadership and management (11.7%); and research, data analysis, proposal and report writing (10%).Concerning the knowledge and skills not adequately attained during undergraduate training, feedback was received from 100 respondents. The top six knowledge and skills themes were medical/clinical nutrition therapy (61%); research, data analysis, proposal and report writing (23%); leadership and management (19%); project planning, management, monitoring and evaluation (17.6%); integrated management of acute malnutrition; and communication, education, and counselling (13% each); and nutrition advocacy (10%).As relates to the knowledge and skills recommended for minimum training, 97 respondents provided feedback. The top recommended knowledge and skills themes were in the categories of medical/clinical nutrition therapy (44.3%); integrated management of acute malnutrition (41.2%); communication, education, and counselling (27.8%); nutrition screening and assessment (25.8%); leadership and management (19.6%), and nutrition advocacy (13.4%).Similar to the responses by HN/HND respondents, the perceptions of academic staff and work/internship supervisors were multifaceted. Illustrative quotes of the academic staff and work/internship supervisors’ responses when coded to the same knowledge and skills domains as was for the HN/HND respondents are summarised in Table Under the domain of nutrition computing, it was expressed that undergraduates needed to have the knowledge and skills necessary for the use of technology, basic computing, and data analysis. Knowledge and skills gaps were noted to exist in the form of inadequate mastery of statistics and limited exposure to the use of modern technology.Under the broad domain of maternal, infant, young child, and adolescent nutrition, stakeholders expressed a need for knowledge and skills in infant and young child feeding, as well as knowledge and skills in specific areas of maternal, infant, young child, and adolescent nutrition. However, some respondents noted the existence of knowledge and skills gaps in infant and young child feeding.In the domain of leadership and management, knowledge and skills were noted to be required in team working skills, interpersonal and organizational skills; critical thinking; and the management of human and material resources. Respondents noted the existence of knowledge and skills gaps in leadership and governance, conflict management and negotiation, and mobilization and fundraising.Some of the knowledge and skills noted as being required in the domain of communication, education, and counselling included nutrition education and counselling, facilitation skills, communication more so as relates to behavioural change, and nutrition education and advocacy. Noted knowledge and skills gaps existed in communication skills and interpersonal skills, confidence talking to the public, education session planning and implementation, inability to effectively communicate with clients, development of IEC materials, and presentation skills.Under the domain of nutrition screening and assessment, knowledge and skills were said to be expected of undergraduates in nutrition anthropometry, biochemical, clinical, and dietary assessment. The undergraduates were however said to have inadequate skills in nutrition assessment.In the domain of project planning and management, knowledge and skills were said to be expected of undergraduates in planning, budgeting, policy formulation, and nutrition governance; understanding of multisectoral nutrition programming, and project implementation. Notable knowledge and skills gaps existed in monitoring and evaluation, project planning, budgeting, and writing bidding proposals for organizations.The expected knowledge and skills under the domain of research, data analysis, proposal, and report writing related to undertaking field and laboratory-based research; statistical data analysis and interpretation; report writing; and analytical skills. However, knowledge and skills gaps were said to exist in different areas including proposal writing, general research knowledge, and report writing and data collection.In the domain of anatomy, physiology, pharmacology, pathology, and biochemistry, respondent expressed a need for knowledge and skills in anatomy, drug prescription with minimal reliance on medical doctors, understanding of the relationship between foods and the blood system, pharmacy and pathology, and biochemistry and food microbiology. Some noted knowledge and skills gaps were in the ability to link nutrition and body system functions, and limitations in anatomy and physiology.In the broad domain of product development and food safety management, knowledge and skills were expected of undergraduates in quality control analysis, food safety in nutrition, and food standards and laws.Under the domain of professional ethics, respondents indicated the need for undergraduates to exhibit knowledge and skills in ethics and professionalism. However, knowledge and skills gaps were noted in work ethics and client management, and general ethics and professionalism.An extra domain of laws, policies, and regulations was created based on the trainer’s and supervisors’ responses. Under this domain, Nutrition and Dietetics professionals were expected to exhibit an understanding of key policies and guidelines on nutrition at the global and national levels. However, it was echoed that HN/HND professionals exhibited knowledge and skills gaps in nutrition policy and legislation.A one-day results validation workshop was undertaken on the 3rd of October 2019 at the Grand Global Hotel located in Makerere Kikoni, Kampala Uganda. The workshop aimed to engage stakeholders in reviewing and commenting on the appropriateness of the study results. The workshop followed a predefined formal agenda that was communicated to the participants before the workshop. Key on the agenda was the oral presentation of the study background, methodology, and results by the principal researcher; plenary reactions, discussions, and suggestions in regards to the presented content; and three group exercises each followed by a plenary presentation and discussions. To document workshop proceedings, three experienced note-takers were engaged in taking notes; audio recording of the plenary presentations and discussions was done, and photographs were taken at different intervals. The validation workshop was attended by 31 participants .In general, the participants judged the study to be vital and timely towards informing on-going processes in the development of a national HN/HND training and practice standard that was considered inexistent at the time of the study; “Uganda has no National standard stipulating the training and practice requirements for nutrition and dietetics …. We hope this research can be used to inform such process”. One of the participants sought clarification on how the study links and informs curriculum reforms; “At what point do the study findings link with the curriculum; is it the issue of competencies not being in the curriculum or is it due to how the teaching is done? How do we link these?”“Issues like water, sanitation, and hygiene; food security; and livelihood support as reported in the findings are very key as they introduce an element of multi-sectorality … caution needs to be undertaken in regards to the nutrition and dietetics training needs under the multisectoral approach. We must be cautious about the knowledge and skills required under the multisectoral setting.”Participants further recognised the multisectoral nature of implementing nutrition interventions at the global and national level and called for the need to take caution when identifying the knowledge and skills required of HN/HND graduates to perform in a multisectoral setting:“We should appreciate that other professions providing services that are supportive of nutrition and dietetics services do exist. We need to know how to link with them to implement multisectoral nutrition and dietetics services.”“We need to know how other professionals perceive of our profession, and the knowledge and competencies they expect of us …. Coming from a clinical and research setting, I sense others don’t know what to expect of nutritionists. Can we collect additional data on this? Getting the perceptions of other professionals that work with nutritionists and dietitians on what they expect of nutritionists and dietitians can enable us to make better curriculum reforms in nutrition and dietetics training.”Relatedly, the need to appreciate the roles of other professions in the multisectoral approach; linking with them, and understanding their views in regards to the knowledge and skills they expect of HN/HND professionals was emphasised:“Why was the response rate on professional ethics low? Is it because adherence to ethics is low in professional nutrition and dietetics practice or is it because nutrition and dietetics professionals do not value ethics? The curriculum needs to fully equip trainees with professional ethics because there is still a challenge on which ethics guide nutrition and dietetics practice in Uganda.”“Patient clerking was missed out in the results yet it is an important competency that has to be mastered by nutritionists and dietitians …”.In discussing the knowledge and skills required for the practice of HN/HND in Uganda, observations were made that some knowledge and skills areas had been lowly ranked:“Nutrition in emergencies is not well taught in Uganda to Bachelor’s students of nutrition yet many undergraduates work in emergency contexts and or with humanitarian agencies whose work entails aspects of emergency nutrition …”.“The current transmission of knowledge is insufficient … fresh undergraduates severely lack practical clinical skills …”.“The undergraduates we have can generate statistics but not use the information yet professionals should be able to interact with the information, generate evidence to guide programming … statistics are basic at the undergraduate level but undergraduates need more than is stipulated for this level …. [Graduates] don’t appreciate the use of statistics to guide programming, this is reflected when they start working.”“Knowledge and skills need to be tailored to the environment in which the undergraduates operate. What challenges are undergraduates facing in the environments they are operating? We should consider the policy and planning environment because these affect professional work.”Some participants also argued that graduates exhibited minimal competency in some of the areas considered core for the practice of HN/HND in Uganda.“It may be important to consider including family planning, strengthening training in procurement and logistics of nutrition materials and supplies, and adding nutrition leadership and management as these are lacking in the HN/HND Bachelors training curriculum.”“Many of the challenges presented are in the services sector but not in policy yet [many] challenges exist in the implementation of nutrition-related policies. Nutrition and dietetics related challenges presented have limited focus on policies being implemented yet the government, in terms of systems capacity, under the Ministries of Health and Agriculture focuses on implementing what is stipulated in the policies. I suggest for the need to undertake further reflection on nutrition-related policies in the country and the capacity of concerned ministries to implement nutrition as stipulated in the existing policies and sectoral strategies …”.“There is a need to improve utilization of HMIS [Health Information Management Systems] data collected from the community by nutritionists.”The need to introduce and or strengthen training in family planning, procurement, leadership, and nutrition policy formulation was recommended:The need to undertake assessments to determine the capacity readiness of institutions of higher learning to train HN/HND in Uganda was also emphasised; “Have you considered looking at the capacity of the different institutions training nutrition undergraduates in Uganda in terms of research, equipment, and human resources …? ”.This study used a cross-sectional mixed methods design to assess the nutrition and dietetic needs and the requisite professional competencies in Uganda. Participants included graduates of the Bachelors in HN/HND respectively obtained from the Makerere and Kyambogo Universities of Uganda in the period 2005–2016; academic staff that train HN/HND in two universities; and work/internship supervisors of the HN/HND graduates. The majority of the HN/HND respondents graduated in the years 2013–2016. The academic staff and HN/HND work/internship supervisors that participated in the study had varied experiences; academic and non-academic. Besides the Universities, non-academic institutions including hospitals, government agencies, and non-governmental organisations were reported to have been instrumental in the training of nutrition and dietetics through offering internship opportunities to HN/HND study interns. Most graduates undertook study internships in non-government organizations, regional and national referral hospitals in the central region of Uganda. Less than half of the graduates had undertaken additional training; those who had done so had mainly obtained master’s level training. Graduates were employed by government and non-government organisations across the different regions of Uganda; with some employed outside the country. Non-governmental organisations were the main employers of HN/HND graduates with the northern and central regions of Uganda having the most concentration of employed graduates.Stakeholders generally indicated that communities faced a variety of nutrition-specific and nutrition-sensitive challenges. Hence, the nutrition interventions requested, provided, and considered a priority to provide to communities were both nutrition-specific and nutrition-sensitive. Nutrition interventions in the areas of awareness, education, and counselling; integrated management of acute malnutrition; and food security and livelihoods were found to be the main ones demanded by communities, provided by employers, and also considered by the graduates as a priority to provide. The nature of work done by HN/HND graduates varied; with the dominant entailing aspects of organizational leadership and management; management of nutrition-related disease conditions both in health facilities and communities; nutrition and health promotion; research and documentation; and advocacy, communication, and awareness. About 20 knowledge and skills areas were identified as being required by HN/HND graduates to implement the different nutrition interventions in Uganda. Of these, integrated management of acute malnutrition; communication, education, and counselling; medical/clinical nutrition therapy; research, proposal and report writing; nutrition screening and assessment; and leadership and management comprised the top six mentioned as being expected of graduates. Although highlighted amongst the top knowledge and skills areas required of HN/HND graduates, medical/clinical nutrition therapy; integrated management of acute malnutrition; communication, education, and counselling; leadership and management; and research, data analysis, proposal and report writing also featured amongst the top knowledge and skills gaps amongst individual HN/HND graduates. HN/HND graduates further indicated not having adequately attained knowledge and skills in most of the key areas they are expected to be competent; pointing to a likely mismatch between the knowledge and skills expected of HN/HND undergraduates to those obtained through training.Bruening et al.  noted thAlthough the findings of this study are mainly based on the provider perspectives, this study reaffirms findings in other literature that communities across Uganda face multiple nutrition and dietetic challenges , 45, 46 Further review of the identified knowledge and skills themes reveals some similarities in the identified knowledge and skills themes to what has been proposed for degree-level training in the regional model nutrition curriculum for health workers based in the East, Central, and Southern Africa Health Community . On the The need for competent Nutrition and Dietetics professionals as highlighted in this study aligns with the aspirations by the Government of Uganda to train and equip graduates with the necessary skills and abilities to meet Uganda’s development needs , 16. It From a training and practice perspective, the finding that HN/HND professionals were working in different sectors, within and outside the country re-emphasises the multisectorality of nutrition and dietetics and highlights a need for HN/HND graduates to be equipped with the knowledge and skills required for working with multiple actors, in a multisectoral setting, within and outside Uganda. As such, the need to reorient the current University HN/HND training programs to ensure that graduates obtain the knowledge and skills required for the job market while creating opportunities for graduates to further obtain and develop professional competencies in nutrition and dietetics is pertinent. We recommend using the study findings as a basis for (1) undertaking further stakeholder dialogues towards developing consensus on the key competencies that should be exhibited by all HN/HND graduates in Uganda and (2) subsequently developing a competency framework that delineates the sets of competencies that should be acquired at different levels of HN/HND training. Such a framework, developed basing on national evidence with the input of different stakeholders, has the added advantage of limiting the wholesale adoption of HN/HND training models based on other country contexts  and may As identified in this study, the training of HN/HND professionals in Uganda requires the engagement of academic institutions for the provision of specialised formal training and non-academic institutions for experiential attachments. As such, there is a need for higher academic institutions to form formal partnerships with non-academic institutions. Forming training partnerships has the advantage of fostering experiential student learning, closer monitoring, and supervision of what students are exposed to during internship training. The formation of such partnerships may however necessitate the setting up of standards or criteria based upon which non-academic institutions are qualified and selected to host HN/HND student interns. However, as is currently, the engagement of non-academic institutions is less formal and no set national standards/criteria exist to guide the selection of which institutions should be engaged in HN/HND internship placements. We recommend the need for a policy that mandates Universities to (1) work with the relevant ministries of health, education, and agriculture, and other non-state actors that support nutrition and dietetic services delivery to develop national HN/HND training and practice standards as well as (2) formalise internship relations through signing Memorandums of Understanding with organisations meeting set practicum standards. Such measures will foster closer collaboration between academic institutions and the different organisation that employ HN/HND graduates in Uganda with the added benefit of improving nutrition and dietetics training and service delivery.Further research to understand (1) the quality and relevancy of the HN/HND curricula currently used by different Universities in Uganda to the national job market requirements and (2) the higher education institutional capacity readiness to offer adequate nutrition and dietetics training in Uganda is needed.Amongst the HN/HND respondents; more females than males responded to the survey. This could be attributed to the social behavioural differences in the way males and females engage in online activities; females are reported to engage more in online information exchange than males . RespondSome of the open responses by the HN/HND graduates were quantitized and analytical judgments arrived at based on the analysis of the quantitized responses rather than the respondent’s direct narratives. The conversion process tends to strip qualitative data of its contextual meaning and may hence introduce some bias in the process .Some graduates with limited access to computers and internet connections and those who perceived the study questions to be targeted to employed graduates/graduates with experience in nutrition and dietetics did not respond. The responses were hence received from a smaller group of respondents and are not be statistically representative of the entire population of HN/HND graduates that completed their undergraduate studies from the Kyambogo and Makerere Universities of Uganda in the years 2005–2016. Relatedly, responses from the employers of HN/HND graduates and organisations that host HN/HND study internships were sought and received from a purposively selected smaller number of HN/HND work/internship supervisors and may not be broadly representative of all stakeholders in this category of study participants.Based on the findings of this study, we conclude that: (1)communities of Uganda face multiple nutrition and dietetics challenges that are being addressed multisectorally; (2)HN/HND graduates trained in Uganda are well positioned to support implementation of different multisectoral nutrition and dietetics interventions but graduates possess knowledge and skills gaps even in some of the areas they are expected to exhibit competency; and (3) there is need to adequately equip HN/HND graduates trained in Uganda with the knowledge and skills required for addressng the multifaceted nutrition and dietetics challenges in the diverse national health systems settings. It is critical that the limitations in HN/HND graduates’ professional competencies as identified in this study and the weaknesses in institutional capacities to address nutrition and dietetics related challenges in different sectors of Uganda as identified in other studies  are addrAdditional file 1: Supplemental File 1-HN-HND Graduates Consent FormR3Additional file 2: Supplemental File 2-Questionnaire for HN-HND GraduatesR3Additional file 3: Supplemental File 3-Questionnaire for Academic StaffsR3Additional file 4: Supplemental File 4-Questionnaire for SupervisorsR3Additional file 5: Supplemental File 5-Consent for Academic staffs-SupervisorsR3


Sir,first GenBank deposition of a RABV from Liberia, and it was a transcontinental strain of RABV genotype 1 (GenBank accession number: MF765758), co-circulating with Africa lineages in the national capital, Monrovia . PreE values and percentage query cover assigned to Indian RABVs KJ201893, KF535201 and KF535200 when aligned with MF765758, as compared with China lineage C RABVs (We appreciate the inclusion of the France RABV strain CVS (GU992321) and the India RABV strains RAB5 and RAB7 (KF535200 and KF535201) and others in the BLAST analysis of MF765758, by Zhao and colleagues. This has added to the knowledge base of the phylogeny of MF765758 and further unravelled the mystery of how MF765758 arrived in Liberia. However, because of the lower  C RABVs , there iThree genetically clustered groups of RABVs (A–C) were recently described, based on the characterisation of RABV nucleoprotein genes in dogs in Southeast China . Phyloge