Non-communicable diseases, particularly cardiovascular diseases (CVDs), have become major contributors to morbidity and mortality in sub-Saharan Africa (SSA) and are projected to surpass infectious diseases as the leading cause of death among adults by 2030. Although CVDs have traditionally been associated with older age and obesity, adverse cardiovascular phenotypes are increasingly being observed in younger and leaner individuals in SSA. This pattern suggests that pathways to CVD risk in SSA may differ from those described in high-income countries. Early-life infectious exposures, undernutrition and socio-demographic conditions common in many SSA settings have been proposed as potential risk factors. Still, empirical evidence linking these exposures to cardiovascular risk in early adulthood remains limited due to a scarcity of long-running birth cohorts in the region.

This protocol describes a new round of data collection nested within the Entebbe Mother and Baby Study (EMaBS), a population-based Ugandan birth cohort established originally as a clinical trial (ISRCTN32849447) between 2003 and 2006 with prospective follow-up from pregnancy through adolescence. All participants currently under follow-up will be invited to participate at approximately 21 years of age. Primary outcomes are physiological determinants of CVD measured in early adulthood, including blood pressure, blood lipid levels, body mass index, body composition and markers of glucose metabolism. Secondary outcomes include behavioural CVD risk factors (diet, physical inactivity, alcohol use and tobacco use) and qualitative measures of CVD knowledge and risk perception. Key exposures of interest include prospectively collected early-life and childhood infectious exposures (malaria and helminth infections), markers of growth and undernutrition, micronutrient status, inflammatory markers, socio-demographic factors and selected genetic variants. Quantitative analyses will use multivariable regression and causal modelling approaches and will be complemented by qualitative interviews and focus group discussions.

The study protocol has been reviewed and approved by the Uganda Virus Research Institute Research and Ethics Committee (UVRI REC Ref: GC/127/35), the Uganda National Council for Science and Technology (UNCST Ref: MV625), and the London School of Hygiene & Tropical Medicine Research Ethics Committee (LSHTM Ethics Ref: 8811). Written informed consent will be obtained from all participants before study activities. Study findings will be shared and discussed with participants and community stakeholders through established engagement platforms. Results will be disseminated to the scientific community through peer-reviewed publications and conference presentations, and data will be made available to other researchers via established data-sharing platforms. We will engage policymakers at the district, national and international levels to facilitate the translation of findings into policy-relevant outputs.

This paper examines the challenges frontline health workers face, as well as their coping practices following district splitting. It also has ramifications for the need to take into account the nexus between district splitting and subnational health system functioning.

A qualitative cross-sectional study employing an exploratory design. Data were collected using an in-depth interview guide for individual interviews. We used a deductive thematic analysis to identify and structure challenges faced and coping mechanisms by health workers in new districts. The data were analysed deductively using Braun and Clarke’s six-step thematic analysis.

Frontline health workers from four randomly selected regions with one parent district selected randomly from each region and a respective child district that had been split from it between 2005 and 2015. Interviews were conducted between June and November 2018.

In-depth interviews were conducted with 24 frontline health workers whose age ranged from 33 to 51 years and these had changed locations between districts after district splitting occurred.

The challenges frontline health workers faced included work-related role changes, social demands, team integration and health system inadequacies. Health workers switched roles across districts, adapting to leadership while balancing clinical and administrative duties. Overall, five themes emerged during analysis. Newly promoted staff faced knowledge gaps in facility management. Social demands included accommodation issues and family/community pressures. Team integration impacted daily work, requiring newcomers to navigate hierarchy and culture. Health system issues, such as understaffing, poor infrastructure, drug shortages and strained work relations, worsened working conditions. Coping practices included induction, leadership training, staff appraisals, duty rosters, supervision, team building, partner support and financial/community planning.

District splitting worsens challenges for frontline health workers. While they show resilience through coping strategies, systemic improvements remain essential. Addressing root causes like better resource distribution, expanded training and stronger administrative support is crucial to achieving the district splitting goal of improving healthcare delivery in newly formed districts in Uganda.