Evaluation of a disability-inclusive ultra-poor graduation programme in Uganda: study protocol for a cluster-randomised controlled trial with process evaluation.

BACKGROUND: There is little evidence on how to support ultra-poor people with disabilities to adopt sustainable livelihoods. The Disability-Inclusive Graduation (DIG) programme targets ultra-poor people with disabilities and/or women living in rural Uganda. The programme is an adaptation of an ultra-poor graduation model that has been shown to be effective in many contexts but not evaluated for people with disabilities. METHODS: The DIG programme works with project participants over a period of 18 months. Participants receive unconditional cash transfers for 6 months, training, access to savings-and-loans groups, and a capital asset that forms the basis of their new livelihood. The programme is also adapted to address specific barriers that people with disabilities face. Eligible households are clustered by geographical proximity in order to deliver the intervention. Eligibility is based on household screening to identify the 'ultra-poor' based on proxy means testing-both households with and without people with disabilities are included in the programme. Clusters are randomly selected prior to implementation, resulting in 96 intervention and 89 control clusters. The primary outcome of the trial is per-capita household consumption. Before the start of the intervention, a baseline household survey is conducted (November 2020) among project participants and those not offered the programme, a similar endline survey is conducted with participants with disabilities at the end of programme implementation in July 2022, and a second endline survey for all participants in October 2023. These activities are complemented by a process evaluation to understand DIG programme implementation, mechanisms, and context using complementary qualitative and quantitative methods. Ethical approval for the research has been received from Mildmay Uganda Research Ethics Committee and London School of Hygiene and Tropical Medicine. DISCUSSION: DIG is a promising intervention to evaluate for people with disabilities, adapted to be disability inclusive across programme components through extensive consultations and collaboration, and has proven efficacy at reducing poverty in other marginalised groups. However, evaluating a well-evidenced intervention among a new target group poses ethical considerations. TRIAL REGISTRATION: Registry for International Development Impact Evaluations, RIDIE-STUDY-ID-626008898983a (20/04/22). ISRCTN registry, ISRCTN78592382 . Retrospectively registered on 17/08/2023.

Sexual and reproductive healthcare utilisation and affordability for South Sudanese refugees and host populations in Northern Uganda: A mixed methods study.

Given Uganda's increasing refugee population, the health financing burden on refugee and host populations is likely to increase because Uganda's integrated health system caters to both populations. We used sexual, reproductive, and maternal health (SRMH) as a lens to assess the utilisation and user cost of health services in Northern Uganda to identify potential gaps in SRMH services and their financing. We conducted a cross-sectional survey among 2,533 refugee and host women and girls in Arua and Kiryandongo districts. We conducted 35 focus group discussions and 131 in-depth interviews with host and South Sudanese refugees, community members, health workers, NGO and governmental actors. Qualitative data were analysed thematically using a framework approach. Quantitative data were analysed using t-test, chi-square tests, multivariate logistical regression, and a two-part model. We found high levels of access to maternal care services among refugee and host communities in Northern Uganda, but lower levels of met need for family planning (FP). Refugees had higher uptake of delivery care than host communities due to better-resourced refugee facilities, but incurred higher costs for delivery kits and food and less for transport due to facilities being closer. FP uptake was low for both groups due to perceived risks, cultural and religious beliefs, and lack of agency for most women. Host communities lack access to essential maternal healthcare services relative to refugees, especially for delivery care. Greater investment is needed to increase the number of host facilities, improve the quality of SRMH services provided, and further enhance delivery care access among host communities. Ongoing funding of delivery kits across all communities is needed and new financing mechanisms should be developed to support non-medical costs for deliveries, which our study found to be substantial in our study. All populations must be engaged in co-designing improved strategies to meet their FP needs.

Feasibility and preliminary effectiveness of integrating HIV prevention into an adolescent empowerment and livelihood intervention at youth clubs in rural Uganda.

The uptake of HIV prevention services is lower among youth than adults in sub-Saharan Africa. Existing youth livelihood trainings offer a potential entry point to HIV prevention services. We determined feasibility and preliminary effectiveness of integrating HIV prevention into youth clubs implementing an empowerment and livelihood for adolescents (ELA) intervention in rural Uganda. Staff conducted community mobilization for youth (15-24 years) over one month. Clubs met (3×/week) over six months, with local peer mentors trained to teach life-skills and sexual/reproductive health education. We integrated mentor-led education on HIV prevention, including pre- and post-exposure prophylaxis (PrEP/PEP). Clubs offered on-site HIV testing, a field trip to a local clinic and PrEP referrals after one month and six months. Surveys were conducted at baseline and six months. Forty-two participants (24 adolescent girls/young women (AGYW) and 18 adolescent boys/young men (ABYM)) joined the clubs. At baseline, no participants accepted referral for PrEP, whereas 5/18 (28%) sexually active, HIV-negative AGYW requested PrEP referral at follow-up. One ABYM requested PEP referral. Integration of HIV prevention services into an established ELA curriculum at mentor-led youth clubs in rural Uganda was feasible. PrEP uptake increased among sexually active AGYW. Evaluation of this approach for HIV prevention among youth merits further study.

Women's groups and COVID-19: An evidence review on savings groups in Africa.

The coronavirus disease 2019 (COVID-19) pandemic and some of the associated policy responses have resulted in significant gendered impacts that may reverse recent progress in gender equality, including in sub-Saharan Africa. This paper presents emerging evidence from studies in diverse contexts in sub-Saharan Africa -with a deep dive into Nigeria and Uganda-on how COVID-19 has affected women's groups, especially savings groups, and how these groups have helped mitigate the gendered effects of the pandemic's and the associated policy responses' consequences up until April 2021. The synthesis presents evidence that savings groups found ways to continue operating, provided leadership opportunities for women during the pandemic, and mitigated some of the negative economic consequences of COVID-19 on individual savings group members. Savings, credit, and group support from other members all likely contributed to the ability of groups to positively affect the resilience of women's group member during COVID-19. Households with a female member in a savings group in Nigeria and Uganda have coped with the crisis better than those not in savings groups. While savings groups have shown the potential for resilience during the pandemic, they often faced financial challenges because of decreased savings, which sometimes resulted in the depletion of group assets. Savings groups also contributed to community responses and provided women a platform for leadership. These findings are consistent with a recent evidence synthesis on how past covariate shocks affected women's groups and their members. We conclude the paper by presenting various policy recommendations to enable savings groups to achieve improvements in women's empowerment and economic outcomes, and research recommendations to address some of the current evidence gaps on how COVID-19 is affecting women's groups and their members.

Effects of Nutrition Counselling and Unconditional Cash Transfer on Child Growth and Family Food Security in Internally Displaced Person Camps in Somalia-A Quasi-Experimental Study.

The effects of nutrition counselling (NC) and unconditional cash transfer (UCT) in improving growth in children under five and household food security are poorly understood in humanitarian settings. Therefore, this study aimed to evaluate the effects of NC and NC combined with unconditional cash transfer (NC + UCT) on children's growth and food security in Somalia. The study was performed with a quasi-experimental design in two districts in the Banadir region of Somalia. Caregivers (n = 255) with mildly to moderately malnourished children aged 6 to 59 months old (n = 184) were randomized to the NC, NC + UCT and control groups. The interventions consisted of weekly NC for three months alone or in combination with UCT. The outcome variables were wasting, underweight, stunting, and food security. Difference-indifferences analysis was used to estimate the effect of the interventions. Our study did not find any significant impacts of NC or NC + UCT on child wasting, underweight, stunting, food security or household expenses. In conclusion, NC, alone or in combination with UCT, did not impact children's growth or household food security. Thus, a culturally tailored NC programme over a longer period, supplemented with cash transfer, could be beneficial to consider when designing interventions to reduce malnutrition and food insecurity.

Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey.

BACKGROUND: The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda. METHODS: Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles. RESULTS: There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups. CONCLUSIONS: Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.

Conceptualizing "agency" within child marriage: Implications for research and practice.

BACKGROUND: The concept of child 'agency' has become increasingly important for international child-centric organizations, non-government organizations (NGOs) and United Nations (UN) agencies, particularly those responding to the issue of child marriage. Interventions to prevent child marriage often include awareness-raising activities focused on sharing information with children on the dangers of child marriage. Such interventions are often based on, and perpetuate, a belief that increased knowledge can lead to an increase in girls' agency. In this framing, agency is presumed to result in a 'good' decision and is positioned as a natural consequence of increased knowledge. This agency is said to enable girls to resist marriages forced upon them by their parents. OBJECTIVE: This discussion paper aims to interrogate dominant conceptualizations of child agency through an exploration of child agency narratives on child marriage. METHODS: This discussion paper is based on critical analysis of existing academic and grey (NGO and UN) literature that explores children's agency in the context of child marriage prevention. RESULTS: This discussion paper suggests that academics, NGOs and UN actors use varied definitions to describe agency. While academic analysis shows that children's agency might be contested, contradictory and fraught, NGO and UN agencies tend to narrowly frame agency. CONCLUSIONS: We suggest that adopting a broader definition of children's agency in research and implementation enables a more nuanced, complex understanding of the drivers of child marriage and the interventions required to address this practice.

Adolescent-led marriage in Somaliland and Puntland: A surprising interaction of agency and social norms.

INTRODUCTION: Child marriage, formal and informal unions when one or both spouses are under 18, disproportionately affects adolescent girls over boys. It has serious consequences for girls' health, wellbeing, and development. Little is known about the ways in which girls' agency and contextual social norms - unwritten rules of (un)acceptable behaviour in a group - intersect to affect child marriage practices. This paper investigates norms and agency as facilitators and obstacles to adolescent girls' marriage in Somaliland and Puntland. METHODS: Participants (n = 156) were men and women living in Somaliland and Puntland. We conducted 36 qualitative semi-structured individual interviews (12 men and 24 women). We also held 15 focus group discussions (8 in Somaliland and 7 in Puntland) with 6-10 people each (n = 120). Mixed focus groups were conducted with men and women together, and were segregated by age. RESULTS: Technology and economic deprivation were important contextual factors in explaining the prevalence of child marriage. Participants reported that adolescent girls' and boys' increased agency contributed to, rather than decreased, child marriage. Access to technology expanded adolescents' freedom from their parents' control. Adolescents used that freedom within the existing system of social norms that rewarded early (as opposed to later) marriage. CONCLUSIONS: Effective interventions that aim to reduce marriage among adolescents living in Somalia (where marriage can be a protective strategy) should integrate a social norms perspective to avoid increasing adolescent-led marriage.

Infant and young child nutritional status and their caregivers' feeding knowledge and hygiene practices in internally displaced person camps, Somalia.

BACKGROUND: In an attempt to design an educational programme targeting caregivers of children aged 6 to 59 months in internally displaced persons camps in Somalia, the objective of this study was twofold. First, to explore the nutritional situation of all children aged 6-59 months enrolled in a nutrition programme provided by Save the Children in 2017 in internally displaced persons camps. Second, to identify gaps in the caregivers' hygiene and feeding practices. METHODS: In a study of 1655 households, 1655 caregivers for 2370 children aged 6 to 59 months enrolled in a nutrition programme provided by Save the Children answered an adapted questionnaire on hygiene and feeding practices. At the same time, based on standard criteria in the questionnaire, naturalistic observations of caregivers' hygiene practices were conducted. Every child in the study was measured with anthropometric Mid-Upper-Arm Circumference measurements for the classification of Moderate Acute Malnutrition, Severe Acute Malnutrition and Global Acute Malnutrition. Descriptive statistics were used for analysis. RESULTS: 1) There was Severe (12.1%) and Global Acute (19.9%) Malnutrition among children included in the nutrition programme, more frequently in the 6-24 month age group compared to the 25-59 month age group (p < 0.01). 2). The practices in the households were below what could generally be considered hygienic. 3) There was poor caregivers' knowledge of breastfeeding benefits and complementary foods. CONCLUSION: Child malnutrition might derive from gaps in the caregiver's knowledge, attitudes, and practices regarding hygiene and infant feeding. An awareness of these gaps can be helpful in designing future educational programmes that target caregivers, particularly in at-risk population groups.