Factors associated with motherhood among urban refugee adolescent girls and young women in informal settlements in Kampala, Uganda.

Adolescent girls and young women (AGYW) in sub-Saharan Africa face a high risk of unintended pregnancy. This risk is compounded in informal settlements, where resources are scarce and access to sexual and reproductive health services is limited. Being a young mother in informal settlements could exacerbate existing experiences of resource scarcity and poor access to sexual and reproductive health services. To explore this, we analyzed the factors associated with motherhood among refugee AGYW in Kampala, Uganda. Between January and March 2018, peer researchers recruited refugee youth aged 15-24 and living in five informal settlements in Kampala to participate in this study. We used a backwards generalized linear model with a log binomial regression to determine if mental health, resource insecurity and sexual and reproductive health variables were associated with motherhood among study participants. Our analysis included 333 AGYW with a mean age of 19.3 years (standard deviation: 2.6). Nearly one-quarter (23 percent; n = 76) of AGYW had children. Having children was associated with greater likelihood of reporting food insecurity (adjusted prevalence ratio [aPR]: 1.96, 95 percent confidence interval [CI]: 1.07-3.61), depressive symptoms (aPR: 2.03, 95 percent CI: 1.09-3.80), and contraception uptake (aPR: 2.37, 95 percent CI: 1.58-3.56) compared to not having children. Mental health and resource insecurity interventions are required for refugee AGYW with children in informal settlements. Sexual and reproductive health services should be promoted to refugee AGYW regardless of motherhood status to prevent unplanned pregnancy.

Exploring the Protective Value of Using Sexting for Condom Negotiation on Condom use Determinants and Practices Among Forcibly Displaced Adolescents in the Slums of Kampala, Uganda.

Given the global growth of adolescent texting, we evaluate texting-based sexual communication as a potential site for interventions encouraging condom use cascades, particularly among displaced adolescents-a population with disproportionate levels of sexually transmitted infections, including HIV. With data from 242 forcibly displaced adolescents in the slums of Kampala, Uganda, we used path analysis to examine pathways from gender/dating relationship to condom determinant (knowledge of where to access condoms) and practices (access/use of condoms), through sexting-based condom negotiation, controlling for sexting practices. We found direct pathways from gender (boys vs. girls) and from dating relationship (dating vs. not) to condom determinant. Sexting-based condom negotiation partially mediated the pathway from gender/dating relationship to condom determinant, and fully mediated the pathways from gender/dating relationship to condom practices. Future digital sexual health interventions should consider the utility of texting-based applications in promoting knowledge and use of condoms among adolescents.

RESUMEN: Dado el crecimiento global de los mensajes de texto de los adolescentes, evaluamos la comunicación sexual basada en mensajes de texto como un sitio potencial para intervenciones que fomenten el uso de condones en cascada, particularmente entre los adolescentes desplazados, una población con niveles desproporcionados de infecciones de transmisión sexual, incluido el VIH. Con datos de 242 adolescentes desplazados por la fuerza en los barrios marginales de Kampala, Uganda, utilizamos el análisis de caminos para examinar los caminos desde la relación de género/citas hasta el determinante del condón (conocimiento de dónde acceder a los condones) y las prácticas (acceso/uso de condones), a través del sexteo. -negociación basada en condones, controlando las prácticas de sexting. Encontramos caminos directos desde el género (niños vs. niñas) y desde la relación de noviazgo (citas vs. no) al determinante del condón. La negociación de condones basada en sexting medió parcialmente el camino de la relación de género/citas al determinante del condón, y medió completamente las vías de la relación de género/citas a las prácticas del condón. Las futuras intervenciones de salud sexual digital deben considerar la utilidad de las aplicaciones basadas en mensajes de texto para promover el conocimiento y el uso de condones entre los adolescentes.

Relational Factors and HIV Testing Practices: Qualitative Insights from Urban Refugee Youth in Kampala, Uganda.

Despite the global phenomenon of refugee urbanization, little is known of relational contexts that shape HIV testing among urban refugee youth. We explored perspectives, experiences, and preferences for social support in HIV testing among refugee youth aged 16-24 in Kampala, Uganda. We conducted five focus groups with refugee youth (n = 44) and five in-depth key informant interviews. Participant narratives signaled relational contexts shaping HIV testing included informal sources (intimate partners and family members) and formal sources (peer educators and professionals). There was heterogeneity in perspectives based on relationship dynamics. While some felt empowered to test with partners, others feared negative relationship consequences. Participant narratives reflected kinship ties that could facilitate testing with family, while others feared coercion and judgment. Peer support was widely accepted. Professional support was key for HIV testing as well as conflict-related trauma. Findings emphasize bonding and bridging social capital as salient components of enabling HIV testing environments.

Sexual and reproductive health factors associated with child, early and forced marriage and partnerships among refugee youth in a humanitarian setting in Uganda: Mixed methods findings.

Preventing early and forced marriage is a global priority, however, sexual and reproductive health (SRH) among youth remains understudied in humanitarian settings. This study examined child, early and forced marriage and partnership (CEFMP) among young refugees in Bidi Bidi refugee settlement, Uganda, and associations with SRH outcomes among young women. This mixed-methods study involved a qualitative phase with young (16-24 years) sexual violence survivors (n=58), elders (n=8) and healthcare providers (n=10), followed by a quantitative phase among refugee youth (16-24 years; n=120) during which sociodemographic and SRH data were collected. We examined SRH outcome differences by CEFMP using Fisher's exact test. Qualitative data showed that CEFMP was a significant problem facing refugee young women driven by stigma, gender norms and poverty. Among youth refugee survey participants, nearly one-third (31.7%) experienced CEFMP (57.9% women, 42.1% men). Among women in CEFMP compared to those who were not, a significantly higher proportion reported forced pregnancy (50.0% vs. 18.4%, p-value=0.018), forced abortion (45.4% vs. 7.0%, p-value=0.002), and missed school due to sexual violence (94.7% vs. 63.0%, p-value=0.016). This study illustrates the need for innovative community-engaged interventions to end CEFMP in humanitarian contexts in order to achieve sexual and reproductive health and rights for youth.

The role of context in shaping HIV testing and prevention engagement among urban refugee and displaced adolescents and youth in Kampala, Uganda: findings from a qualitative study.

OBJECTIVE: To explore experiences, preferences and engagement with HIV testing and prevention among urban refugee and displaced adolescents and youth in Kampala, Uganda, with a focus on the role of contextual factors in shaping access and uptake. METHODS: This qualitative community-based study with urban refugee and displaced youth aged 16-24 living in Kampala's informal settlements involved five focus groups (FG), including two with young women, two with young men, and one with sex workers from March to May 2019. We also conducted five in-depth key informant interviews. We conducted thematic analysis informed by Campbell and Cornish's conceptualisation of material and symbolic contexts. RESULTS: Refugee/displaced youth participants (n = 44; mean age: 20.25, SD: 2.19; men: n = 17; women: n = 27) were from the Democratic Republic of Congo (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1). Participant narratives reflected material and symbolic contexts that shaped HIV testing awareness, preferences and uptake. Material contextual factors that presented barriers to HIV testing and prevention engagement included transportation costs to clinics, overcrowded living conditions that limited access to private spaces, low literacy and language barriers. Symbolic contexts that constrained HIV testing engagement included medical mistrust of HIV testing and inequitable gender norms. Religion emerged as an opportunity to connect with refugee communities and to address conservative religious positions on HIV and sexual health. CONCLUSION: Efforts to increase access and uptake along the HIV testing and prevention cascade can meaningfully engage urban refugee and displaced youth to develop culturally and contextually relevant services to optimise HIV and sexual health outcomes.

Gender, transactional sex, and HIV prevention cascade engagement among urban refugee and displaced adolescents and youth in Kampala, Uganda.

HIV prevention needs among urban refugee and displaced youth engaged in transactional sex are understudied. We examined associations between transactional sex and the HIV prevention cascade among urban refugee/displaced youth in Kampala, Uganda. We conducted a cross-sectional survey with a peer-driven sample of refugee/displaced adolescent girls and young women (n = 324) and adolescent boys and young men (n = 88) aged 16-24 living in Kampala's informal settlements. We conducted gender-disaggregated multivariable linear and logistic regressions to examine associations between past 12-month transactional sex and: lifetime HIV testing, condom self-efficacy, and recent [past 3-month] consistent condom use. Among the 27% of young women reporting transactional sex, 63% reported HIV testing. In multivariable analyses with young women, transactional sex was associated with higher condom self-efficacy, increased consistent condom use, but not HIV testing. Among the 48% of young men reporting transactional sex, 50% reported HIV testing. In multivariable analyses with young men, transactional sex was associated with lower HIV testing but not with condom self-efficacy or consistent condom use. Young men were 68% less likely to report HIV testing if transactional sex engaged. Findings point to urgent HIV testing gaps among transactional sex engaged urban refugee/displaced youth and a need for gender-tailored HIV prevention strategies.

Sexually transmitted infection (STI) knowledge and perceptions among people in HIV-sero-different partnerships in rural southwestern Uganda.

Globally, over one million people acquire curable sexually transmitted infections (STI) each day. Understanding how people think about STIs is key to building culturally appropriate STI prevention and treatment programs. We explored STI knowledge and perceptions in rural, southwestern Uganda to inform future interventions. From August 2020 to December 2020, we conducted individual in-depth interviews among adult men and women (≥18 years) with recent or current personal or partner pregnancy, a history of an STI diagnosis and treatment, and membership in an HIV-sero-different relationship. Interviews explored STI knowledge, perceptions, and barriers and facilitators to engaging in STI care. We used inductive and deductive approaches to generate a codebook guided by the healthcare literacy skills framework in a thematic analysis. Ten men with STI, five of their female partners, eighteen women with STI, and four of their male partners participated in individual in-depth interviews. The median age was 41 (range 27-50) for men and 29 (range 22-40) for women. Sixteen (43%) participants were with HIV. Significant themes include: 1) Participants obtained STI knowledge and information from the community (friends, family members, acquaintances) and medical professionals; 2) While participants knew STIs were transmitted sexually, they also believed transmission occurred via non-sexual mechanisms. 3) Participants associated different connotations and amounts of stigma with each STI, for example, participants reported that syphilis was passed down "genetically" from parent to child. 4) Participants reported uncertainty about whether STIs affected pregnancy outcomes and whether antenatal STI treatment was safe. The complicated nature of STIs has led to understandable confusion in settings without formal sexual healthcare education. Robust counseling and education prior to sexual debut will help allow men and women to understand the signs, symptoms, and treatments necessary for STI cure and to navigate often complicated and overburdened healthcare systems.

Mixed-methods findings from the Ngutulu Kagwero (agents of change) participatory comic pilot study on post-rape clinical care and sexual violence prevention with refugee youth in a humanitarian setting in Uganda.

There is a dearth of evidence-based post-rape clinical care interventions tailored for refugee adolescents and youth in low-income humanitarian settings. Comics, a low-cost, low-literacy and youth-friendly method, integrate visual images with text to spark emotion and share health-promoting information. We evaluated a participatory comic intervention to increase post-exposure prophylaxis (PEP) knowledge and acceptance, and prevent sexual and gender-based violence, in Bidi Bidi refugee settlement, Uganda. Following a formative qualitative phase, we conducted a pre-test post-test pilot study with refugee youth (aged 16-24 years) (n = 120). Surveys were conducted before (t0), after (t1), and two-months following (t2) workshops. Among participants (mean age: 19.7 years, standard deviation: 2.4; n = 60 men, n = 60 women), we found significant increases from t0 to t1, and from t0 to t2 in: (a) PEP knowledge and acceptance, (b) bystander efficacy, and (c) resilient coping. We also found significant decreases from t0 to t1, and from t0 to t2 in sexual violence stigma and depression. Qualitative feedback revealed knowledge and skills acquisition to engage with post-rape care and violence prevention, and increased empathy to support survivors. Survivor-informed participatory comic books are a promising approach to advance HIV prevention through increased PEP acceptance and reduced sexual violence stigma with refugee youth.Trial registration: ClinicalTrials.gov identifier: NCT04656522.

A Participatory Comic Book Workshop to Improve Youth-Friendly Post-Rape Care in a Humanitarian Context in Uganda: A Case Study.

BACKGROUND: Graphic medicine formats, such as comic books in which health information is presented alongside images, may be a useful learning tool to improve post-rape care and youth-friendly service provision among health care providers in humanitarian contexts. We describe the development and pilot-testing of a workshop using a comic book to improve youth-friendly post-rape care with providers in Bidi Bidi refugee settlement, Uganda. PROGRAM DEVELOPMENT AND PILOTING: We conducted 6 focus groups with refugee young men (n=3) and women (n=3) aged 16-24 years and 28 in-depth individual interviews (refugee youth: n=12; health care providers: n=8; elders: n=8). Findings informed the development of a workshop that included a participatory comic book on sexual and gender-based violence (SGBV) and youth, SGBV stigma, youth-friendly health care, and post-exposure prophylaxis. Comic book illustrations specifically addressed health care confidentiality and examples of being a supportive health care provider. Then, we conducted a 1-day workshop with health care providers (n=20) that included structured activities addressing SGBV impacts and related stigma and included comic book discussions. Open-ended survey data were collected 8 weeks after the workshop to explore health care providers' experiences with the workshop, perceived impact of the intervention on their work, and support required to implement youth-friendly services for SGBV survivors. Qualitative data were analyzed using thematic approaches. Open-ended response data indicated that: comic book methods were informative and interactive; health care providers felt more empowered to offer youth-friendly services and spaces; and health care providers want additional SGBV training and institutional support for youth-friendly spaces and community engagement. IMPLICATIONS: A comic book intervention has the potential to meaningfully engage health care providers in humanitarian contexts to provide youth-friendly health care, acquire skills for engaging in SGBV prevention, create youth-friendly clinic spaces, and identify health care and community SGBV prevention needs.

Findings from the Tushirikiane mobile health (mHealth) HIV self-testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala, Uganda.

INTRODUCTION: Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda. METHODS: We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16-24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions. RESULTS: We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up). CONCLUSIONS: Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.

Addressing the Syndemics of HIV, Mental Health, and COVID-19 Using the Health and Human Rights Framework among Youth Living with HIV, in Uganda: an Interpretive Phenomenological Study.

Stigma and discrimination negatively impact the prevention, treatment, and care of HIV. The COVID-19 pandemic increased this complexity and created a cluster of synergistic health contexts, wherein the physiological aspects of HIV and the social and environmental conditions increased the vulnerability in health outcomes for youth living with HIV (YPLHIV) in Kampala, Uganda. We used interpretive phenomenological analysis (IPA) and the syndemics framework to understand the lived experiences of YPLHIV. From December 2020 to May 2021, six qualitative focus groups were held with 31 youth living with HIV to understand the lived experiences of YPLHIV. The guided questions used were audio-recorded, transcribed verbatim, and coded for thematic analysis. Findings highlight the complexity of intersecting stigma of HIV and COVID-19 that have worsened antiretroviral treatment adherence and mental health issues due to lack of access to critical needs such as fears of food insecurity, health-related worries, the fear of perishing due to COVID-19, and human rights concerns related to gender and sexual identity. The study recommends addressing human rights-related concerns in addition to health-related concerns to comprehensively mitigate the syndemics of HIV and COVID-19 for YPLHIV in Uganda.

Examining the substance use, violence, and HIV and AIDS (SAVA) syndemic among urban refugee youth in Kampala, Uganda: cross-sectional survey findings.

BACKGROUND: Interactions between substance use, violence, HIV and AIDS, known as the 'SAVA' syndemic, are understudied among refugee youth. We assessed the synergistic effects of frequent alcohol use, depression and violence on HIV vulnerability among urban refugee youth aged 16-24 years in Kampala, Uganda. METHODS: We conducted a cross-sectional survey between January and April 2018 with a convenience sample of refugee youth aged 16-24 years living in informal settlements in Kampala (Kabalagala, Rubaga, Kansanga, Katwe, Nsambya). We assessed non-communicable health conditions (frequent [≥3 times per week] alcohol use [FAU]; depression); violence (young adulthood violence [YAV] at age ≥16 years, intimate partner violence [IPV]), and HIV vulnerability (past 12-month transactional sex; recent [past 3-month] multiple [≥2] sex partners). We calculated the prevalence and co-occurrence of non-communicable health conditions, violence and HIV vulnerability variables. We then conducted multivariable logistic regression analyses to first create unique profiles of FAU, depression, YAV and IPV exposures, and second to assess for interactions between exposures on HIV vulnerability outcomes. RESULTS: Most participants (n=445; mean age: 19.59, SD: 2.6; women: n=333, 74.8%, men: n=112, 25.2%) reported at least one non-communicable health condition or violence exposure (n=364, 81.8%), and over half (n=278, 62.4%) reported co-occurring exposures. One-fifth reported FAU (n=90; 20.2%) and one-tenth (n=49; 11%) major depression. In logistic regression models including all two-way product terms, adjusted for sociodemographics, we found (a) multiplicative interaction for joint effects of FAU and IPV (adjusted OR (aOR)=4.81, 95% CI: 1.32 to 17.52) on multiple sex partners, and (b) multiplicative interaction for joint effects of FAU and IPV (aOR=3.72, 95% CI: 1.42 to 9.74), and YAV and depression (aOR=7.13, 95% CI: 1.34 to 37.50), on transactional sex. CONCLUSION: Findings signal the importance of addressing the SAVA syndemic among urban refugee youth in Uganda. Synergistic interactions indicate that addressing FAU, depression or violence may concomitantly reduce HIV vulnerability with urban refugee youth.

Support for Texting-Based Condom Negotiation Among Forcibly Displaced Adolescents in the Slums of Kampala, Uganda: Cross-sectional Validation of the Condom Use Negotiated Experiences Through Technology Scale.

BACKGROUND: Promoting sexual health among forcibly displaced adolescents is a global public health priority. Digital sexual communication strategies (eg, sexting) may increase adolescents' confidence in discussing sexual health issues and negotiating condom use. However, limited evidence exists describing validated measures for text-based condom negotiation in the literature. OBJECTIVE: This study helps fill this gap by adapting and examining the psychometric properties of a condom use experience through technology (condom use negotiated experiences through technology [CuNET]) scale. METHODS: Using peer network sampling, 242 forcibly displaced adolescents (aged 16-19 years) living in Kampala's slums were recruited for participation between January and March 2018. A subscale (embarrassment to negotiate condom use) of the Multidimensional Condom Attitudes Scale was adapted to incorporate sexting, yielding CuNET. Participants were randomly assigned to calibration and validation subsamples to conduct exploratory and confirmatory factor analyses to establish and validate the scale. CuNET measured participants' support levels for texting-based condom negotiation via sexting based on gender, and multivariable logistic regression was used to explore its associations with sexual health outcomes (recent consistent condom use, access to sexual and reproductive health services, and lifetime sexually transmitted infection testing). RESULTS: The one-factor CuNET with the validation sample was valid (χ24=5.3; P=.26; root mean square error of approximation=0.05, 90% CI 0.00-0.16; comparative fit index=0.99; Tucker-Lewis index=0.99; standardized root mean square residual=0.006), and reliability (Cronbach α=.98). Adolescent girls showed significantly lower levels of support for using sexting to negotiate condom use (mean 13.60, SE 0.70 vs mean 21.48, SE 1.23; P=.001). In multivariable analyses, a 1-point increase in the CuNET score was associated with increased odds of recent consistent condom use (adjusted odds ratio [aOR] 1.73, 95% CI 1.24-2.41) but not with access to sexual and reproductive health services (aOR 1.51, 95% CI 0.99-2.30) or lifetime sexually transmitted infection testing (aOR 0.90, 95% CI 0.64-1.26). CONCLUSIONS: The unidimensional CuNET scale is valid and reliable for forcibly displaced adolescents living in slums in Kampala, gender-sensitive, and relevant for predicting consistent condom use among urban displaced and refugee adolescents. Further development of this scale will enable a better understanding of how adolescents use digital tools for condom negotiation.

Social contextual factors associated with lifetime HIV testing among the Tushirikiane urban refugee youth cohort in Kampala, Uganda: Cross-sectional findings.

BACKGROUND: Urban refugee youth may live in social contexts characterized by structural drivers of HIV such as poverty and violence. Knowledge gaps remain regarding HIV testing practices among urban refugee youth, despite the increasing trend toward refugee settlement in urban contexts. This study examined social contextual factors associated with lifetime HIV testing among urban refugee youth in Kampala, Uganda. METHODS: We conducted a community-based study with a peer-recruited cohort of urban refugee youth aged 16-24 years living in Kampala's informal settlements, and present baseline cross-sectional findings. We conducted descriptive statistics and logistic regression to examine socio-demographic (e.g., gender and age), material (e.g., income insecurity and education), relational (e.g., social support), and symbolic contexts (e.g., HIV-related stigma and intimate partner violence (IPV]) associated with lifetime HIV testing. RESULTS: Participants (n = 450) had a mean age of 20.4 years (standard deviation: 2.4 years), most lived in Uganda for 1-5 years (53.2%), and less than half reported lifetime HIV testing (43.4%). In multivariable analyses, odds of lifetime HIV testing were higher among youth with secondary school education or higher (adjusted odds ratio (aOR]: 2.30, 95% confidence interval (CI]: 1.27-4.17), currently employed (aOR: 1.79, 95% CI: 1.03-3.10), and reporting IPV (aOR: 3.61, 95% CI: 1.43-9.10). Having children was marginally associated with HIV testing (aOR: 2.17, 95% CI: 0.98-4.81, p = 0.052). CONCLUSIONS: Findings demonstrate suboptimal HIV testing and the importance of tailored strategies to reach urban refugee youth who are unemployed and have limited formal education. There is a need to meaningfully engage urban refugee youth to create enabling environments for sexual health.

The prevalence and correlates of depression before and after the COVID-19 pandemic declaration among urban refugee adolescents and youth in informal settlements in Kampala, Uganda: A longitudinal cohort study.

PURPOSE: There is scant research examining urban refugee youth mental health outcomes, including potential impacts of the COVID-19 pandemic. We examine prevalence and ecosocial risk factors of depression in the periods before and after the COVID-19 pandemic declaration among urban refugee youth in Kampala, Uganda. METHODS: Data from a cohort of refugee youth (n = 367) aged 16-24 years were collected in periods before (February 2020) and after (December 2020) the WHO COVID-19 pandemic declaration. We developed crude and adjusted generalized estimating equation logistic regression models to examine demographic and ecosocial factors (food insecurity, social support, intimate partner violence) associated with depression, and include time-ecosocial interactions to examine if associations differed before and after the pandemic declaration. RESULTS: The prevalence of depression was high, but there was no significant difference before (27.5%), and after (28.9%) the pandemic declaration (P = .583). In adjusted models, food insecurity (aOR: 2.54; 95% CI: 1.21-5.33) and experiencing violence (aOR: 2.53; 95% CI: 1.07-5.96) were associated with increased depression, and social support was associated with decreased depression (aOR: 0.85; 95% CI: 0.81-0.89). CONCLUSIONS: These findings highlight the urgent need for interventions to address chronic depression, food insecurity, and ongoing effects of violence exposure among urban refugee youth in Kampala.

Exploring resource scarcity and contextual influences on wellbeing among young refugees in Bidi Bidi refugee settlement, Uganda: findings from a qualitative study.

BACKGROUND: Contextual factors including poverty and inequitable gender norms harm refugee adolescent and youths' wellbeing. Our study focused on Bidi Bidi refugee settlement that hosts more than 230,000 of Uganda's 1.4 million refugees. We explored contextual factors associated with wellbeing among refugee adolescents and youth aged 16-24 in Bidi Bidi refugee settlement. METHODS: We conducted 6 focus groups (n = 3: women, n = 3: men) and 10 individual interviews with young refugees aged 16-24 living in Bidi Bidi. We used physical distancing practices in a private outdoor space. Focus groups and individual interviews explored socio-environmental factors associated with refugee youth wellbeing. Focus groups were digitally recorded, transcribed verbatim, and coded by two investigators using thematic analysis. Analysis was informed by a social contextual theoretical approach that considers the interplay between material (resource access), symbolic (cultural norms and values), and relational (social relationships) contextual factors that can enable or constrain health promotion. RESULTS: Participants included 58 youth (29 men; 29 women), mean age was 20.9 (range 16-24). Most participants (82.8%, n = 48) were from South Sudan and the remaining from the Democratic Republic of Congo (17.2% [n = 10]). Participant narratives revealed the complex interrelationships between material, symbolic and relational contexts that shaped wellbeing. Resource constraints of poverty, food insecurity, and unemployment (material contexts) produced stress and increased sexual and gender-based violence (SGBV) targeting adolescent girls and women. These economic insecurities exacerbated inequitable gender norms (symbolic contexts) to increase early marriage and transactional sex (relational context) among adolescent girls and young women. Gendered tasks such as collecting water and firewood also increased SGBV exposure among girls and young women, and this was exacerbated by deforestation. Participants reported negative community impacts (relational context) of COVID-19 that were associated with fear and panic, alongside increased social isolation due to business, school and church closures. CONCLUSIONS: Resource scarcity produced pervasive stressors among refugee adolescents and youth. Findings signal the importance of gender transformative approaches to SGBV prevention that integrate attention to resource scarcity. These may be particularly relevant in the COVID-19 pandemic. Findings signal the importance of developing health enabling social contexts with and for refugee adolescents and youth.

Ngutulu Kagwero (agents of change): study design of a participatory comic pilot study on sexual violence prevention and post-rape clinical care with refugee youth in a humanitarian setting in Uganda.

With over 1.4 million refugees, Uganda is Sub-Saharan Africa's largest refugee-hosting nation. Bidi Bidi, Uganda's largest refugee settlement, hosts over 230,000 residents. There is a dearth of evidence-based sexual violence prevention and post-rape clinical care interventions in low- and middle-income humanitarian contexts tailored for refugee youth. Graphic medicine refers to juxtaposing images and narratives, often through using comics, to convey health promotion messaging. Comics can offer youth-friendly, low-cost, scalable approaches for sexual violence prevention and care. Yet there is limited empirical evaluation of comic interventions for sexual violence prevention and post-rape clinical care. This paper details the study design used to develop and pilot test a participatory comic intervention focused on sexual violence prevention through increasing bystander practices, reducing sexual violence stigma, and increasing post exposure prophylaxis (PEP) knowledge with youth aged 16-24 and healthcare providers in Bidi Bidi. Participants took part in a single-session peer-facilitated workshop that explored social, sexual, and psychological dimensions of sexual violence, bystander interventions, and post-rape clinical care. In the workshop, participants completed a participatory comic book based on narratives from qualitative data conducted with refugee youth sexual violence survivors. This pilot study employed a one-group pre-test/post-test design to assess feasibility outcomes and preliminary evidence of the intervention's efficacy. Challenges included community lockdowns due to COVID-19 which resulted in study implementation delays, political instability, and attrition of participants during follow-up surveys. Lessons learned included the important role of youth facilitation in youth-centred interventions and the promise of participatory comics for youth and healthcare provider engagement for developing solutions and reducing stigma regarding SGBV. The Ngutulu Kagwero (Agents of change) project produced a contextually and age-tailored comic intervention that can be implemented in future fully powered randomized controlled trials to determine effectiveness in advancing sexual violence prevention and care with youth in humanitarian contexts.

Kukaa Salama (Staying Safe): study protocol for a pre/post-trial of an interactive mHealth intervention for increasing COVID-19 prevention practices with urban refugee youth in Kampala, Uganda.

INTRODUCTION: With over 82.4 million forcibly displaced persons worldwide, there remains an urgent need to better describe culturally, contextually and age-tailored strategies for preventing COVID-19 in humanitarian contexts. Knowledge gaps are particularly pronounced for urban refugees who experience poverty, overcrowded living conditions and poor sanitation access that constrain the ability to practise COVID-19 mitigation strategies such as physical distancing and frequent hand washing. With over 1.4 million refugees, Uganda is sub-Saharan Africa's largest refugee hosting nation. More than 90 000 of Uganda's refugees live in Kampala, most in informal settlements, and 27% are aged 15-24 years old. There is an urgent need for tailored COVID-19 responses with urban refugee adolescents and youth. This study aims to evaluate the effectiveness of an 8-week interactive informational mobile health intervention on COVID-19 prevention practices among refugee and displaced youth aged 16-24 years in Kampala, Uganda. METHODS AND ANALYSIS: We will conduct a pre-test/post-test study nested within a larger cluster randomised trial. Approximately 385 youth participants will be enrolled and followed for 6 months. Data will be collected at three time points: before the intervention (time 1); immediately after the intervention (time 2) and at 16-week follow-up (time 3). The primary outcome (self-efficacy to practise COVID-19 prevention measures) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health practices; food and water security; COVID-19 vaccine acceptability) will be evaluated using descriptive statistics and regression analyses. ETHICS AND DISSEMINATION: This study has been approved by the University of Toronto Research Ethics Board, the Mildmay Uganda Research Ethics Committee, and the Uganda National Council for Science & Technology. The results will be published in peer-reviewed journals, and findings communicated through reports and conference presentations. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04631367).

Intersecting stigma and HIV testing practices among urban refugee adolescents and youth in Kampala, Uganda: qualitative findings.

INTRODUCTION: HIV-related risks may be exacerbated in humanitarian contexts. Uganda hosts 1.3 million refugees, of which 60% are aged under 18. There are knowledge gaps regarding HIV testing facilitators and barriers, including HIV and intersecting stigmas, among urban refugee youth. In response, we explored experiences and perspectives towards HIV testing strategies, including HIV self-testing, with urban refugee youth in Kampala, Uganda. METHODS: We implemented a qualitative study with refugee cisgender youth aged 16 to 24 living in Kampala's informal settlements from February-April 2019. We conducted five focus groups with refugee youth, including two with adolescent boys and young men, two with adolescent girls and young women and one with female sex workers. We also conducted five key informant (KI) interviews with government, non-government and community refugee agencies and HIV service providers. We conducted thematic analyses to understand HIV testing experiences, perspectives and recommendations. RESULTS: Participants (n = 49) included young men (n = 17) and young women (n = 27) originally from the Democratic Republic of Congo [DRC] (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1), in addition to five KI (gender: n = 3 women, n = 2 men; country of origin: n = 2 Rwanda, n = 2 Uganda, n = 1 DRC). Participant narratives revealed stigma drivers included fear of HIV infection; misinformation that HIV is a "Ugandan disease"; and blame and shame for sexual activity. Stigma facilitators included legal precarity regarding sex work, same-sex practices and immigration status, alongside healthcare mistreatment and confidentiality concerns. Stigma experiences were attributed to the social devaluation of intersecting identities (sex work, youth, refugees, sexual minorities, people living with HIV, women). Participants expressed high interest in HIV self-testing. They recommended HIV self-testing implementation strategies to be peer supported and expressed concerns regarding sexual- and gender-based violence with partner testing. CONCLUSIONS: Intersecting stigma rooted in fear, misinformation, blame and shame, legal precarity and healthcare mistreatment constrain current HIV testing strategies with urban refugee youth. Findings align with the Health Stigma and Discrimination Framework that conceptualizes stigma drivers and facilitators that devalue intersecting health conditions and social identities. Findings can inform multi-level strategies to foster enabling HIV testing environments with urban refugee youth, including tackling intersecting stigma and leveraging refugee youth peer support.

Mobile Health-Supported HIV Self-Testing Strategy Among Urban Refugee and Displaced Youth in Kampala, Uganda: Protocol for a Cluster Randomized Trial (Tushirikiane, Supporting Each Other).

BACKGROUND: HIV is the leading cause of mortality among youth in sub-Saharan Africa. Uganda hosts over 1.43 million refugees, and more than 83,000 live in Kampala, largely in informal settlements. There is limited information about HIV testing uptake and preferences among urban refugee and displaced youth. HIV self-testing is a promising method for increasing testing uptake. Further, mobile health (mHealth) interventions have been effective in increasing HIV testing uptake and could be particularly useful among youth. OBJECTIVE: This study aims to evaluate the feasibility and effectiveness of two HIV self-testing implementation strategies (HIV self-testing intervention alone and HIV self-testing combined with an mHealth intervention) in comparison with the HIV testing standard of care in terms of HIV testing outcomes among refugee/displaced youth aged 16 to 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 randomization will be performed with a 1:1:1 method. Approximately 450 adolescents (150 per cluster) will be enrolled and followed for 12 months. Data will be collected at the following three time points: baseline enrollment, 8 months after enrollment, and 12 months after enrollment. Primary outcomes (HIV testing frequency, HIV status knowledge, linkage to confirmatory testing, and linkage to HIV care) and secondary outcomes (depression, condom use efficacy, consistent condom use, sexual relationship power, HIV stigma, and adolescent sexual and reproductive health stigma) will be evaluated. RESULTS: The study has been conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (June 14, 2019), Mildmay Uganda (November 11, 2019), and the Uganda National Council for Science and Technology (August 3, 2020). The Tushirikiane trial launched in February 2020, recruiting a total of 452 participants. Data collection was paused for 8 months due to COVID-19. Data collection for wave 2 resumed in November 2020, and as of December 10, 2020, a total of 295 participants have been followed-up. The third, and final, wave of data collection will be conducted between February and March 2021. CONCLUSIONS: This study will contribute to the knowledge of differentiated HIV testing implementation strategies for urban refugee and displaced youth living in informal settlements. We will share the findings in peer-reviewed manuscripts and conference presentations. TRIAL REGISTRATION: ClinicalTrials.gov NCT04504097; https://clinicaltrials.gov/ct2/show/NCT04504097. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26192.