Adverse childhood experiences, mental distress, self-harm and suicidality, and cumulative HIV risk by sex in Lesotho.

BACKGROUND: Adverse childhood experiences (ACEs) have been understudied in low- and middle-income countries, especially in sub-Saharan Africa. OBJECTIVES, PARTICIPANTS, SETTING: We explored associations between mental distress, self-harm or suicidality, and HIV risk and individual and cumulative ACEs (sexual, emotional, and physical violence; witnessing community and interparental violence; orphanhood) among youth aged 13-24 in Lesotho. METHODS: Multivariable logistic regressions stratified by sex using nationally representative 2018 Lesotho Violence Against Children and Youth Survey (nfemale = 7101; nmale = 1467) data. RESULTS: Over 75 % of males and females experienced at least 1 ACE. Among males, physical and community violence were significantly associated with mental distress; orphan status and emotional violence was associated with self-harm/suicidality. Males who witnessed interparental violence had higher odds of disclosing 2 types and 3 or more types of HIV risk versus none. Among females, being a double orphan and having experienced sexual, emotional, physical, community, and interparental violence were significantly associated with mental distress and any self-harm/suicidality in both models. Females who experienced physical violence had higher odds of disclosing 3 or more risk types versus no risk. Statistically significant associations emerged between cumulative ACEs and mental distress, self-harm/suicidality, and higher levels of HIV risk for both males and females. CONCLUSIONS: Differential patterns of associations between ACEs and mental health problems and HIV risk emerged by sex. Scalable, integrated individual and community efforts to prevent ACEs, provide mental health supports, and encourage safer sexual behaviors among those exposed are needed and could benefit youth in Lesotho.

"Here, your only relative is money " why slum social networks do not facilitate neighborhood community development: insights through a sanitation lens.

INTRODUCTION: Though social networks which are deemed vehicles of community development exist in slum areas, underdevelopment still persists in these areas. We explored the nature and role of social networks in facilitating community development in the slums of Kampala through a sanitation lens. METHODS: Qualitative Social Network Analysis (SNA) was done to understand the nature of slum social networks primarily through the analysis of sanitation behavior. Data were collected through six Focus Group Discussions (FGD), six In-depth Interviews (IDIs), and 18 Key Informant Interviews (KII) with Government, civil society and private stakeholders. We used both inductive and deductive thematic analysis. RESULTS: Four themes emerged in our analysis; i); Unsupportive environments, uncooperative neighbours and uncertainty of tenure: participants reported slums as unsupportive of community development due to a shortage of space, poverty and unplanned services. Tenants perceived landlords as exploitative and predatory and wished the tables are turned. This notion of cyclic exploitation did not encourage collective action for community good. Short-term economic survival trumped long-term community interests ii) Patronage and poor service delivery: varying degrees of patronage led to multiple forms of illegalities and violations such as tax evasion. Due to vested interests and corruption among public officials, the slum population was lethargic. iii) Intersecting realities of poverty and unemployment: slum dwellers lived on the margins daily. Hence, poor living conditions were a secondary concern. iv) Social relations for personal development: Slum social networks were driven by individual interests rather than community good. Slum dwellers prioritized connections with people of common socio-economic interests. As such social networks were instrumental only if they 'added value'. CONCLUSION: Social networks in slums are only concerned about survival needs. Slums require responses that address the complexity of slum formation and broader livelihood challenges, as well as re-assessing the meaning of community. We posit that more needs to be done in understanding the meaning and workings of a sociology beyond physical societies. Poverty is a modifier of social systems and processes and should be a concern for all stakeholders involved in slum development.

'When will the doctor be around so that I come by?!' Geo-socio effects on health care supply, access and utilisation: experiences from Kalangala Islands, Uganda.

BACKGROUND: The study set out to give an in-depth intersection of geo, eco-socio exposition of the factors relating to geography, healthcare supply and utilization in an island setting. This analysis is informed by what has emerged to be known as social epidemiology. We provide in-depth explanation of context to health care access, utilization and outcomes. We argue that health care delivery has multiple intersections that are experientially complex, multi-layered and multi-dimensional to the disadvantage of vulnerable population segments of society in the study area. METHODS: We used a cross-sectional qualitative exploratory design. Qualitative methods facilitated an in-depth exploration and understanding of this island dispersed and peripheral setting. Data sources included a review of relevant literature and an ethnographic exploration of the lived experiences of community members while seeking and accessing health care. Data collection methods included in-depth interviews (IDI) from selected respondents, observation, focus group discussions (FGDs) and key informant interviews (KII). RESULTS: We report based on the health care systems model which posits that, health care activities are diverse but interconnected in a complex way. The identified themes are; the role of geography, access (geographical and financial) to health services, demand and utilization, Supplies, staffing and logistical barriers and a permissive and transient society. When and how to travel for care was beyond a matter of having a health need/ being sick and need arising. A motivated workforce is as critical as health facilities themselves in determining healthcare outcomes. CONCLUSION: Geography doesn't work and affect health outcomes in isolation. Measures that target only individuals will not be adequate to tackle health inequalities because aspects of the collective social group and physical environment may also need to be changed in order to reduce health variations.

Re-conceptualizing sustainable urban sanitation in Uganda: why the roots of 'Slumification' must be dealt with.

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

Livelihood Risk, Culture, and the HIV Interface: Evidence from Lakeshore Border Communities in Buliisa District, Uganda.

BACKGROUND: While studies have focused on HIV prevalence and incidence among fishing communities, there has been inadequate attention paid to the construction and perception of HIV risk among fisher folk. There has been limited research with respect to communities along Lake Albert on the border between Uganda and the Democratic Republic of Congo (DRC). METHODS: We conducted a qualitative study on three landing sites of Butiaba, Bugoigo, and Wanseko on the shores of Lake Albert along the border of Uganda and the Democratic Republic of Congo. Data were collected using 12 Focus Group Discussions and 15 key informant interviews. Analysis was done manually using content and thematic approaches. RESULTS: Lakeshore livelihoods split families between men, women, and children with varying degrees of exposure to HIV infection risk. Sustaining a thriving fish trade was dependent on taking high risks. For instance, profits were high when the lake was stormy. Landing sites were characterized by widespread prostitution, alcohol consumption, drug abuse, and child labour. Such behaviors negatively affected minors and in many ways predisposed them to HIV infection. The lake shore-border heterogeneity resulted in a population with varying HIV knowledge, attitudes, behavior, and competencies to risk perception and adaptation amidst negative masculinities and negative resilience. CONCLUSION: The susceptibility of lakeshore communities to HIV is attributable to a complex combination of geo-socio, the available (health) services, economic, and cultural factors which converged around the fishing livelihood. This study reveals that HIV risk assessment is an interplay of plural rationalities within the circumstances and constraints that impinge on the daily lives by different actors. A lack of cohesion in a multiethnic setting with large numbers of outsiders and a large transient population made the available HIV interventions less effective.