Cigarette smoking and misperceived norms among adults in rural Uganda: a population-based study.

BACKGROUND: Little is known about perceived norms about cigarette smoking in Uganda or the extent to which perceptions drive personal cigarette smoking behaviour. METHODS: We conducted a cross-sectional study in 2016-2018 that targeted all adults who resided within eight villages in Rwampara District, southwestern Uganda. Personal cigarette smoking frequency was elicited by self-report. We also asked participants what they believed to be the cigarette smoking frequency of most other adult men and women in their villages (i.e., perceived norms). Frequent cigarette smoking was defined as 4+ times/week. We compared perceived norms to cigarette smoking frequency reports aggregated at the village level. We used multivariable Poisson regression to estimate the association between perceived norms and personal cigarette smoking behaviour. RESULTS: Among 1626 participants (91% response rate), 92 of 719 men (13%) and 6 of 907 women (0.7%) reported frequent smoking. However, 1030 (63%) incorrectly believed most men in their villages smoked cigarettes frequently. Additionally, 116 (7%) incorrectly believed that most women in their villages smoked cigarettes frequently. These misperceptions were pervasive across social strata. Men who misperceived frequent cigarette smoking as the norm among other men in their villages were more likely to smoke frequently themselves (adjusted relative risk=1.49; 95% CI, 1.13 to 1.97). CONCLUSIONS: Most adults overestimated cigarette smoking frequency among village peers. Men who incorrectly believed that frequent smoking was the norm were more likely to engage in frequent smoking themselves. Applying a 'social norms approach' intervention by promoting existing healthy norms may prevent smoking initiation or motivate reductions in smoking among men in rural Uganda.

Perceptions About Local ART Adherence Norms and Personal Adherence Behavior Among Adults Living with HIV in Rural Uganda.

Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.

RESUMEN: Aunque las normas mal percibidas impulsan los comportamientos personales de salud, no sabemos acerca de este fenómeno en el contexto de la terapia antirretroviral (TAR). Este estudio transversal incluyó a todas las personas que viven con el VIH (PVVS) y con TAR en ocho pueblos de una parroquia en una región rural del suroeste de Uganda. Utilizamos encuestas para medir los informes de adherencia personal al TAR (no faltar ninguna dosis de TAR en los últimos 7 días se consideró como acción óptima; mientras que faltar las dosis se consideraron como acción subóptima) y las normas percibidas sobre la norma local de adherencia al TAR (si cada individuo pensó o no que 'la mayoría de las otras PVVS en esta parroquia omitieron alguna dosis en los últimos 7 días). Usamos modelos multivariables de regresión de Poisson para estimar la asociación entre las normas percibidas y la adherencia personal. De las 159 PVVS con TAR (tasa de respuesta del 95%), 142 (89%) reportaron que no faltaron ningua dosis. Sin embargo, 119 (75%) pensaron que la mayoría de los individuos en esta población de PVVS con TAR eran suboptimalmente adherentes. Esta percepción incorrecta sobre la norma local de adherencia al TAR fue prevalente en todos los subgrupos de PVVS. La percepción incorrecta de que la norma local de adherencia al TAR era subóptima se asoció con una menor probabilidad de adherencia óptima entre las PVVS casadas (riesgo relativo ajustado [aRR] = 0,83; intervalo de confianza [IC] del 95% 0,71-0,97). La asociación fue similar pero imprecisamente se estima para todas las PVVS (aRR = 0,91; IC 95% 0,82-1,01). Las intervenciones para corregir las normas mal percibidas de TAR, como una intervención independiente o como un complemento de otros programas de promoción de la adherencia, pueden influir en el comportamiento de la adherencia al TAR y tal vez reducir el estigma relacionado con el VIH.

Ease of marital communication and depressive symptom severity among men and women in rural Uganda: cross-sectional, whole-population study.

PURPOSE: Depression is a major contributor to the global burden of disease. The extent to which marital communication may influence depression in contexts with little mental health support is unknown. METHODS: We conducted a whole-population study of married adult residents of eight villages in a rural region of southwestern Uganda. Depression symptom severity was measured using a modified version of the Hopkins Symptom Checklist for Depression, with > 1.75 classified as a positive screen for probable depression. Respondents were asked to report about ease of marital communication ('never easy', 'easy once in a while', 'easy most of the time' or 'always easy'). Sex-stratified, multivariable Poisson regression models were fit to estimate the association between depression symptom severity and marital communication. RESULTS: Among 492 female and 447 male participants (response rate = 96%), 23 women and 5 men reported communication as 'never easy' and 154 women and 72 men reported it as 'easy once in a while'. Reporting communication as 'never easy' was associated with an increased risk of probable depression among women (adjusted relative risk [ARR], 2.06; 95% confidence interval [CI], 1.08-3.93, p = 0.028) and among men (ARR, 7.10; 95% CI 1.70-29.56, p = 0.007). CONCLUSION: In this whole-population study of married adults in rural Uganda, difficulty of marital communication was associated with depression symptom severity. Additional research is needed to assess whether communication training facilitated by local leaders or incorporated into couples-based services might be a novel pathway to address mental health burden.

Family Strengthening in the Context of COVID-19: Adapting a Community-Based Intervention from Kenya to the United States.

COVID-19 led to widespread disruption of services that promote family well-being. Families impacted most were those already experiencing disparities due to structural and systemic barriers. Existing support systems faded into the background as families became more isolated. New approaches were needed to deliver evidence-based, low-cost interventions to reach families within communities. We adapted a family strengthening intervention developed in Kenya ("Tuko Pamoja") for the United States. We tested a three-phase participatory adaptation process. In phase 1, we conducted community focus groups including 11 organizations to identify needs and a community partner. In phase 2, the academic-community partner team collaboratively adapted the intervention. We held a development workshop and trained community health workers to deliver the program using an accelerated process combining training, feedback, and iterative revisions. In phase 3, we piloted Coping Together with 18 families, collecting feedback through session-specific surveys and participant focus groups. Community focus groups confirmed that concepts from Tuko Pamoja were relevant, and adaptation resulted in a contextualized intervention-"Coping Together"-an 8-session virtual program for multiple families. As in Tuko Pamoja, communication skills are central and applied for developing family values, visions, and goals. Problem-solving and coping skills then equip families to reach goals, while positive emotion-focused activities promote openness to change. Sessions are interactive, emphasizing skills practice. Participants reported high acceptability and appropriateness, and focus groups suggested that most content was understood and applied in ways consistent with the theory of change. The accelerated reciprocal adaptation process and intervention could apply across resource-constrained settings.

Adverse childhood experiences, adult depression, and suicidal ideation in rural Uganda: A cross-sectional, population-based study.

BACKGROUND: Depression is recognized globally as a leading cause of disability. Early-life adverse childhood experiences (ACEs) have been shown to have robust associations with poor mental health during adulthood. These effects may be cumulative, whereby a greater number of ACEs are progressively associated with worse outcomes. This study aimed to estimate the associations between ACEs and adult depression and suicidal ideation in a cross-sectional, population-based study of adults in Uganda. METHODS AND FINDINGS: Between 2016 and 2018, research assistants visited the homes of 1,626 adult residents of Nyakabare Parish, a rural area in southwestern Uganda. ACEs were assessed using a modified version of the Adverse Childhood Experiences-International Questionnaire, and depression symptom severity and suicidal ideation were assessed using the Hopkins Symptom Checklist for Depression (HSCL-D). We applied a validated algorithm to determine major depressive disorder diagnoses. Overall, 1,458 participants (90%) had experienced at least one ACE, 159 participants (10%) met criteria for major depressive disorder, and 28 participants (1.7%) reported suicidal ideation. We fitted regression models to estimate the associations between cumulative number of ACEs and depression symptom severity (linear regression model) and major depressive disorder and suicidal ideation (Poisson regression models). In multivariable regression models adjusted for age, sex, primary school completion, marital status, self-reported HIV status, and household asset wealth, the cumulative number of ACEs was associated with greater depression symptom severity (b = 0.050; 95% confidence interval [CI], 0.039-0.061, p < 0.001) and increased risk for major depressive disorder (adjusted relative risk [ARR] = 1.190; 95% CI, 1.109-1.276; p < 0.001) and suicidal ideation (ARR = 1.146; 95% CI, 1.001-1.311; p = 0.048). We assessed the robustness of our findings by probing for nonlinearities and conducting analyses stratified by age. The limitations of the study include the reliance on retrospective self-report as well as the focus on ACEs that occurred within the household. CONCLUSIONS: In this whole-population, cross-sectional study of adults in rural Uganda, the cumulative number of ACEs had statistically significant associations with depression symptom severity, major depressive disorder, and suicidal ideation. These findings highlight the importance of developing and implementing policies and programs that safeguard children, promote mental health, and prevent trajectories toward psychosocial disability.

Correlates of attendance at community engagement meetings held in advance of bio-behavioral research studies: A longitudinal, sociocentric social network study in rural Uganda.

BACKGROUND: Community engagement is central to the conduct of health-related research studies as a way to determine priorities, inform study design and implementation, increase recruitment and retention, build relationships, and ensure that research meets the goals of the community. Community sensitization meetings, a form of community engagement, are often held prior to the initiation of research studies to provide information about upcoming study activities and resolve concerns in consultation with potential participants. This study estimated demographic, health, economic, and social network correlates of attendance at community sensitization meetings held in advance of a whole-population, combined behavioral, and biomedical research study in rural Uganda. METHODS AND FINDINGS: Research assistants collected survey data from 1,630 adults participating in an ongoing sociocentric social network cohort study conducted in a rural region of southwestern Uganda. These community survey data, collected between 2016 and 2018, were linked to attendance logs from community sensitization meetings held in 2018 and 2019 before the subsequent community survey and community health fair. Of all participants, 264 (16%) attended a community sensitization meeting before the community survey, 464 (28%) attended a meeting before the community health fair, 558 (34%) attended a meeting before either study activity (survey or health fair), and 170 (10%) attended a meeting before both study activities (survey and health fair). Using multivariable Poisson regression models, we estimated correlates of attendance at community sensitization meetings. Attendance was more likely among study participants who were women (adjusted relative risk [ARR]health fair = 1.71, 95% confidence interval [CI], 1.32 to 2.21, p < 0.001), older age (ARRsurvey = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001; ARRhealth fair = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001), married (ARRsurvey = 1.74, 95% CI, 1.29 to 2.35, p < 0.001; ARRhealth fair = 1.41, 95% CI, 1.13 to 1.76, p = 0.002), and members of more community groups (ARRsurvey = 1.26 per group, 95% CI, 1.10 to 1.44, p = 0.001; ARRhealth fair = 1.26 per group, 95% CI, 1.12 to 1.43, p < 0.001). Attendance was less likely among study participants who lived farther from meeting locations (ARRsurvey = 0.54 per kilometer, 95% CI, 0.30 to 0.97, p = 0.041; ARRhealth fair = 0.57 per kilometer, 95% CI, 0.38 to 0.86, p = 0.007). Leveraging the cohort's sociocentric design, social network analyses suggested that information conveyed during community sensitization meetings could reach a broader group of potential study participants through attendees' social network and household connections. Study limitations include lack of detailed data on reasons for attendance/nonattendance at community sensitization meetings; achieving a representative sample of community members was not an explicit aim of the study; and generalizability may not extend beyond this study setting. CONCLUSIONS: In this longitudinal, sociocentric social network study conducted in rural Uganda, we observed that older age, female sex, being married, membership in more community groups, and geographical proximity to meeting locations were correlated with attendance at community sensitization meetings held in advance of bio-behavioral research activities. Information conveyed during meetings could have reached a broader portion of the population through attendees' social network and household connections. To ensure broader input and potentially increase participation in health-related research studies, the dissemination of research-related information through community sensitization meetings may need to target members of underrepresented groups.

Portrayals of mental illness, treatment, and relapse and their effects on the stigma of mental illness: Population-based, randomized survey experiment in rural Uganda.

BACKGROUND: Mental illness stigma is a fundamental barrier to improving mental health worldwide, but little is known about how to durably reduce it. Understanding of mental illness as a treatable medical condition may influence stigmatizing beliefs, but available evidence to inform this hypothesis has been derived solely from high-income countries. We embedded a randomized survey experiment within a whole-population cohort study in rural southwestern Uganda to assess the extent to which portrayals of mental illness treatment effectiveness influence personal beliefs and perceived norms about mental illness and about persons with mental illness. METHODS AND FINDINGS: Study participants were randomly assigned to receive a vignette describing a typical woman (control condition) or one of nine variants describing a different symptom presentation (suggestive of schizophrenia, bipolar, or major depression) and treatment course (no treatment, treatment with remission, or treatment with remission followed by subsequent relapse). Participants then answered questions about personal beliefs and perceived norms in three domains of stigma: willingness to have the woman marry into their family, belief that she is receiving divine punishment, and belief that she brings shame on her family. We used multivariable Poisson and ordered logit regression models to estimate the causal effect of vignette treatment assignment on each stigma-related outcome. Of the participants randomized, 1,355 were successfully interviewed (76%) from November 2016 to June 2018. Roughly half of respondents were women (56%), half had completed primary school (57%), and two-thirds were married or cohabiting (64%). The mean age was 42 years. Across all types of mental illness and treatment scenarios, relative to the control vignette (22%-30%), substantially more study participants believed the woman in the vignette was receiving divine punishment (31%-54%) or believed she brought shame on her family (51%-73%), and most were unwilling to have her marry into their families (80%-88%). In multivariable Poisson regression models, vignette portrayals of untreated mental illness, relative to the control condition, increased the risk that study participants endorsed stigmatizing personal beliefs about mental illness and about persons with mental illness, irrespective of mental illness type (adjusted risk ratios [ARRs] varied from 1.7-3.1, all p < 0.001). Portrayals of effectively treated mental illness or treatment followed by subsequent relapse also increased the risk of responses indicating stigmatizing personal beliefs relative to control (ARRs varied from 1.5-3.0, all p < 0.001). The magnitudes of the estimates suggested that portrayals of initially effective treatment (whether followed by relapse or not) had little moderating influence on stigmatizing responses relative to vignettes portraying untreated mental illness. Responses to questions about perceived norms followed similar patterns. The primary limitations of this study are that the vignettes may have omitted context that could have influenced stigma and that generalizability beyond rural Uganda may be limited. CONCLUSIONS: In a population-based, randomized survey experiment conducted in rural southwestern Uganda, portrayals of effectively treated mental illness did not appear to reduce endorsement of stigmatizing beliefs about mental illness or about persons with mental illness. These findings run counter to evidence from the United States. Further research is necessary to understand the relationship between mental illness treatment and stigmatizing attitudes in Uganda and other countries worldwide. TRIAL REGISTRATION: The experimental procedures for this study were registered with ClinicalTrials.gov as "Measuring Beliefs and Norms About Persons With Mental Illness" (NCT03656770).

Social Vulnerability, COVID-19, Racial Violence, and Depressive Symptoms: a Cross-sectional Study in the Southern United States.

BACKGROUND: In March 2020, the novel 2019 coronavirus disease (COVID-19) was declared a pandemic. In May 2020, George Floyd was murdered, catalyzing a national racial reckoning. In the Southern United States, these events occurred in the context of a history of racism and high rates of poverty and discrimination, especially among racially and ethnically minoritized populations. OBJECTIVES: In this study, we examine social vulnerabilities, the perceived impacts of COVID-19 and the national racial reckoning, and how these are associated with depression symptoms in the South. METHODS: Data were collected from 961 adults between June and November 2020 as part of an online survey study on family well-being during COVID-19. The sample was majority female (87.2%) and consisted of 661 White participants, 143 Black participants, and 157 other racial and ethnic minoritized participants. Existing social vulnerability, perceived impact of COVID-19 and racial violence and protests on families, and depressive symptoms were assessed. Hierarchical regression analysis was used to predict variance in depressive symptoms. RESULTS: Half of the sample (52%) reported a negative impact of COVID-19, and 66% reported a negative impact of national racial violence/protests. Depressive symptoms were common with 49.8% meeting the cutoff for significant depressive symptoms; Black participants had lower levels of depressive symptoms. Results from the hierarchical regression analysis indicate social vulnerabilities and the perceived negative impact of COVID-19 and racial violence/protests each contribute to variance in depressive symptoms. Race-specific sensitivity analysis clarified distinct patterns in predictors of depressive symptoms. CONCLUSION: People in the South report being negatively impacted by the confluence of the COVID-19 pandemic and the emergence of racial violence/protests in 2020, though patterns differ by racial group. These events, on top of pre-existing social vulnerabilities, help explain depressive symptoms in the South during 2020.

Maternal adverse childhood experiences, child mental health, and the mediating effect of maternal depression: A cross-sectional, population-based study in rural, southwestern Uganda.

OBJECTIVES: This study aimed to examine the intergenerational effects of maternal adverse childhood experiences (ACEs) and child mental health outcomes in rural Uganda, as well as the potentially mediating role of maternal depression in this pathway. Additionally, we sought to test the extent to which maternal social group membership attenuated the mediating effect of maternal depression on child mental health. METHODS: Data come from a population-based cohort of families living in the Nyakabare Parish, a rural district in southwestern Uganda. Between 2016 and 2018, mothers completed surveys about childhood adversity, depressive symptoms, social group membership, and their children's mental health. Survey data were analyzed using causal mediation and moderated-mediation analysis. RESULTS: Among 218 mother-child pairs, 61 mothers (28%) and 47 children (22%) showed symptoms meeting cutoffs for clinically significant psychological distress. In multivariable linear regression models, maternal ACEs had a statistically significant association with severity of child conduct problems, peer problems, and total child difficulty scores. Maternal depression mediated the relationship between maternal ACEs and conduct problems, peer problems, and total difficulty, but this mediating effect was not moderated by maternal group membership. CONCLUSIONS: Maternal depression may act as a potential mechanism linking maternal childhood adversity with poor child mental health in the next generation. Within a context of elevated rates of psychiatric morbidity, high prevalence of childhood adversity, and limited healthcare and economic infrastructures across Uganda, these results emphasize the prioritization of social services and mental health resources for rural Ugandan families.

Bringing Parent-Child Interaction Therapy to South Africa: Barriers and Facilitators and Overall Feasibility-First Steps to Implementation.

There is a large assessment and treatment gap in child and adolescent mental health services, prominently so in low- and middle-income countries, where 90% of the world's children live. There is an urgent need to find evidence-based interventions that can be implemented successfully in these low-resource contexts. This pre-pilot study aimed to explore the barriers and facilitators to implementation as well as overall feasibility of Parent-Child Interaction Therapy (PCIT) in South Africa. A reflective and consensus building workshop was used to gather South African PCIT therapist (N = 4) perspectives on barriers, facilitators, and next steps to implementation in that country. Caregiver participants (N = 7) receiving the intervention in South Africa for the first time were also recruited to gather information on overall feasibility. Facilitators for implementation, including its strong evidence base, manualisation, and training model were described. Barriers relating to sustainability and scalability were highlighted. Largely positive views on acceptability from caregiver participants also indicated the promise of PCIT as an intervention in South Africa. Pilot data on the efficacy of the treatment for participating families are a next step. These initial results are positive, though research on how implementation factors contribute to the longer-term successful dissemination of PCIT in complex, heterogeneous low-resource settings is required.

Adverse childhood experiences, alcohol consumption, and the modifying role of social participation: population-based study of adults in southwestern Uganda.

Background: Adverse childhood experiences (ACEs) include multiple forms of child maltreatment, including abuse and neglect, as well as other forms of household dysfunction. Studies from Uganda have revealed a high prevalence of child abuse, as well as one of the highest levels of alcohol consumption in Africa. Few population-based studies from Africa have estimated associations between ACEs and adult alcohol use, or assessed the potential buffering effects of social participation. Methods: This cross-sectional, population-based study was conducted in a rural parish in southwestern Uganda between 2016 and 2018. We assessed self-reported ACEs using a modified version of the Adverse Childhood Experiences - International Questionnaire (ACE-IQ) scale. We measured heavy alcohol consumption using a 3-item scale previously validated in this population. We measured social participation using a 10-item scale eliciting participants' membership and participation in different community groups over the past two months. We fitted multivariable Poisson regression models to estimate the associations between ACEs and heavy alcohol consumption, and to assess for the potential buffering effects of social participation. Results: We estimated statistically significant associations between the total ACE score and heavy alcohol consumption (adjusted relative risk [ARR] per ACE=1.17; 95% CI, 1.09-1.25; P ≤0.001). Social participation had a statistically significant moderating effect on the association between total ACE score and heavy alcohol consumption (P=0.047 for interaction): the estimated association between total ACE score and heavy alcohol consumption among study participants who did not participate in a community group was larger, with a narrower confidence interval (ARR=1.21 per ACE; 95% CI, 1.11-1.33; P<0.001), while the estimated association among study participants who did participate in a community group was smaller and less precisely estimated (ARR=1.12 per ACE; 95% CI, 1.02-1.24; P=0.02). Conclusions: Our findings demonstrate an association between ACEs and heavy alcohol consumption behavior among adults in rural Uganda. The adverse effects of ACEs were buffered in part by social participation. To prevent or reduce harmful alcohol use behaviors among adults, it is important to address the chronic stress caused by ACEs.

Overestimation of alcohol consumption norms as a driver of alcohol consumption: a whole-population network study of men across eight villages in rural, southwestern Uganda.

BACKGROUND AND AIMS: Little is known about how perceived norms about alcohol consumption may influence high alcohol consumption rates in Uganda. This study estimated the accuracy of perceived norms about men's alcohol consumption and estimated the association between perceived norms and personal alcohol consumption. DESIGN: Cross-sectional, whole-population, sociocentric social network study. SETTING: Eight rural villages in Rwampara District, southwestern Uganda in 2016-18. PARTICIPANTS: A total of 719 men aged 18 years and older (representing 91% of permanent resident men). MEASUREMENTS: Self-reported frequent (≥ 4 days per week) and heavy alcohol consumption (six or more drinks on one occasion, more than three occasions of intoxication, or spending an excessive amount on alcohol). Participants also reported whether they thought most other men in their village engaged in frequent and heavy alcohol consumption (perceived norms). Using the network study design, we calculated alcohol consumption behavior within villages and social networks. Perceived norms were compared with aggregated self-reports. Multivariable Poisson regression models were used to estimate the association between perceived norms and individual behavior. FINDINGS: Throughout villages, frequent and heavy alcohol consumption ranged from 7 to 37%. However, 527 (74%) participants perceived, contrary to fact, that most other men in their villages frequently consumed alcohol, and 576 (81%) perceived that most others heavily consumed alcohol. Overestimation of alcohol consumption by others was pervasive among socio-demographic subgroups and was present irrespective of the actual consumption behavior at the village level and within social networks. Men who misperceived these alcohol consumption behaviors as being common were more likely to engage in frequent [adjusted relative risk (aRR) = 3.98; 95% confidence interval (CI) = 1.69-9.34) and heavy (aRR = 4.75; 95% CI = 2.33-9.69) alcohol consumption themselves. CONCLUSIONS: Most men in eight rural Ugandan villages incorrectly thought that frequent and heavy alcohol consumption were common among men in their villages. These misperceived norms had a strong positive association with individual drinking behavior.

Perceived and misperceived norms about khat and/or cannabis use among adults in southwest Uganda.

BACKGROUND: Studies from high-income contexts have found evidence that norms about substance use are misperceived. The accuracy of perceived norms about khat and cannabis use in Uganda have not previously been described. METHODS: We conducted a population-based study targeting all resident adults across eight villages in southwestern Uganda. Personal khat and/or cannabis use frequency was based on self-report. We measured perceived norms about substance use by eliciting individuals' perceptions about how often most other adult men and most other adult women in their villages used these substances. We compared perceived norms to aggregated village rates of use to assess the extent to which norms were misperceived. We used multivariable Poisson regression to estimate correlates of misperceived norms. RESULTS: Among 1626 participants (91% response rate), only 29 men (4%) and 9 women (1%) reported any lifetime use of khat and/or cannabis. However, 695 participants (43%) did not think lifetime abstinence was the norm among men in their villages, and 256 participants (16%) did not think lifetime abstinence was the norm among women. Moreover, 219 participants (13%) incorrectly believed most men in their village regularly used khat and/or cannabis (≥4 times per week). Misperceived norms were present across subgroups and were correlated with larger social networks, symptoms of depression, loneliness, and younger age. CONCLUSION: In this study of all adults across 8 villages in rural Uganda, many participants misperceived norms about khat and/or cannabis use. Providing accurate information about prevailing norms in the local population may help prevent initiation of khat and/or cannabis use among adults in this context.

Do household asset wealth measurements depend on who is surveyed? Asset reporting concordance within multi-adult households in rural Uganda.

BACKGROUND: In resource-limited settings, the Filmer & Pritchett asset index is frequently used to measure household economic status. Little is known about how its validity is affected by differential reporting or recall within households. METHODS: As part of a whole-population survey in a rural region of southwestern Uganda, we elicited household asset information from married dyads (404 men and 404 matched women) residing within the same households. We assessed the extent to which the asset index yielded differing measures of relative household wealth, depending on whether the husband's or wife's survey data were used in its calculation. To estimate agreement, we used Cohen's κ for binary and categorical variables, and Cronbach's α for continuous variables. We also assessed the extent to which asset wealth quintiles assigned based on husbands' vs wives' reporting were concordant, and whether discordance was related to demographic characteristics. RESULTS: For most individual assets, agreement ranged from moderate to very good. Asset index scores based on husbands' vs wives' reporting were positively correlated (Pearson r = 0.85). Corresponding wealth quintiles were moderately concordant (weighted κ = 0.65); 171 households (43%) differed by one or more quintiles when the husbands' vs wives' reporting was used, and 43 (11%) differed by two or more quintiles. Concordance in asset wealth quintile could not be explained by joint educational attainment, age, or age difference. CONCLUSIONS: There is significant intra-household variability in household asset reporting that can materially affect how households are classified on a widely used measure of relative household asset wealth.

"When you have no water, it means you have no peace": A mixed-methods, whole-population study of water insecurity and depression in rural Uganda.

BACKGROUND: Lack of access to clean water has well known implications for communicable disease risks, but the broader construct of water insecurity is little studied, and its mental health impacts are even less well understood. METHODS AND FINDINGS: We conducted a mixed-methods, whole-population study in rural Uganda to estimate the association between water insecurity and depression symptom severity, and to identify the mechanisms underlying the observed association. The whole-population sample included 1776 adults (response rate, 91.5%). Depression symptom severity was measured using a modified 15-item Hopkins Symptom Checklist for Depression. Water insecurity was measured with a locally validated 8-item Household Water Insecurity Access Scale. We fitted multivariable linear and Poisson regression models to the data to estimate the association between water insecurity and depression symptom severity, adjusting for age, marital status, self-reported overall health, household asset wealth, and educational attainment. These models showed that water insecurity was associated with depression symptom severity (b = 0.009; 95% confidence interval [CI], 0.004-0.15) and that the estimated association was larger among men (b = 0.012; 95% CI, 0.008-0.015) than among women (b = 0.008; 95% CI, 0.004-0.012. We conducted qualitative interviews with a sub-group of 30 participants, focusing on women given their traditional role in household water procurement in the Ugandan context. Qualitative analysis, following an inductive approach, showed that water insecurity led to "choice-less-ness" and undesirable social outcomes, which in turn led to emotional distress. These pathways were amplified by gender-unequal norms. CONCLUSIONS: Among men and women in rural Uganda, the association between water insecurity and depression symptom severity is statistically significant, substantive in magnitude, and robust to potential confounding. Data from the qualitative interviews provide key narratives that reveal the mechanisms through which women's lived experiences with water insecurity may lead to emotional distress.

Relative wealth, subjective social status, and their associations with depression: Cross-sectional, population-based study in rural Uganda.

Depression is a leading cause of disability worldwide, and has been found to be a consistent correlate of socioeconomic status (SES). The relative deprivation hypothesis proposes that one mechanism linking SES to health involves social comparisons, suggesting that relative SES rather than absolute SES is of primary importance in determining health status. Using data from a whole-population sample of 1,620 participants residing in rural southwestern Uganda, we estimated the independent associations between objective and subjective relative wealth and probable depression, as measured by the depression subscale of the Hopkins Symptom Checklist (HSCLD). Objective relative wealth was measured by an asset index based on information about housing characteristics and household possessions, which was used to rank study participants into quintiles (within each village) of relative household asset wealth. Subjective relative wealth was measured by a single question asking participants to rate their wealth, on a 5-point Likert scale, relative to others in their village. Within the population, 460 study participants (28.4%) screened positive for probable depression. Using Poisson regression with cluster-robust error variance, we found that subjective relative wealth was associated with probable depression, adjusting for objective relative wealth and other covariates (adjusted relative risk [aRR] comparing lowest vs. highest level of subjective relative wealth = 1.90, 95% confidence interval [CI]: 1.18, 3.06). Objective relative wealth was not associated with probable depression (aRR comparing lowest vs. highest quintile of objective relative wealth = 1.09, 95% CI: 0.77, 1.55). These results suggest that, in this context, subjective relative wealth is a stronger correlate of mental health status compared with objective relative wealth. Our findings are potentially consistent with the relative deprivation hypothesis, but more research is needed to explain how relative differences in wealth are (accurately or inaccurately) perceived and to elucidate the implications of these perceptions for health outcomes.