What's driving girls' adolescent marriage decline in Rakai, Uganda? The interplay between adolescent pregnancies and social determinants, 1999 - 2018.

Few studies have sought to untangle the influence of social determinants and pregnancy on adolescent marriage declines. Using longitudinal data from 15- to 17-year-old girls in the Rakai Community Cohort Survey, we assessed how education, socio-economic status, orphanhood and pregnancy contributed to trends in adolescent marriage. We examined descriptive trends and logistic regressions of the associations between social determinants and adolescent marriage, and conducted causal mediation analysis to assess the extent that pregnancy mediated the effect of education on marriage. Between 1999-2018, adolescent marriages and pregnancies dropped substantially (24%-6% and 28%-8%). Girls' secondary schooling was strongly associated with lower marriage risk (aOR marriage=0.09; 95%CI=0.07-0.12), accounting for time. Lower pregnancy rates partially explained the effect of secondary schooling on lower adolescent marriage (aOR indirect effect=0.55; 95%CI=0.421-0.721). Findings affirm the importance of education in preventing adolescent marriages but call attention to the role of pregnancies in influencing adolescent marriages.

Capacity to Consent to Research Among Adolescent-Parent Dyads in Rakai, Uganda.

OBJECTIVES: To assess the cognitive capacity of early, middle, and late adolescents and their parents or guardians to provide informed consent to a population-based cohort study. STUDY DESIGN: Adolescent-parent/guardian dyads including 40 early (n = 80; 10-14 years), 20 middle (15-17 years), and 20 late (18-19 years) adolescents were recruited from the Rakai Community Cohort Study, an open demographic cohort in Uganda. Participants were administered the MacArthur Competence Assessment Tool for Clinical Research, a structured open-ended assessment; interviews were recorded and transcribed. Twenty transcripts were scored independently by two coders; the intraclass correlation coefficient was 0.89. The remaining interviews were scored individually. We compared mean scores for early and middle/late adolescents using a one-sided t test and score differences between parent/guardian and adolescent dyads using two-sided paired t tests. RESULTS: Early adolescents (mean score, 28.8; 95% CI, 27.1-30.5) scored significantly lower (P < .01) than middle/late adolescents (32.4; 31.6-33.1). In paired dyad comparisons, we observed no statistically significant difference in scores between parents/guardians and middle/late adolescents (difference, -0.2; 95% CI, -1.0-0.6). We found a statistically significant difference in scores between parents/guardians and early adolescents (difference, 3.0; 95% CI, 1.2-4.8). CONCLUSIONS: The capacity of adolescents-of different ages and in diverse settings-to comprehend risks, benefits, and other elements of informed consent is a critical but understudied area in research ethics. Our findings support the practice of having middle and late adolescents provide independent informed consent for sexual and reproductive health studies. Early adolescents may benefit from supported decision-making approaches.

Gendered access to digital capital and mobile phone ownership among young people in Rakai, Uganda.

This article examines how gendered access to digital capital-in the form of the social and economic resources needed to own and use a mobile phone-is connected to key adult milestones, such as securing employment and engaging in romantic relationships. Descriptive statistical analysis of 11,030 young people aged 15-24 in Rakai, Uganda indicated that men were more likely to own mobile phones than women. Analysis of qualitative interviews with young people (N = 31) and ethnographic participant observations among young people (N = 24) add nuance and depth to the observed gender difference. We go beyond a 'categorical' approach to gender (i.e. comparing rates between men and women) to examine how access to digital capital is gendered both for men and for women. Mobile phone ownership both reproduces and destabilises gendered social organisation in ways that have implications for economic opportunities, social connections, HIV risk and overall health and well-being. Young men had greater access to the benefits of mobile phone ownership, whereas young women's access to those benefits was impeded by covert and overt gendered mechanisms of control that limited access to digital capital. Findings suggest that mhealth initiatives, increasingly deployed to reach under-resourced populations, must take into account gendered access to digital capital.

The negative health spillover effects of universal primary education policy: Ethnographic evidence from Uganda.

Scholars of global health have embraced universal education as a structural intervention to prevent HIV. Yet the costs of school, including fees and other ancillary costs, create an economic burden for students and their families, indicating both the challenge of realising the potential of education for preventing HIV and the ways in which the desire for education may produce vulnerabilities to HIV for those struggling to afford it. To explore this paradox, this article draws from collaborative, team-based ethnographic research conducted from June to August 2019 in the Rakai district of Uganda. Respondents reported that education is the most significant cost burden faced by Ugandan families, sometimes amounting to as much as 66% of yearly household budgets per student. Respondents further understood paying for children's schooling as both a legal requirement and a valued social goal, and they pointed to men's labour migrations to high HIV-prevalence communities and women's participation in sex work as strategies to achieve that. Building from regional evidence showing young East African women participate in transactional, intergenerational sex to secure school fees for themselves, our findings point to the negative health spillover effects of Uganda's universal schooling policies for the whole family.

Debating Sex and Sovereignty: Uganda's New National Sexuality Education Policy.

Introduction: This article examines recent moral panics over sex education in Uganda from historical perspectives. Public outcry over comprehensive sexuality education erupted in 2016 over claims that children were being taught "homosexuality" by international NGOs. Subsequent debates over sex education revolved around defending what public figures claimed were national, religious, and cultural values from foreign infiltration. Methods: This paper is grounded in a survey of Uganda's two English-print national newspapers (2016-2018), archival research of newspapers held at Uganda's Vision Group media company (1985-2005), analyses of public rhetoric as reported in nationally circulating media, textual analysis of Uganda's National Sexuality Education Framework (2018), formal interviews with Ugandan NGO officers (3), and semi-structured interviews with Ugandan educators (3). Results: Uganda's current panic over sex education reignited longstanding anxieties over foreign interventions into the sexual health and rights of Ugandans. We argue that in the wake of a 35-year battle with HIV/AIDS and more recent controversies over LGBT rights, both of which brought international donor resources and governance, the issue of where and how to teach young people about sex became a new battleground over the state's authority to govern the health and economic prosperity of its citizens. Conclusions: Ethno- and religio-nationalist rhetoric used to oppose the state's new sexuality education policy was also used to justify sex education as a tool for economic development. Policy Implications: Analyzing rhetoric mobilized by both supporters and detractors of sex education reveals the contested political terrain policy advocates must navigate in Uganda and other postcolonial contexts.

HIV combination prevention and declining orphanhood among adolescents, Rakai, Uganda, 2001-18: an observational community cohort study.

BACKGROUND: Orphanhood increased markedly in the 1980s and 1990s in sub-Saharan Africa because of HIV-related mortality. Little is known about the contribution of HIV interventions, such as antiretroviral therapy (ART) and male medical circumcision, to more recent trends in orphanhood. In this study, we examined trends over time in maternal-only, paternal-only, and double orphanhood among adolescents before and after ART and male medical circumcision became widely available in the Rakai region of south-central Uganda. We sought to understand the association between adolescent orphanhood and HIV combination prevention (community-level ART use and prevalence of male medical circumcision). We hypothesised that increasing combination prevention, including greater use of ART and higher prevalence of male medical circumcision, would be associated with a lower probability of orphanhood. METHODS: We examined the prevalence of orphanhood among adolescents aged 15-19 years, before and after roll-out of ART in mid-2004 and male medical circumcision in 2007, using data from 28 continuously followed communities within the Rakai Community Cohort Study. We used multinomial logistic regression with clustered SEs to estimate adjusted relative risk ratios (RRs) for maternal-only, paternal-only, and double orphanhood compared with non-orphanhood over 11 survey rounds between 2001 and 2018. Controlling for community HIV prevalence, household socioeconomic status, and adolescent age, we examined the association between community prevalence of ART use among people living with HIV and prevalence of male circumcision, including traditional circumcision. The primary outcome was orphanhood among adolescents aged 15-19 years. FINDINGS: Orphanhood declined from 52% (920 of 1768 participants) in 2001-02 to 23% (592 of 2609 participants) by 2016-18 (p<0·0001), while double orphanhood declined from 20% (346 of 1768 participants) to 3% (86 of 2609 participants) (p<0·0001). Community prevalence of ART use among people living with HIV increased from 11% (105 of 945 participants) in 2005-06 to 78% (1163 of 1485 participants) in 2016-18. Male circumcision rates rose from 19% (147 of 790 participants) in 2005-06 to 65% (3535 of 5433 participants) in 2016-18. In the multinomial logistic regression model, a 10% increase in community prevalence of ART use was associated with a decrease in maternal orphanhood (adjusted relative RR 0·90, 95% CI 0·85-0·95) and double orphanhood (0·80, 0·75-0·85). In the post-ART era, a 10% increase in the community prevalence of male circumcision was associated with a decrease in paternal orphanhood (2005-18, adjusted relative RR 0·92, 0·87-0·97) and double orphanhood (0·91, 0·85-0·98). INTERPRETATION: Widespread availability and uptake of HIV combination prevention was associated with marked reductions in orphanhood among adolescents. Reductions in orphanhood promise improved health and social outcomes for young people. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases.

Household wealth and HIV incidence over time, rural Uganda, 1994-2018.

OBJECTIVE: To examine the relationship between household wealth and HIV incidence in rural Uganda over time from 1994 to 2018. In research conducted early in the epidemic, greater wealth (i.e. higher socioeconomic status, SES) was associated with higher HIV prevalence in sub-Saharan Africa (SSA); this relationship reversed in some settings in later years. DESIGN: Analysis of associations over time in a population-based open cohort of persons 15-49 years from 17 survey-rounds in 28 continuously followed communities of the Rakai Community Cohort Study (RCCS). METHODS: The RCCS sample averaged 8622 individuals and 5387 households per round. Principal components analysis was used to create a nine-item asset-based measure of household wealth. Poisson regression with generalized estimating equation (GEE) and exchangeable correlation structure was used to estimate HIV incidence rate ratios (IRRs) by SES quartile, survey-round, sex, and age group. RESULTS: From 1994 to 2018, SES rose considerably, and HIV incidence declined from 1.45 to 0.40 per 100 person-years (IRR = 0.39, 95% CI = 0.32--0.47, P < 0.001). HIV incidence was similar by SES category in the initial survey intervals (1994-1997); however, higher SES groups showed greater declines in HIV incidence over time. Multivariable analyses showed significant associations between HIV incidence and SES (IRR = 0.55 for highest compared with lowest quartile, 95% CI = 0.45--0.66, P < 0.001) controlling for time, sex, and age group. CONCLUSION: Beyond the early years of the RCCS, higher SES was associated with lower HIV incidence and SES gradients widened over time. The poor, like other key populations, should be targeted for HIV prevention, including treatment as prevention.

Beyond interviews and focus groups: a framework for integrating innovative qualitative methods into randomised controlled trials of complex public health interventions.

BACKGROUND: Randomised controlled trials (RCTs) are widely used for establishing evidence of the effectiveness of interventions, yet public health interventions are often complex, posing specific challenges for RCTs. Although there is increasing recognition that qualitative methods can and should be integrated into RCTs, few frameworks and practical guidance highlight which qualitative methods should be integrated and for what purposes. As a result, qualitative methods are often poorly or haphazardly integrated into existing trials, and researchers rely heavily on interviews and focus group discussions. To improve current practice, we propose a framework for innovative qualitative research methods that can help address the challenges of RCTs for complex public health interventions. METHODS: We used a stepped approach to develop a practical framework for researchers. This consisted of (1) a systematic review of the innovative qualitative methods mentioned in the health literature, (2) in-depth interviews with 23 academics from different methodological backgrounds working on RCTs of public health interventions in 11 different countries, and (3) a framework development and group consensus-building process. RESULTS: The findings are presented in accordance with the CONSORT (Consolidated Standards of Reporting Trials) Statement categories for ease of use. We identify the main challenges of RCTs for public health interventions alongside each of the CONSORT categories, and potential innovative qualitative methods that overcome each challenge are listed as part of a Framework for the Integration of Innovative Qualitative Methods into RCTs of Complex Health Interventions. Innovative qualitative methods described in the interviews include rapid ethnographic appraisals, document analysis, diary methods, interactive voice responses and short message service, community mapping, spiral walks, pair interviews and visual participatory analysis. CONCLUSIONS: The findings of this study point to the usefulness of observational and participatory methods for trials of complex public health interventions, offering a novel contribution to the broader literature about the need for mixed methods approaches. Integrating a diverse toolkit of qualitative methods can enable appropriate adjustments to the intervention or process (or both) of data collection during RCTs, which in turn can create more sustainable and effective interventions. However, such integration will require a cultural shift towards the adoption of method-neutral research approaches, transdisciplinary collaborations, and publishing regimes.

Testing a proof of concept model for group couples counseling in family planning in Northern Uganda.

INTRODUCTION: The post-conflict Acholi sub-region of Uganda is undergoing a period of transition that is influencing access, acceptability and use of family planning (FP). Low FP use and high unmet need for FP in Uganda's northern region provides a unique opportunity to test a community-based group counseling approach to reduce unintended pregnancies among young couples. We share findings from a proof of concept testing model in delivering fertility awareness methods (FAM) to groups of couples by trained non-health community youth agents. METHODS: The group counseling model was developed for couples interested in two FAM-standard days method (SDM) and TwoDay Method-within rural communities in Northern Uganda. WALAN was tested in a three-month proof of concept phase, employing 24 direct observations of group counseling sessions; quantitative interviews with 9 couples using either SDM or TwoDay Method; 2 focus group discussions with youth facilitators, and; 9 key informant interviews with providers and leaders. RESULTS: The proof of concept results suggest model feasibility and acceptability among participating communities. Couples learned how to use FAM correctly. All 9 interviewed female users reported 100% correct knowledge of method use. Couples also reported high levels of satisfaction for both methods. SDM and TwoDay Method participants reported comfort and satisfaction in learning about FAM in small groups with other couples. CONCLUSION: The proof of concept phase confirmed intervention feasibility, albeit with some model adjustments. The results were used to inform the pilot intervention, launched in April 2016 within 15 other villages in the same region.

Jordan's 2002 to 2012 Fertility Stall and Parallel USAID Investments in Family Planning: Lessons From an Assessment to Guide Future Programming.

Health practitioners, researchers, and donors are stumped about Jordan's stalled fertility rate, which has stagnated between 3.7 and 3.5 children per woman from 2002 to 2012, above the national replacement level of 2.1. This stall paralleled United States Agency for International Development (USAID) funding investments in family planning in Jordan, triggering an assessment of USAID family planning programming in Jordan. This article describes the methods, results, and implications of the programmatic assessment. Methods included an extensive desk review of USAID programs in Jordan and 69 interviews with reproductive health stakeholders. We explored reasons for fertility stagnation in Jordan's total fertility rate (TFR) and assessed the effects of USAID programming on family planning outcomes over the same time period. The assessment results suggest that the increased use of less effective methods, in particular withdrawal and condoms, are contributing to Jordan's TFR stall. Jordan's limited method mix, combined with strong sociocultural determinants around reproduction and fertility desires, have contributed to low contraceptive effectiveness in Jordan. Over the same time period, USAID contributions toward increasing family planning access and use, largely focused on service delivery programs, were extensive. Examples of effective initiatives, among others, include task shifting of IUD insertion services to midwives due to a shortage of female physicians. However, key challenges to improved use of family planning services include limited government investments in family planning programs, influential service provider behaviors and biases that limit informed counseling and choice, pervasive strong social norms of family size and fertility, and limited availability of different contraceptive methods. In contexts where sociocultural norms and a limited method mix are the dominant barriers toward improved family planning use, increased national government investments toward synchronized service delivery and social and behavior change activities may be needed to catalyze national-level improvements in family planning outcomes.