{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T20:54:52Z","timestamp":1781643292382,"version":"3.54.5"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,3,16]],"date-time":"2026-03-16T00:00:00Z","timestamp":1773619200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T00:00:00Z","timestamp":1777248000000},"content-version":"vor","delay-in-days":42,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100009633","name":"Eunice Kennedy Shriver National Institute of Child Health and Human Development","doi-asserted-by":"publisher","award":["R21HD106002"],"award-info":[{"award-number":["R21HD106002"]}],"id":[{"id":"10.13039\/100009633","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Women's Health"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Infertility counseling for women after genital fistula repair presents unique medical, emotional, and social challenges. This study aims to explore the counseling strategies employed by fistula care providers in Uganda, the challenges they face, and to identify implications for practice.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This qualitative study involved in-depth interviews with 30 fistula care providers in Uganda. The interviews focused on their experiences, strategies, and challenges in providing infertility counseling to women who had undergone genital fistula repair. The data were analyzed thematically to identify key themes and insights.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The study identified various counseling strategies, including providing emotional support, setting realistic expectations, and referring patients to specialists. Providers have employed individualized approaches, particularly considering patients\u2019 hysterectomy status, with additional counseling sessions for those affected. Cultural attitudes toward infertility influence the counseling process, and financial constraints significantly impact patients\u2019 options. Providers reported emotional challenges in discussing sensitive issues and managing patients\u2019 responses, highlighting a need for better training and support.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Infertility counseling for women after genital fistula repair requires a comprehensive approach addressing medical, emotional, and social dimensions. Our findings highlight significant provider challenges, including the emotional toll of counseling, lack of specific training, and systemic barriers such as patient financial constraints and limited access to specialist care. Enhancing training for fistula care providers in counseling skills and integrating psychosocial support can improve care quality and address these challenges effectively.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12905-026-04388-0","type":"journal-article","created":{"date-parts":[[2026,3,16]],"date-time":"2026-03-16T15:22:07Z","timestamp":1773674527000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Counseling strategies and challenges for addressing infertility and infertility concerns following female genital fistula repair: perspectives from fistula care providers in Uganda"],"prefix":"10.1186","volume":"26","author":[{"given":"Suvarna Jyothi","family":"Kantipudi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Umar","family":"Senoga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hadija","family":"Nalubwama","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justus K.","family":"Barageine","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abner P.","family":"Korn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alison M.","family":"El Ayadi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,3,16]]},"reference":[{"issue":"6","key":"4388_CR1","doi-asserted-by":"publisher","first-page":"501","DOI":"10.5603\/GP.a","volume":"93","author":"K Pyra","year":"2022","unstructured":"Pyra K, Szmygin M, Szmygin H, Jargiello T, Rechberger T, Wozniak S. Uretero-vaginal fistulas - clinical presentation, treatment and literature overview. Ginekol Pol. 2022;93(6):501\u20135. https:\/\/doi.org\/10.5603\/GP.a. 2021.0240 PubMed PMID: 35315024.","journal-title":"Ginekol Pol"},{"issue":"1","key":"4388_CR2","doi-asserted-by":"publisher","first-page":"744","DOI":"10.1186\/s12884-022-05051-w","volume":"22","author":"CJ Ngongo","year":"2022","unstructured":"Ngongo CJ, Raassen TJIP, Mahendeka M, Lombard L, van Roosmalen J, Temmerman M. A retrospective review of genital fistula occurrence in nine African countries. BMC Pregnancy Childbirth. 2022;22(1):744. https:\/\/doi.org\/10.1186\/s12884-022-05051-w. PubMed PMID: 36195839; PubMed Central PMCID: PMC9531465.","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"4388_CR3","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1186\/s12905-019-0732-3","volume":"19","author":"M Animut","year":"2019","unstructured":"Animut M, Mamo A, Abebe L, Berhe MA, Asfaw S, Birhanu Z. The sun keeps rising but darkness surrounds us: a qualitative exploration of the lived experiences of women with obstetric fistula in Ethiopia. BMC Womens Health. 2019;19(1):37. https:\/\/doi.org\/10.1186\/s12905-019-0732-3. PubMed PMID: 30808352; PubMed Central PMCID: PMC6390300.","journal-title":"BMC Womens Health"},{"key":"4388_CR4","volume-title":"Report of the Secretary-General. A\/75\/264","author":"United Nations General Assembly","year":"2020","unstructured":"United Nations General Assembly. Intensifying efforts to end obstetric fistula within a decade. Report of the Secretary-General. A\/75\/264. New York, NY: United Nations; 2020. Jul. Report No."},{"key":"4388_CR5","unstructured":"Optimizing Postpartum Care | ACOG. [cited 2024 Sep 9]. Available from: https:\/\/www.acog.org\/clinical\/clinical-guidance\/committee-opinion\/articles\/2018\/05\/optimizing-postpartum-care"},{"key":"4388_CR6","doi-asserted-by":"publisher","unstructured":"Kamel FR, Ramadan S, Elbana H, Kamal F. Pregnant Women`s knowledge and Attitude Regarding Obstetric Fistula. Benha J Appl Sci 2023 Apr 1. https:\/\/doi.org\/10.21608\/bjas.2023.195110.1088","DOI":"10.21608\/bjas.2023.195110.1088"},{"key":"4388_CR7","volume-title":"Uganda Demographic and Health Survey 2022","author":"Uganda Bureau of Statistcs","year":"2023","unstructured":"Uganda Bureau of Statistcs. Uganda Demographic and Health Survey 2022. Kampala, Uganda: UBOS; 2023."},{"issue":"5","key":"4388_CR8","doi-asserted-by":"publisher","first-page":"e0303020","DOI":"10.1371\/journal.pone.0303020","volume":"19","author":"LB Zeleke","year":"2024","unstructured":"Zeleke LB, Welsh A, Abeje G, Khejahei M. Proportions and determinants of successful surgical repair of obstetric fistula in low- and middle-income countries: A systematic review and meta-analysis. PLoS ONE. 2024;19(5):e0303020. https:\/\/doi.org\/10.1371\/journal.pone.0303020.","journal-title":"PLoS ONE"},{"issue":"9","key":"4388_CR9","doi-asserted-by":"publisher","first-page":"999","DOI":"10.1093\/heapol\/czy","volume":"33","author":"I Epiu","year":"2018","unstructured":"Epiu I, Alia G, Mukisa J, Tavrow P, Lamorde M, Kuznik A. Estimating the cost and cost-effectiveness for obstetric fistula repair in hospitals in Uganda: a low income country. Health Policy Plan. 2018;33(9):999\u20131008. https:\/\/doi.org\/10.1093\/heapol\/czy. 078 PubMed PMID: 30252051; PubMed Central PMCID: PMC6263022.","journal-title":"Health Policy Plan"},{"key":"4388_CR10","unstructured":"Fistula Surgery Training Initiative. | Figo. [cited 2024 Sep 23]. Available from: https:\/\/www.figo.org\/what-we-do\/figo-projects\/fistula-surgery-training-initiative"},{"issue":"2","key":"4388_CR11","doi-asserted-by":"publisher","first-page":"2","DOI":"10.3126\/njog.v13i2.21846","volume":"13","author":"A Shallon","year":"2018","unstructured":"Shallon A, Ojengbede OA, Mugisha JF, Odukogbe ATA. Social Reintegration and Rehabilitation of Obstetric Fistula Patients Before and After Repair in Sub-Saharan Africa: A Systematic Review. Nepal J Obstet Gynaecol. 2018;13(2):2. Located at: Nigeria.","journal-title":"Nepal J Obstet Gynaecol"},{"issue":"3","key":"4388_CR12","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1016\/j.ijgo.2011.01.006","volume":"113","author":"AL Wilson","year":"2011","unstructured":"Wilson AL, Chipeta E, Kalilani-Phiri L, Taulo F, Tsui AO. Fertility and pregnancy outcomes among women with obstetric fistula in rural Malawi. Int J Gynecol Obstet. 2011;113(3):196\u20138. https:\/\/doi.org\/10.1016\/j.ijgo.2011.01.006.","journal-title":"Int J Gynecol Obstet"},{"issue":"11","key":"4388_CR13","doi-asserted-by":"publisher","first-page":"e1152","DOI":"10.1016\/S2214-109X(17)30366-2","volume":"5","author":"A Delamou","year":"2017","unstructured":"Delamou A, Delvaux T, Ayadi AME, Tripathi V, Camara BS, Beavogui AH, Romanzi L, Cole B, Bouedouno P, Diallo M, Barry TH, Camara M, Diallo K, Leveque A, Zhang WH, De Brouwere V. Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study. Lancet Glob Health. 2017;5(11):e1152\u201360. (17)30366-2 PubMed PMID: 28941996; PubMed Central PMCID: PMC6530985.","journal-title":"Lancet Glob Health"},{"key":"4388_CR14","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1016\/j.clinbiochem.2018","volume":"62","author":"M Vander Borght","year":"2018","unstructured":"Vander Borght M, Wyns C. Fertility and infertility: Definition and epidemiology. Clin Biochem. 2018;62:2\u201310. https:\/\/doi.org\/10.1016\/j.clinbiochem.2018. 03.012 PubMed PMID: 29555319.","journal-title":"Clin Biochem"},{"issue":"1","key":"4388_CR15","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1186\/s40738-020-00090-3","volume":"6","author":"MS Abebe","year":"2020","unstructured":"Abebe MS, Afework M, Abaynew Y. Primary and secondary infertility in Africa: systematic review with meta-analysis. Fertil Res Pract. 2020;6(1):20. https:\/\/doi.org\/10.1186\/s40738-020-00090-3. PubMed PMID: 33292584; PubMed Central PMCID: PMC7709409.","journal-title":"Fertil Res Pract"},{"issue":"3","key":"4388_CR16","doi-asserted-by":"publisher","first-page":"174","DOI":"10.1177\/1757913912472415","volume":"133","author":"B Rouchou","year":"2013","unstructured":"Rouchou B. Consequences of infertility in developing countries. Perspect Public Health. 2013;133(3):174\u20139. doi:10.1177\/1757913912472415 PubMed PMID: 23327901.","journal-title":"Perspect Public Health"},{"issue":"12","key":"4388_CR17","doi-asserted-by":"publisher","first-page":"49","DOI":"10.29063\/ajrh2022\/v26i","volume":"26","author":"L Temitope","year":"2022","unstructured":"Temitope L. A qualitative synthesis of the impact of infertility on the mental health of African women. Afr J Reprod Health. 2022;26(12):49\u201357. https:\/\/doi.org\/10.29063\/ajrh2022\/v26i. 12.6 PubMed PMID: 37585085.","journal-title":"Afr J Reprod Health"},{"issue":"12","key":"4388_CR18","doi-asserted-by":"publisher","first-page":"e0002680","DOI":"10.1371\/journal.pgph.0002680","volume":"3","author":"ABMN Hasan","year":"2023","unstructured":"Hasan ABMN, Sharif AB, Jahan I, Begum MR. Mental health status and the quality of life of infertile women receiving fertility treatment in Bangladesh: A cross-sectional study. PLOS Glob Public Health. 2023;3(12):e0002680. https:\/\/doi.org\/10.1371\/journal.pgph.0002680. PubMed PMID: 38079385; PubMed Central PMCID: PMC10712886.","journal-title":"PLOS Glob Public Health"},{"issue":"1","key":"4388_CR19","doi-asserted-by":"publisher","first-page":"151","DOI":"10.1186\/s12978-018-0596-2","volume":"15","author":"S Dierickx","year":"2018","unstructured":"Dierickx S, Rahbari L, Longman C, Jaiteh F, Coene G. I am always crying on the inside: a qualitative study on the implications of infertility on women\u2019s lives in urban Gambia. Reprod Health. 2018;15(1):151. https:\/\/doi.org\/10.1186\/s12978-018-0596-2. PubMed PMID: 30208896; PubMed Central PMCID: PMC6134751.","journal-title":"Reprod Health"},{"key":"4388_CR20","doi-asserted-by":"publisher","DOI":"10.1037\/sah0000643","author":"AM El Ayadi","year":"2025","unstructured":"El Ayadi AM, Conway A, Padhye M, Mittal A, Nocon J, Barr-Walker J, Kennerly A, Ryan NE. A comprehensive understanding of global female genital fistula and stigma: A systematic scoping review and meta-analysis. Stigma Health. 2025. https:\/\/doi.org\/10.1037\/sah0000643.","journal-title":"Stigma Health"},{"issue":"1","key":"4388_CR21","doi-asserted-by":"publisher","first-page":"73","DOI":"10.3109\/14647273.2013.774217","volume":"16","author":"M Crawshaw","year":"2013","unstructured":"Crawshaw M, Hunt J, Monach J, Pike S. British Infertility Counselling Association - Guidelines for Good Practice in Infertility Counselling. Third edition 2012. Hum Fertil. 2013;16(1):73\u201388. https:\/\/doi.org\/10.3109\/14647273.2013.774217.","journal-title":"Hum Fertil"},{"issue":"2","key":"4388_CR22","doi-asserted-by":"publisher","first-page":"e240063","DOI":"10.1530\/RAF-24-0063","volume":"6","author":"MJ Mutumba-Nakalembe","year":"2025","unstructured":"Mutumba-Nakalembe MJ, Janes CR, FERTILITY CARE IN LOW- AND MIDDLE-INCOME COUNTRIES. Policy, politics, and macro-level influences on implementation in Uganda. Reprod Fertil. 2025;6(2):e240063. https:\/\/doi.org\/10.1530\/RAF-24-0063. PubMed PMID: 40478691.","journal-title":"Reprod Fertil"},{"issue":"2","key":"4388_CR23","doi-asserted-by":"publisher","first-page":"100481","DOI":"10.1016\/j.xagr.2025.100481","volume":"5","author":"AP Korn","year":"2025","unstructured":"Korn AP, Barageine JK, Nalubwama H, Okiring J, Nalubega F, Asiimwe SI, Matovu A, El Ayadi AM. Pregnancy outcomes following surgical repair of female genital fistula in Uganda. AJOG Glob Rep. 2025;5(2):100481. https:\/\/doi.org\/10.1016\/j.xagr.2025.100481. PubMed PMID: 40264448; PubMed Central PMCID: PMC12013486.","journal-title":"AJOG Glob Rep"},{"issue":"1","key":"4388_CR24","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12913-020-05691-8","volume":"20","author":"J Rugk\u00e5sa","year":"2020","unstructured":"Rugk\u00e5sa J, Tveit OG, Berteig J, Hussain A, Ruud T. Collaborative care for mental health: a qualitative study of the experiences of patients and health professionals. BMC Health Serv Res. 2020;20(1):1\u201310. https:\/\/doi.org\/10.1186\/s12913-020-05691-8.","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"4388_CR25","doi-asserted-by":"publisher","first-page":"119","DOI":"10.1002\/capr.12609","volume":"24","author":"I Schamong","year":"2024","unstructured":"Schamong I, D\u2019Astolfo L, Bollmann S, Brakemeier EL, Kube T. How expectations and therapeutic style influence counselling outcome. Couns Psychother Res. 2024;24(1):119\u201335. https:\/\/doi.org\/10.1002\/capr.12609.","journal-title":"Couns Psychother Res"},{"issue":"1","key":"4388_CR26","doi-asserted-by":"publisher","first-page":"82","DOI":"10.1186\/s12873-023-00856-0","volume":"23","author":"O Kituuka","year":"2023","unstructured":"Kituuka O, Mwaka E, Munabi I, Galukande M. Experiences of patients and next of kin on informed consent process for emergency surgery in two Urban university teaching hospitals in Uganda: a comparative cross sectional study. BMC Emerg Med. 2023;23(1):82. https:\/\/doi.org\/10.1186\/s12873-023-00856-0.","journal-title":"BMC Emerg Med"},{"key":"4388_CR27","doi-asserted-by":"publisher","first-page":"205031212311766","DOI":"10.1177\/20503121231176666","volume":"11","author":"O Kituuka","year":"2023","unstructured":"Kituuka O, Munabi IG, Mwaka ES, Galukande M, Harris M, Sewankambo N. Informed consent process for emergency surgery: A scoping review of stakeholders\u2019 perspectives, challenges, ethical concepts, and policies. Sage Open Med. 2023;11:20503121231176666. https:\/\/doi.org\/10.1177\/20503121231176666.","journal-title":"Sage Open Med"},{"key":"4388_CR28","unstructured":"EngenderHealth. Momentum Safe Surgery in Family Planning and Obstetrics at the XXIV FIGO World Congress of Gynecology and Obstetrics. New York: EngenderHealth. 2023 [cited 2025 Jul 22]. Available from: https:\/\/www.engenderhealth.org\/momentum-safe-surgery-in-family-planning-and-obstetrics-at-the-xxiv-figo-world-congress-of-gynecology-and-obstetrics"},{"key":"4388_CR29","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1186\/1472-6874-13-17","volume":"13","author":"K Ried","year":"2013","unstructured":"Ried K, Alfred A. Quality of life, coping strategies and support needs of women seeking Traditional Chinese Medicine for infertility and viable pregnancy in Australia: a mixed methods approach. BMC Womens Health. 2013;13:17. https:\/\/doi.org\/10.1186\/1472-6874-13-17. PubMed PMID: 23570255; PubMed Central PMCID: PMC3635943.","journal-title":"BMC Womens Health"},{"issue":"6","key":"4388_CR30","doi-asserted-by":"publisher","first-page":"871","DOI":"10.1007\/s12529-017-9656-1","volume":"24","author":"Y Benyamini","year":"2017","unstructured":"Benyamini Y, Gozlan M, Weissman A. Normalization as a Strategy for Maintaining Quality of Life While Coping with Infertility in a Pronatalist Culture. Int J Behav Med. 2017;24(6):871\u20139. https:\/\/doi.org\/10.1007\/s12529-017-9656-1. PubMed PMID: 28620775.","journal-title":"Int J Behav Med"},{"key":"4388_CR31","unstructured":"Risk factors for vaginal fistula symptoms in Sub. -Saharan Africa: a pooled analysis of national household survey data - PubMed. [cited 2025 Jul 22]. Available from: https:\/\/pubmed-ncbi-nlm-nih-gov.ucsf.idm.oclc.org\/27098261\/"},{"issue":"4","key":"4388_CR32","doi-asserted-by":"publisher","first-page":"411","DOI":"10.1093\/humupd\/dmv016","volume":"21","author":"MC Inhorn","year":"2015","unstructured":"Inhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. Hum Reprod Update. 2015;21(4):411\u201326. https:\/\/doi.org\/10.1093\/humupd\/dmv016. PubMed PMID: 25801630.","journal-title":"Hum Reprod Update"},{"issue":"1","key":"4388_CR33","doi-asserted-by":"publisher","first-page":"729","DOI":"10.1186\/s12884-020-03428-3","volume":"20","author":"P Pilli","year":"2020","unstructured":"Pilli P, Sekweyama P, Kayira A. Women\u2019s experiences following emergency Peripartum hysterectomy at St. Francis hospital Nsambya. A qualitative study. BMC Pregnancy Childbirth. 2020;20(1):729. https:\/\/doi.org\/10.1186\/s12884-020-03428-3.","journal-title":"BMC Pregnancy Childbirth"},{"key":"4388_CR34","doi-asserted-by":"publisher","unstructured":"Experience of infertility-related stigma in Africa. a systematic review and mixed methods meta-synthesis | International Health | Oxford Academic [Internet]. [cited 2025 Jul 22]. Available from: https:\/\/academic.oup.com\/inthealth\/advance-article\/doi\/https:\/\/doi.org\/10.1093\/inthealth\/ihaf060\/8151279","DOI":"10.1093\/inthealth\/ihaf060\/8151279"},{"key":"4388_CR35","unstructured":"Mental health care in Uganda. - The Lancet Psychiatry [Internet]. [cited 2025 Jul 22]. Available from: https:\/\/www.thelancet.com\/journals\/lanpsy\/article\/PIIS2215-0366(22)00305-4\/fulltext"},{"issue":"1","key":"4388_CR36","doi-asserted-by":"publisher","first-page":"1247","DOI":"10.1186\/s12889-019-7566-7","volume":"19","author":"BW Dubale","year":"2019","unstructured":"Dubale BW, Friedman LE, Chemali Z, Denninger JW, Mehta DH, Alem A, Fricchione GL, Dossett ML, Gelaye B. Systematic review of burnout among healthcare providers in sub-Saharan Africa. BMC Public Health. 2019;19(1):1247. https:\/\/doi.org\/10.1186\/s12889-019-7566-7.","journal-title":"BMC Public Health"}],"container-title":["BMC Women's Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12905-026-04388-0","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12905-026-04388-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12905-026-04388-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T20:12:37Z","timestamp":1781640757000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12905-026-04388-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,16]]},"references-count":36,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["4388"],"URL":"https:\/\/doi.org\/10.1186\/s12905-026-04388-0","relation":{},"ISSN":["1472-6874"],"issn-type":[{"value":"1472-6874","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,16]]},"assertion":[{"value":"11 December 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 March 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"16 March 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Study procedures were reviewed and approved by the University of California San Francisco Institutional Review Board (IRB# 19-27901), the Mulago Hospital Research and Ethics Committee (MHREC# 1674), and Uganda National Council for Science and Technology (HS 2706). All participants provided written confirmation of informed consent. The research was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"No individual participant\u2019s data is included in this manuscript in a manner that would allow for personal identification. All data are presented in aggregate form, ensuring the confidentiality and anonymity of the participants.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"224"}}