Exploring ecosocial contexts of alcohol use and misuse during the COVID-19 pandemic among urban refugee youth in Kampala, Uganda: Multi-method findings.

Urban refugees may be disproportionately affected by socio-environmental stressors that shape alcohol use, and this may have been exacerbated by additional stressors in the COVID-19 pandemic. This multi-method study aimed to understand experiences of, and contextual factors associated with, alcohol use during the pandemic among urban refugee youth in Kampala, Uganda. We conducted a cross-sectional survey (n = 335), in-depth individual interviews (IDI) (n = 24), and focus groups (n = 4) with urban refugee youth in Kampala. We also conducted key informant interviews (n = 15) with a range of stakeholders in Kampala. We conducted multivariable logistic regression analyses with survey data to examine socio-demographic and ecosocial (structural, community, interpersonal) factors associated with ever using alcohol and alcohol misuse. We applied thematic analyses across qualitative data to explore lived experiences, and perceived impacts, of alcohol use. Among survey participants (n = 335, mean age= 20.8, standard deviation: 3.01), half of men and one-fifth of women reported ever using alcohol. Among those reporting any alcohol use, half (n = 66, 51.2 %) can be classified as alcohol misuse. In multivariable analyses, older age, gender (men vs. women), higher education, and perceived increased pandemic community violence against women and children were associated with significantly higher likelihood of ever using alcohol. In multivariable analyses, very low food security, relationship status, transactional sex, and lower social support were associated with increased likelihood of alcohol misuse. Qualitative findings revealed: (1) alcohol use as a coping mechanism for stressors (e.g., financial insecurity, refugee-related stigma); and (2) perceived impacts of alcohol use on refugee youth health (e.g., physical, mental). Together findings provide insight into multi-level contexts that shape vulnerability to alcohol mis/use among urban refugee youth in Kampala and signal the need for gender-tailored strategies to reduce socio-environmental stressors.

Kukaa Salama (Staying Safe): a pre-post trial of an interactive informational mobile health intervention for increasing COVID-19 prevention practices with urban refugee youth in Uganda.

BACKGROUND: Tailored coronavirus disease 2019 (COVID-19) prevention strategies are needed for urban refugee youth in resource-constrained contexts. We developed an 8-wk interactive informational mobile health intervention focused on COVID-19 prevention practices informed by the Risk, Attitude, Norms, Ability, Self-regulation-or RANAS-approach. METHODS: We conducted a pre-post trial with a community-recruited sample of refugee youth aged 16-24 y in Kampala, Uganda. Data were collected before (T1) and immediately following (T2) the intervention, and at the 16-wk follow up (T3), to examine changes in primary (COVID-19 prevention self-efficacy) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health [SRH] access; food/water security; COVID-19 vaccine acceptability). RESULTS: Participants (n=346; mean age: 21.2 [SD 2.6] y; cisgender women: 50.3%; cisgender men: 48.0%; transgender persons: 1.7%) were largely retained (T2: n=316, 91.3%; T3: n=302, 87.3%). In adjusted analyses, COVID-19 prevention self-efficacy, risk awareness, attitudes and vaccine acceptance increased significantly from T1 to T2, but were not sustained at T3. Between T1 and T3, COVID-19 norms and self-regulation significantly increased, while community violence, water insecurity and community SRH access decreased. CONCLUSIONS: Digital approaches for behaviour change hold promise with urban refugee youth but may need booster messaging and complementary programming for sustained effects.

HIV Vulnerabilities Associated with Water Insecurity, Food Insecurity, and Other COVID-19 Impacts Among Urban Refugee Youth in Kampala, Uganda: Multi-method Findings.

Food insecurity (FI) and water insecurity (WI) are linked with HIV vulnerabilities, yet how these resource insecurities shape HIV prevention needs is understudied. We assessed associations between FI and WI and HIV vulnerabilities among urban refugee youth aged 16-24 in Kampala, Uganda through individual in-depth interviews (IDI) (n = 24), focus groups (n = 4), and a cross-sectional survey (n = 340) with refugee youth, and IDI with key informants (n = 15). Quantitative data was analysed via multivariable logistic and linear regression to assess associations between FI and WI with: reduced pandemic sexual and reproductive health (SRH) access; past 3-month transactional sex (TS); unplanned pandemic pregnancy; condom self-efficacy; and sexual relationship power (SRP). We applied thematic analytic approaches to qualitative data. Among survey participants, FI and WI were commonplace (65% and 47%, respectively) and significantly associated with: reduced SRH access (WI: adjusted odds ratio [aOR]: 1.92, 95% confidence interval [CI]: 1.19-3.08; FI: aOR: 2.31. 95%CI: 1.36-3.93), unplanned pregnancy (WI: aOR: 2.77, 95%CI: 1.24-6.17; FI: aOR: 2.62, 95%CI: 1.03-6.66), and TS (WI: aOR: 3.09, 95%CI: 1.22-7.89; FI: aOR: 3.51, 95%CI: 1.15-10.73). WI participants reported lower condom self-efficacy (adjusted ß= -3.98, 95%CI: -5.41, -2.55) and lower SRP (adjusted ß= -2.58, 95%CI= -4.79, -0.37). Thematic analyses revealed: (1) contexts of TS, including survival needs and pandemic impacts; (2) intersectional HIV vulnerabilities; (3) reduced HIV prevention/care access; and (4) water insecurity as a co-occurring socio-economic stressor. Multi-method findings reveal FI and WI are linked with HIV vulnerabilities, underscoring the need for HIV prevention to address co-occurring resource insecurities with refugee youth.

Mobile Health-Supported Virtual Reality and Group Problem Management Plus: Protocol for a Cluster Randomized Trial Among Urban Refugee and Displaced Youth in Kampala, Uganda (Tushirikiane4MH, Supporting Each Other for Mental Health).

BACKGROUND: Although mental health challenges disproportionately affect people in humanitarian contexts, most refugee youth do not receive the mental health support needed. Uganda is the largest refugee-hosting nation in Africa, hosting over 1.58 million refugees in 2022, with more than 111,000 living in the city of Kampala. There is limited information about effective and feasible interventions to improve mental health outcomes and mental health literacy, and to reduce mental health stigma among urban refugee adolescents and youth in low- and middle-income countries (LMICs). Virtual reality (VR) is a promising approach to reduce stigma and improve mental health and coping, yet such interventions have not yet been tested in LMICs where most forcibly displaced people reside. Group Problem Management Plus (GPM+) is a scalable brief psychological transdiagnostic intervention for people experiencing a range of adversities, but has not been tested with adolescents and youth to date. Further, mobile health (mHealth) strategies have demonstrated promise in promoting mental health literacy. OBJECTIVE: The aim of this study is to evaluate the feasibility and effectiveness of two youth-tailored mental health interventions (VR alone and VR combined with GMP+) in comparison with the standard of care in improving mental health outcomes among refugee and displaced youth aged 16-24 years in Kampala, Uganda. METHODS: A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomized in a 1:1:1 design. Approximately 330 adolescents (110 per cluster) are enrolled and will be followed for approximately 16 weeks. Data will be collected at three time points: baseline enrollment, 8 weeks following enrollment, and 16 weeks after enrollment. Primary (depression) and secondary outcomes (mental health literacy, attitudes toward mental help-seeking, adaptive coping, mental health stigma, mental well-being, level of functioning) will be evaluated. RESULTS: The study will be conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (#40965; May 12, 2021), Mildmay Uganda Research Ethics Committee (MUREC-2021-41; June 24, 2021), and Uganda National Council for Science & Technology (SS1021ES; January 1, 2022). A qualitative formative phase was conducted using focus groups and in-depth, semistructured key informant interviews to understand contextual factors influencing mental well-being among urban refugee and displaced youth. Qualitative findings will inform the VR intervention, SMS text check-in messages, and the adaptation of GPM+. Intervention development was conducted in collaboration with refugee youth peer navigators. The trial launched in June 2022 and the final follow-up survey will be conducted in November 2022. CONCLUSIONS: This study will contribute to the knowledge of youth-tailored mental health intervention strategies for urban refugee and displaced youth living in informal settlements in LMIC contexts. Findings will be shared in peer-reviewed publications, conference presentations, and with community dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT05187689; https://clinicaltrials.gov/ct2/show/NCT05187689. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42342.

Age-Based Anthropometric Cutoffs Provide Inconsistent Estimates of Undernutrition: Findings from a Cross-Sectional Assessment of Late-Adolescent and Young Women in Rural Pakistan.

Ambiguity around age ranges for adolescence and adulthood can make the application of age-based nutrition cutoffs confusing. We examined how estimates generated using the age-based anthropometric cutoffs for adolescent girls (10 to <19 y) and women of reproductive age (15-49 y) compared between late-adolescent and young women, and determined how application of both cutoffs affected late-adolescents' estimates. Using cross-sectional data from participants aged 15-23 y in the Pakistan-based Matiari emPowerment and Preconception Supplementation (MaPPS) Trial (n = 25,447), notably large differences in estimates were observed for stunting (30.5% and 7.9% for late-adolescent and young women, respectively; P < 0.001) and thinness (9.3% and 30.8%, respectively; P < 0.001). When both cutoffs were applied to adolescents' data, estimate differences were maintained. With each year of age, the difference for stunting increased and thinness decreased. Given the discrepancies observed both between and within groups, clarity around application of anthropometric cutoffs for youth (aged 15-24 y) is needed. This trial was registered at clinicaltrials.gov as NCT03287882.

Combined Clinical Audits and Low-Dose, High-frequency, In-service Training of Health Care Providers and Community Health Workers to Improve Maternal and Newborn Health in Mali: Protocol for a Pragmatic Cluster Randomized Trial.

BACKGROUND: Although most births in Mali occur in health facilities, a substantial number of newborns still die during delivery and within the first 7 days of life, mainly because of existing training deficiencies and the challenges of maintaining intrapartum and postpartum care skills. OBJECTIVE: This trial aims to assess the effectiveness and cost-effectiveness of an intervention combining clinical audits and low-dose, high-frequency (LDHF) in-service training of health care providers and community health workers to reduce perinatal mortality. METHODS: The study is a three-arm cluster randomized controlled trial in the Koulikoro region in Mali. The units of randomization are each of 84 primary care facilities. Each trial arm will include 28 facilities. The facilities in the first intervention arm will receive support in implementing mortality and morbidity audits, followed by one-day LDHF training biweekly, for 6 months. The health workers in the second intervention arm (28 facilities) will receive a refresher course in maternal neonatal and child health (MNCH) for 10 days in a classroom setting, in addition to mortality and morbidity audits and LDHF hands-on training for 6 months. The control arm, also with 28 facilities, will consist solely of the standard MNCH refresher training delivered in a classroom setting. The main outcomes are perinatal deaths in the intervention arms compared with those in the control arm. A final sample of approximately 600 deliveries per cluster was expected for a total of 30,000 newborns over 14 months. Data sources included both routine health records and follow-up household surveys of all women who recently gave birth in the study facility 7 days postdelivery. Data collection tools will capture perinatal deaths, complications, and adverse events, as well as the status of the newborn during the perinatal period. A full economic evaluation will be conducted to determine the incremental cost-effectiveness of each of the case-based focused LDHF hands-on training strategies in comparison to MNCH refresher training in a classroom setting. RESULTS: The trial is complete. The recruitment began on July 15, 2019, and data collection began on July 23, 2019, and was completed in November 2020. Data cleaning or analyses began at the time of submission of the protocol. CONCLUSIONS: The results will provide policy makers and practitioners with crucial information on the impact of different health care provider training modalities on maternal and newborn health outcomes and how to successfully implement these strategies in resource-limited settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT03656237; https://clinicaltrials.gov/ct2/show/NCT03656237. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/28644.

Tools for measuring gender equality and women's empowerment (GEWE) indicators in humanitarian settings.

BACKGROUND: Effective measurement of Gender Equality and Women's Empowerment (GEWE) is challenging in low and middle-income countries (LMICs), and even more so in humanitarian settings. Conflict, natural disasters, and epidemics may increase gender inequities, but also present an opportunity to address them. This scoping review describes and identifies gaps in the measurement tools, methods, and indicators used to measure GEWE in humanitarian settings, and presents a dashboard that can be used by researchers, organizations and governments to identify GEWE measurement tools. METHODS: Scientific articles published between January 2004 and November 2019 were identified using Embase, Medline, PsycInfo, CINAHL, Scopus, and PAIS index. Relevant non peer-reviewed literature was downloaded from the websites of humanitarian organizations. Publications on women and/or girls impacted by a humanitarian crisis in a LMIC, within 5 years of data collection, were included. Publications were double-screened in the title/abstract and full-text stages. We used a machine learning software during the title/abstract screening to increase the efficiency of the process. Measurement tools, sampling and data collection methods, gap areas (geographical, topical and contextual), and indicators were catalogued for easy access in an interactive Tableau dashboard. RESULTS: Our search yielded 27,197 publications and 2396 non peer-reviewed literature reports. One hundred and seventy publications were included in the final review. Extracted indicators were categorized into seven domains: economic, health, human development, leadership, psychological, security and justice, and sociocultural. The vast majority of studies were observational, and over 70% utilized a cross-sectional study design. Thirty-eight toolkits and questionnaires were identified in this review, of which 19 (50%) were designed specifically for humanitarian settings. Sociocultural was the largest domain in number of studies and indicators in this review, with gender-based violence indicators reported in 66% of studies. Indicators of economic, human development and leadership were uncommon in the peer-reviewed literature. DISCUSSION: While there has been some effort to measure GEWE in conflict-affected and other humanitarian settings, measurement has largely focused on violence and security issues. A more comprehensive framework for measuring GEWE in these settings is needed; objective measurement of women's empowerment and gender equality should be prioritized by organizations providing humanitarian aid.

Feasibility of vitamin D supplementation interventions to mitigate HIV pre-exposure prophylaxis-related bone mineral density loss: a cross-sectional survey.

BACKGROUND: Daily tenofovir disoproxil fumarate (TDF)/emtricitabine as HIV pre-exposure prophylaxis (PrEP) causes subclinical decreases in bone mineral density (BMD). We surveyed PrEP users to assess feasibility for a clinical trial of vitamin D supplementation to mitigate TDF-induced BMD loss. METHODS: We recruited participants using or starting PrEP in Toronto and Vancouver. The primary objective was to assess the acceptability of daily or weekly vitamin D supplementation. We also assessed the acceptability of calcium supplementation, existing use of non-pharmacological bone health interventions, prevalence of osteoporosis risk factors, and bone health knowledge (Osteoporosis Knowledge Test, OKT). RESULTS: Of 161 participants, 72.1% were current PrEP users, 18.0% were starting PrEP, and 9.9% did not indicate their PrEP status. All identified as males, 88.8% as gays, and 67.1% as Whites. Median (IQR) age was 32.0 (29.0, 40.0) years, and 62.1% reported family income $$60,000/year. Among those not already using the interventions, willingness to supplement with daily vitamin D, weekly vitamin D, or daily calcium was very high at 90.9%, 96.4%, and 93.0 %, respectively. Only 31.0% reported adequate dietary calcium intake, while 42.9% reported $1 osteoporosis risk factor (most commonly, alcohol and smoking). Overall bone health knowledge was low, as median (IQR) OKT score was 16/32. In post hoc comparisons, current PrEP users may have been more likely than new PrEP users to engage in bone loading exercise (Bone-specific Physical Activity Questionnaire score=12.5 vs 3.6, P=0.001) and have greater bone health knowledge (OKT=17 vs 14, P=0.08), but they had similar levels of current vitamin D supplementation (37.4% vs 21.4%, P=0.11), calcium supplementation (11.2% vs 13.8%, P=0.70), and adequate dietary calcium intake (32.7% vs 25.0%, P=0.43). DISCUSSION: The high acceptability of vitamin D and calcium supplementation in this cohort suggests that enrollment into a clinical trial of such interventions to mitigate PrEP-induced BMD loss is feasible.