Original Research

Perceptions of long-term impact and change following a midwife-led biomass smoke education programme for mothers in rural Uganda: a qualitative study


name here
Lucy L Cartwright1
MSc, Research Assistant *

name here
Lynne E Callaghan2
PhD, Senior Research Fellow

name here
Rupert CM Jones3
MD, Associate Professor

name here
Rebecca Nantanda4
PhD, Paediatrician and Senior Research Fellow

name here
James Fullam5
PhD, Research Fellow


1, 2, 3 Community and Primary Care Research Group, University of Plymouth, Plymouth Science Park, Derriford, Plymouth PL6 8BX, UK

4 Lung Institute, Makerere University, Upper Mulago Hill, PO Box 7749, Kampala, Uganda

5 European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, TR1 3HD, UK

ACCEPTED: 14 December 2021

early abstract:

Introduction: Women and children in Uganda and other low- and middle-income countries are exposed to disproportionately high levels of household air pollution from biomass smoke generated by smoke-producing cookstoves, especially in rural areas. This population is therefore particularly vulnerable to the negative health effects caused by household air pollution, including negative pregnancy outcomes and other health issues throughout life. The Midwife Project, a collaboration between research and health teams in the UK and Uganda, began in 2016 to implement an education programme on lung health for mothers in Uganda, to reduce the health risks to women and children. Education materials were produced to guide midwives in the delivery of health messages across four rural Health Centres and mixed-methods results of knowledge questionnaires and interviews demonstrated knowledge acquisition, acceptability and feasibility. This qualitative follow-up study aimed to improve understanding of the longer-term impact of this education programme from the perspective of midwives, Village Health Team members and mothers, in consideration of rolling the programme out more widely in rural Uganda.
Methods: Purposive sampling was carried out to recruit consenting antenatal or postnatal women, midwives and Village Health Team members who had been involved in an education session. Individual interviews were conducted with twelve mothers and four Village Health Team members, and four focus groups were conducted with ten midwives in total. Interviews and focus groups were conducted across all four Health Centres by two researchers and six translators as appropriate depending on language spoken (English or Lusoga). These were semi-structured and directed by topic guides. Reflective and observational notes were also made. A thematic analysis was carried out by two researchers, along with production of a narrative for each mother to enrich understanding of each individual story.
Findings: Midwives and Village Health Teams had continued with the programme well past the project end date and all mothers expressed making, or intending to make, changes, suggesting long-term feasibility and acceptability. Main themes generated were: ability to change and changes made, ability to change dictated by money, importance of practical education, perceived health improvements, and passing on knowledge. Additional findings were that some education topics appeared overlooked, and there was a lack of clarity about the Village Health Team role for the purposes of this programme. Some mothers had been motivated to overcome financial barriers, for example, by reconstructing cooking areas cheaply themselves. However, information given in the programme about building advice and potential financial gains was inconsistent.
Conclusions: Recommendations for future biomass smoke education should include explicit building advice, emphasis on financial gains, encouragement to share the knowledge acquired, and clarification of the Village Health Team role. These programme changes will improve focus and relevancy, optimise impact, and with behaviour change and implementation strategy in mind, could be used for widespread roll-out in rural Uganda. Future research should include quantitative data collection to objectively examine surprising perceived health benefits, including reduction in malaria and burns, and further qualitative work on why some education content appears neglected.