Prevalence and Correlates of Substance Use Among Youth Living with HIV in Fishing Communities in Uganda.

Alcohol and drug use (ADU) poses a significant barrier to optimal HIV treatment outcomes for adolescents and youths living with HIV (AYLHIV). We aimed to investigate the prevalence and correlates of ADU among ALHIV in Ugandan fishing communities, areas characterized by high HIV and poverty rates. AYLHIV aged 18-24, who knew they were HIV-positive, were selected from six HIV clinics. Substance use was determined through self-report in the last 12 months and urine tests for illicit substances. Utilizing a socioecological framework, the study structured variables into a hierarchical logistic regression analysis to understand the multi-layered factors influencing ADU. Self-reported past 12 months substance use was 42%, and 18.5% of participants had a positive urine test for one or more substances, with alcohol, benzodiazepines, and marijuana being the most commonly used. With the addition of individual-level socio-demographics, indicators of mental health functioning, interpersonal relationships, and community factors, the logistic regression analysis revealed greater exposure to adverse childhood experiences increased the odds of substance use (Odds Ratio [OR] = 1.24; 95% Confidence Interval [CI]: 1.03-1.55). Additionally, exposure to alcohol advertisements at community events significantly raised the odds of substance use (OR = 3.55; 95% CI: 1.43-8.83). The results underscore the high prevalence among AYLHIV and emphasize the need for comprehensive interventions targeting individual (e.g., life skills education and mental health supports), interpersonal (e.g., peer support and family-based interventions), community (e.g., community engagement programs, restricted alcohol advertisements and illicit drug access), and policies (e.g., integrated care models and a national drug use strategy), to address ADU.

Low HIV Viral Load Suppression and Its Implications for Controlling HIV among Refugee Adolescents and Youth Living in Refugee Settlements in Uganda: A Cross-sectional Analysis.

Viral load suppression (VLS) is considered crucial in the global efforts to end the HIV/AIDS pandemic and young people lag behind adults in this important indicator. However, little is known about VLS among refugee adolescents and youth (RAY), a vulnerable group, often ignored by research, with multiple intersecting risk factors and unique challenges. The goal of this study was to determine the prevalence of VLS and examine associated risk and protective factors among RAY in refugee settlements in Uganda, a country severely affected by the HIV/AIDS pandemic and currently hosting the most refugees in sub-Saharan Africa (SSA). We analyzed cross-sectional data from a pilot cluster randomized trial with 180 participants (ages 13-30) recruited from 20 health centers in three refugee settlements between July and December 2023. We employed a hierarchical (mixed-effects) logistic regression model to examine the association between selected demographic, psychosocial, and economic factors and VLS. The prevalence of VLS among RAY was very low at just 52%. Factors associated with VLS included financial stability, adherence self-efficacy, and HIV status disclosure. Having financial savings was associated with VLS (adjusted odds ratio:2.68; 95% CI: 1.48-5.11; p = 0.003). Treatment support from others including teachers and health care providers had five-fold odds of VLS (5.0, 1.64-15.24; p = 0.005). Conversely, older age and interactions between stigma/self-efficacy and stigma/HIV status disclosure were associated with viral load non-suppression. This study highlights the urgent need for tailored interventions targeting economic and psychosocial hardships like poverty, stigma, and food insecurity to enhance HIV VLS and other treatment outcomes among RAY.

The longitudinal impact of an evidence-based multiple family group intervention (Amaka Amasanyufu) on family cohesion among children in Uganda: Analysis of the cluster randomized SMART Africa-Uganda scale-up study (2016-2022).

Family functioning plays a critical role in childhood disruptive behavior disorders (The Family Journal, 2003, 11(1), 33-41; Research in Nursing and Health, 2016, 39(4), 229-243). Yet, there is limited research on the impact of evidence-based family strengthening interventions on improving family cohesion as a protective factor among children experiencing behavioral challenges. To address this gap, we analyzed data (N = 636) from the SMART Africa-Uganda study (2016-2022), a cluster randomized clinical trial testing an evidence-based family-strengthening intervention called Amaka Amasanyufu (translated as "Happy Families" in the local language). Children aged 8-13 and their caregivers were recruited from 26 public primary schools that were randomized to: (1) control condition receiving generalized psychosocial literature (10 schools), (2) intervention delivered via parent peers (eight schools), and (3) intervention delivered via community healthcare workers (eight schools). Children completed the family cohesion questionnaire at baseline, 8 weeks, 16 weeks, and 6 months post-intervention completion. The intervention effectiveness was evaluated via a three-level logistic mixed effects model with pairwise comparisons across study conditions within each time point. Participants in the parent-peer intervention group had greater odds of being in the higher family cohesion group than participants in the control group at 8 weeks (OR = 3.24), 16 weeks (OR = 1.88) and 6 months (OR = 2.07). At 8 weeks, 16 weeks, and 6 months, participants in the community health worker group had 3.98, 2.08, and 1.79 times greater odds of being in the higher family cohesion group than participants in the control group, respectively. Our findings strengthen the evidence base for Amaka Amansayufu as an effective intervention that can be utilized in SSA to improve family cohesion in families with children experiencing behavioral challenges.

The Impact of an Economic Strengthening Intervention on Academic Achievement Among Adolescents Living with HIV: Findings from the Suubi + Adherence Cluster-Randomized Trial in Uganda (2012-2018).

We examined the impact of a family-based economic strengthening intervention on school dropout and repeating a class among ALWHIV in Uganda. In this cluster-randomized trial (2012-2018) conducted in 39 clinics, we recruited adolescents aged 10-16 years living with HIV. We included data from 613 adolescents. We plotted a Kaplan Meier survival curve and fitted Cox proportional hazards models to test the effect of the economic strengthening intervention on school dropout. The incidence of school dropout was 13.0% and 9.6% in the control and intervention groups, respectively. Also, economic empowerment reduced the risk of school dropout, aHR = 0.68 (95% CI 0.52-0.88), p-value 0.004. In other words, participants in the intervention group had 32% reduced hazards of dropping out of school. Also, increasing age aHR = 1.54 (95% CI 1.42-1.66), p-value < 0.001 and double orphanhood aHR = 0.67 (95% CI 0.47-0.96) p-value 0.030 increased the risks for dropping out of school. The intervention was not efficacious in reducing the rates of repeating a class. The intervention offered the ALWHIV an opportunity to live a productive adult life. More research is required on these kinds of interventions intended to keep ALWHIV and those impacted by HIV in school.

The longitudinal impact of an evidence-based multiple family group intervention (Amaka Amasanyufu) on oppositional defiant disorder and impaired functioning among children in Uganda: analysis of a cluster randomized trial from the SMART Africa-Uganda scale-up study (2016-2022).

BACKGROUND: Oppositional Defiant Disorders (ODDs) and other Disruptive Behavior Disorders (DBDs) are common among children and adolescents in poverty-impacted communities in sub-Saharan Africa. Without early intervention, its progression into adulthood can result in dire consequences. We examined the impact of a manualized family strengthening intervention called Amaka Amasanyufu designed to reduce ODDs and other DBDs among school-going children residing in low-resource communities in Uganda. METHODS: We used longitudinal data from the SMART Africa-Uganda study (2016-2022). Public primary schools were randomized to: (1) Control condition (receiving usual care comprising generalized psychosocial functioning literature), 10 schools; (2) intervention delivered via parent peers (Amaka-parents), 8 schools or; (3) intervention delivered via community healthcare workers (Amaka-community), 8 schools. All the participants were blinded. At baseline, 8- and 16-weeks postintervention initiation, caregivers completed the Iowa Conners Scale, which measured Oppositional Defiant Disorder (ODD) and Impairment Rating Scale to evaluate children's overall impairment and impaired functioning with peers, siblings, and parents; impaired academic progress, self-esteem, and family functioning. Three-level linear mixed-effects models were fitted to each outcome. Pairwise comparisons of postbaseline group means within each time point were performed using Sidak's adjustment for multiple comparisons. Only children positive for ODD and other DBDs were analyzed. RESULTS: Six hundred and thirty-six children screened positive for ODDs and other DBDs (Controls: n = 243; Amaka-parents: n = 194; Amaka-community: n = 199). At 8 weeks, Amaka-parents' children had significantly lower mean scores for overall impairment compared to controls, (mean difference: -0.71, p = .001), while Amaka-community children performed better on ODD (mean difference: -0.84, p = .016). At 16 weeks, children in both groups were performing better on ODD and IRS than controls, and there were no significant differences between the two intervention groups. CONCLUSIONS: The Amaka Amasanyufu intervention was efficacious in reducing ODD and impaired functioning relative to usual care. Hence, the Amaka Amasanyufu intervention delivered either by Amaka-community or Amaka-parents has the potential to reduce negative behavioral health outcomes among young people in resource-limited settings and improve family functioning. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03081195. Registered on 16 March 2017.

Family-level correlates of disruptive behavior challenges among children in Southwestern Uganda.

Introduction: This exploratory study sought to examine the extent to which family-level factors are associated with disruptive behavioral disorder (DBD) symptoms, including oppositional defiant disorder (ODD) and conduct disorder (CD) among school children in Uganda, a low-resource country in SSA. The examination of key influences within the SSA context is important to guide needed investments in mental health care and family-level support. Importantly, identifying families at higher risk can inform the development of contextualized family interventions that reinforce positive parenting practices. Method: We analyzed baseline data (N = 2110) from the NIH-funded Strengthening Mental health And Research Training in Africa (SMART Africa) scale-up study in Southwestern Uganda. Children aged 8-13 and their caregivers were recruited from 30 public primary schools. DBDs were examined using the DBD rating scale, Iowa Conners, and Impairment scales. Logistic regression analysis using cluster adjusted robust standard errors to adjust for within-school clustering was conducted to assess the association between DBD symptoms and family-level factors, including parenting practices, marital status, and family size. Results: Results indicate that poor parental supervision (OR = 1.17; CI: 1.13, 1.21; P <.001), divorced families (OR = 1.33; CI: 1.03, 1.72; P <.05), and widowed families (OR = 1.48; CI: 1.10, 2.00; P <.01) were associated with higher DBD symptoms among children. On the other hand, caregiver age (OR = 0.99; CI: 0.98, 0.99; P <.01) was associated with lower DBD symptoms among children. Moreover, caregiver employment and parental education were not statistically significant in the model. Conclusion: Findings from the study reveal an association between family-level factors and behavioral difficulties among children in Uganda suggesting that divorced and widowed families may benefit from additional support in caring for children. Moreover, caregivers may also benefit from programs that provide tools for effective parental supervision.

Suubi+Adherence-Round 2: A study protocol to examine the longitudinal HIV treatment adherence among youth living with HIV transitioning into young adulthood in Southern Uganda.

BACKGROUND: Youth living with HIV (YLHIV) in Sub-Saharan African (SSA) are less likely to adhere to antiretroviral therapy (ART) and other health-related regimens. As a consequence, YLHIV are not only at risk for health problems and mental health comorbidities, but are also at risk for cognitive deficits, including in areas of memory and executive functioning. The Suubi+Adherence study followed 702 adolescents (10-16 years of age) receiving bolstered standard of care and a family economic empowerment intervention comprising an incentivized youth financial savings account (YSA) augmented with financial literacy training (FLT) and peer mentorship. The study findings pointed to superior short-term viral suppression and positive adolescent health and mental health functioning among participants receiving the intervention. The original group of adolescents who received Suubi+Adherence are now transitioning into young adulthood. This paper presents a protocol for the follow-up phase titled Suubi+Adherence Round 2. METHODS: The original cohort in Suubi+Adherence will be tracked for an additional five years (2020-2025). Specifically, the long term follow-up will allow to: 1) ascertain the extent to which the short term outcomes identified in the first 6 years of the intervention are maintained as the same group transitions through young adulthood; and 2) address new scientific questions regarding ART adherence; HIV care engagement; protective health behaviors; and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. Additionally, the team examines the potential mechanisms through which the observed long-term outcomes happen. Moreover, the Suubi+Adherence-Round 2 adds a qualitative component and extends the cost effectiveness component. DISCUSSION: Guided by asset and human development theories, Suubi+Adherence-R2 will build on the recently concluded Suubi+Adherence study to conduct one of the largest and longest running studies of YLHIV in SSA as they transition into young adulthood. The study will address new scientific questions regarding long-term ART adherence, HIV care engagement, protective health behaviors, and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. The findings may inform efforts to improve HIV care among Uganda's YLHIV, with potential replicability in other low-resource countries. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT01790373.

From "4Rs and 2Ss" to "Amaka Amasanyufu" (Happy Families): Adapting a U.S.-based Evidence-Based Intervention to the Uganda Context.

In Uganda, one in five children presents mental health challenges, including disruptive behavior disorders (DBDs). DBDs can persist through adulthood and result in negative outcomes. Effective interventions for DBDs have been developed and tested in high-poverty communities in developed countries. Yet, most African countries, such as Uganda, lack such interventions. This paper describes the adaptation process of an evidence-based intervention of U.S. origin to optimize fit to context with intervention fidelity, as part of a randomized trial conducted with youth that exhibit behavioral challenges and their caregivers in 30 schools in Uganda. The process involved: initial meetings with headteachers and teachers to introduce the study and the main concepts of the intervention; initial manual review focusing on 4Rs and 2Ss content by the Uganda team; engagement of community stakeholders for additional feedback on content and cultural relevance; final revision of the manual; and collection of children's drawings for the illustration of the manual. This paper describes both similarities and differences between the original and adapted intervention content and methods of delivery. The findings also highlight the importance of involving community stakeholders in the adaptation process.

En Uganda, uno de cada cinco niños presenta problemas de salud mental, incluidos los trastornos del comportamiento disruptivo (TCD). Los TCD pueden continuar hasta la adultez y tener consecuencias negativas. Se han desarrollado intervenciones eficaces para los TCD, las cuales se han evaluado en comunidades con altos índices de pobreza en países desarrollados. Sin embargo, la mayoría de los países africanos, como Uganda, carecen de dichas intervenciones. Este artículo describe el proceso de adaptación de una intervención factual de origen estadounidense para optimizar su adaptación al contexto con la fidelidad de la intervención como parte de un ensayo aleatorizado realizado con jóvenes que presentan problemas conductuales y sus cuidadores en 30 escuelas de Uganda. El proceso consistió en reuniones iniciales con directores y maestros para presentar el estudio y los conceptos principales de la intervención; una revisión inicial del manual centrada en el contenido de la intervención "4Rs and 2 Ss" por parte del equipo de Uganda; la participación de partes interesadas de la comunidad para obtener comentarios adicionales sobre el contenido y la relevancia cultural; la revisión final del manual; y la recopilación de dibujos de los niños para la ilustración del manual. Este artículo describe tanto las similitudes como las diferencias entre el contenido de la intervención original y la adaptada y los métodos de implementación. Los resultados también destacan la importancia de hacer participar a las partes interesadas en el proceso de adaptación.

Prevalence of behavioral disorders and attention deficit/hyperactive disorder among school going children in Southwestern Uganda.

BACKGROUND: Disruptive Behavioral Disorders (DBDs) and Attention Deficit/Hyperactivity Disorder (ADHD) are chronic, impairing, and costly child and adolescent mental health challenges which, when untreated, can result in disruptions in school performance, friendships and family relations. Yet, there is dearth of prevalence data on child and adolescent behavioral challenges within sub-Saharan Africa, including Uganda. This study aims to estimate the prevalence rate of behavioral challenges and ADHD among young school going children and early adolescents (ages 8-13 at study enrollment), utilizing a school-based sample in southwest Uganda. METHODS: We present screening results from a 5-year scale-up study titled SMART Africa-Uganda (2016-2021), set across 30 public primary schools located in the greater Masaka region in Uganda, a region heavily impacted by poverty and HIV/AIDS. Specifically, we draw on screening data from caregivers of 2434 children that used well-established standardized measures that had been pre-tested in the region. These were: 1) oppositional defiant disorder (ODD) and conduct disorder (CD) subscales of the Disruptive Behavior Disorders (DBD) scale; and 2) the Iowa Connors and Impairment scales. Slightly over half of the children in the sample were female (52%), with a mean age of 10.27 years. RESULTS: Of the 2434 participants screened for disruptive behaviors: 1) 6% (n = 136) scored positive on ODD and 2% (n = 42) scored positive on CD subscales of the DBD scale; 2) 9.61% (n = 234), and 2.67% (n = 65) were reported to have elevated symptoms of ODD and ADHD on the Iowa Connors caregiver report scale respectively. Twenty-five percent (n = 586) of children were described by their caregivers as having experienced some form of impairment in at least four domains of the Impairment scale. CONCLUSION: The results indicate the presence of behavioral challenges and ADHD among school going children, aged 8-13 years, in Uganda. Given the negative outcomes associated with behavioral challenges as children transition to adolescence and adulthood, detecting these emerging behavioral challenges early is critical in developing appropriate interventions. School settings could be considered as one of the contextually-relevant, culturally-appropriate, and non-stigmatizing venues to implement screening procedures and to detect emerging behavioral challenges and to make necessary referrals.

Correction: Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS)- Protocol for a Pilot Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/49352.].

The Post-intervention Impact of Amaka Amasanyufu on Behavioral and Mental Health Functioning of Children and Adolescents in Low-Resource Communities in Uganda: Analysis of a Cluster-Randomized Trial From the SMART Africa-Uganda Study (2016-2022).

PURPOSE: Disruptive behavioral disorders (DBDs) are common among children/adolescents in sub-Saharan Africa. A 16-week manualized multiple family group (MFG) intervention called Amaka Amasanyufu designed to reduce DBDs among school-going children/adolescents in low-resource communities in Uganda was efficacious in reducing symptoms of poor mental health relative to usual care in the short-term (4 months post-intervention-initiation). We examined whether intervention effects are sustained 6 months postintervention. METHODS: We used longitudinal data from 636 children positive for DBDs: (1) Control condition, 10 schools, n = 243; (2) MFG delivered via parent peers (MFG-PP), eight schools, n = 194 and; (3) MFG delivered via community healthcare workers (MFG-CHW), eight schools, n = 199 from the SMART Africa-Uganda study (2016-2022). All participants were blinded. We estimated three-level linear mixed-effects models and pairwise comparisons at 6 months postintervention and time-within-group effects to evaluate the impact on Oppositional Defiant Disorder (ODD), impaired functioning, depressive symptoms, and self-concept. RESULTS: At 6 months postintervention, children in MFG-PP and MFG-CHW groups had significantly lower means for ODD (mean difference [MD] = -1.08 and -1.35) impaired functioning (MD = -1.19 and -1.16), and depressive symptoms (MD = -1.06 and -0.83), than controls and higher means for self-concept (MD = 3.81 and 5.14). Most outcomes improved at 6 months compared to baseline. There were no differences between the two intervention groups. DISCUSSION: The Amaka Amasanyufu intervention had sustained effects in reducing ODD, impaired functioning, and depressive symptoms and improving self-concept relative to usual care at 6 months postintervention. Our findings strengthen the evidence that the intervention effectively reduces DBDs and impaired functioning among young people in resource-limited settings and was sustained over time.

"I decided to participate .because I saw it as benefiting our community and families": a qualitative study of lay providers' experiences with delivering an evidence-based mental health intervention for families in Uganda.

BACKGROUND: Children and adolescents who live in resource-limited communities in sub-Saharan Africa (SSA) experience significant mental health problems, including behavioral problems. In SSA, one of the most significant impediments to expanding services is a scarcity of mental health specialists. Task-shifting can effectively solve the mental health care gap in low-resource settings, yet it is underutilized in child and adolescent mental health. Moreover, the experiences of lay providers are understudied in global mental health, despite their potential impact on intervention effectiveness. In this study, we examined the experiences of community health workers and parent peers with the task-shifting of an evidence-based family strengthening intervention in Uganda. METHODS: As part of a larger randomized clinical trial, semi-structured in-depth interviews were conducted with 24 facilitators selected using stratified purposive sampling. Interviews explored their decision to participate in the program; experiences with the training; and experiences with intervention delivery. All interviews were conducted in Luganda (local language) and audio recorded. They were transcribed verbatim and translated into English. Thematic analysis was used to analyze the data. RESULTS: Despite concerns around lack of previous experience and time commitment, facilitators reported high relevance of the intervention to the families in their communities as well as their own as a motivation to participate. They also identified financial incentives as a motivating factor. These two factors also ensured their attendance at the training. They were satisfied with the content and skills provided during the training and felt prepared to deliver the intervention. During intervention delivery, they enjoyed seeing the families engaged and participating actively in the sessions as well as observing positive changes in the families. Some challenges with family attendance and engagement were noted. The facilitators reported an increased sense of self-efficacy and competence over time; and expressed high satisfaction with supervision. CONCLUSION: Facilitators' positive experiences point to the high acceptability and appropriateness of task-shifting this intervention in low-resource settings. As the global mental health field continues to be interested in task-shifting interventions to lay providers, successful examples should be studied so that evidence-based models can be put in place to support them through the process.

Assessing the Feasibility of Economic Approaches to Prevent Substance Abuse Among Adolescents: Protocol for a Mixed Methods Study.

BACKGROUND: Adolescent alcohol and drug use (ADU) is a significant public health challenge. Uganda, one of the poorest countries in Sub-Saharan Africa (SSA), has the second-highest rate of per capita alcohol consumption in SSA, and over one-third of Ugandan adolescents have used alcohol in their lifetime (over 50% of them engage in heavy episodic drinking). These estimates further increase in fishing villages, a key HIV-vulnerable population, where ADU is normative. However, few studies have assessed ADU among adolescents and youths living with HIV despite their increased risk for ADU and its impact on engagement in HIV care. Moreover, data on risk and resilience factors for ADU are scarce as only few studies evaluating ADU interventions in SSA have reported positive outcomes. The majority have been implemented in school settings, potentially excluding adolescents in fishing communities with high school dropout rates, and none have targeted risk factors including poverty and mental health, which are rampant among adolescents and youths living with HIV and their families, undermine their coping skills and resources, and have been associated with increased risk for ADU among them. OBJECTIVE: We propose a mixed methods study with a sample of 200 adolescents and youths living with HIV (aged 18-24 years) seen at 6 HIV clinics in southwestern Uganda's fishing communities to (1) examine the prevalence and consequences of ADU and identify the multilevel risk and resilience factors associated with ADU among them and (2) explore the feasibility and short-term effects of an economic empowerment intervention on ADU among them. METHODS: This study comprises four components: (1) focus group discussions (FGDs) with adolescents and youths living with HIV (n=20) and in-depth qualitative interviews with health providers (n=10) from 2 randomly selected clinics; (2) a cross-sectional survey with 200 adolescents and youths living with HIV; (3) a randomized controlled trial with a subgroup of adolescents and youths living with HIV (n=100); and (4) 2 postintervention FGD with adolescents and youths living with HIV (n=10 per group). RESULTS: Participant recruitment for the first qualitative phase has completed. As of May 4, 2023, ten health providers from 6 clinics have been recruited, provided written consent to participate, and participated in in-depth qualitative interviews. Two FGDs was conducted with 20 adolescents and youths living with HIV from 2 clinics. Data transcription, translation, and analysis of qualitative data has commenced. The cross-sectional survey will commence shortly after and dissemination of the main study findings is targeted for 2024. CONCLUSIONS: Our findings will advance our understanding of ADU among adolescents and youths living with HIV and inform the design of future interventions to address ADU among them. TRIAL REGISTRATION: ClinicalTrials.gov NCT05597865; https://clinicaltrials.gov/ct2/show/NCT05597865. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/46486.

Bridges-Round 2: A study protocol to examine the longitudinal HIV risk prevention and care continuum outcomes among orphaned youth transitioning to young adulthood.

BACKGROUND: Youth orphaned by HIV in sub-Saharan Africa experience immense hardships including social disadvantage, adverse childhood events and limited economic prospects. These adversities disrupt the normative developmental milestones and can gravely compromise their health and emotional wellbeing. The Bridges to the Future study (2012-2018) prospectively followed 1,383 adolescents, between 10-16 years, to evaluate the efficacy and cost-effectiveness of a family-based economic empowerment intervention comprising of child development accounts, financial literacy training, family income generating activities and peer mentorship. Study findings show efficacy of this contextually-driven intervention significantly improving mental health, school retention and performance and sexual health. However, critical questions, such as those related to the longitudinal impact of economic empowerment on HIV prevention and engagement in care remain. This paper presents a protocol for the follow-up phase titled, Bridges Round 2. METHODS: The Original Bridges study participants will be tracked for an additional four years (2022-2026) to examine the longitudinal developmental and behavioral health outcomes and potential mechanisms of the effect of protective health behaviors of the Bridges cohort. The study will include a new qualitative component to examine participants' experiences with the intervention, the use of biomedical data to provide the most precise results of the highly relevant, but currently unknown sexual health outcomes among study participants, as well as a cost-benefit analysis to inform policy and scale-up. DISCUSSION: Study findings may contribute to the scientific knowledge for low-resource communities on the potential value of providing modest economic resources to vulnerable boys and girls during childhood and early adolescence and how these resources may offer long-term protection against known HIV risks, poor mental health functioning and improve treatment among the HIV treatment care continuum.

Short-Term Impact of "Amaka Amasanyufu" Multiple Family Group Intervention on Mental Health Functioning of Children With Disruptive Behavior Disorders in Uganda.

OBJECTIVE: We evaluate the mid-intervention (8 weeks) and short-term (16 weeks) impact of a culturally adapted multiple family group (MFG) intervention, "Amaka Amasanyufu," on the mental health of children with disruptive behavior disorders (DBDs) and primary caregivers in Uganda. METHOD: We analyzed data from the Strengthening mental health and research training in Sub-Saharan Africa (SMART) Africa-Uganda study. Schools were randomized to the following: a control group; an MFG facilitated by parent peers (MFG-PP); or an MFG facilitated by community health workers (MFG:CHW). All participants were blinded to interventions provided to other participants and study hypotheses. At 8 weeks and 16 weeks, we evaluated differences in depressive symptoms and self-concept among children and in mental health and caregiving-related stress among caregivers. Three-level linear mixed-effects models were fitted. Pairwise comparisons of post-baseline group means were performed using the Sidak adjustment for multiple comparisons and standardized mean differences. Data from 636 children with DBDs and caregivers (controls: n = 243, n = 10 schools; MFG-PP: n = 194, n = 8 schools; MFG-CHW: n = 199, n = 8 schools) were analyzed. RESULTS: There were significant group-by-time interactions for all outcomes, and differences were observed mid-intervention, with short-term effects at 16 weeks (end-intervention). MFG-PP and MFG-CHW children had significantly lower depressive symptoms and higher self-concept, whereas caregivers had significantly lower caregiving-related stress and fewer mental health problems, than controls. There was no difference between intervention groups. CONCLUSION: Amaka Amasanyufu MFG intervention is effective for reducing depressive symptoms and improving self-concept among children with DBDs while reducing parental stress and mental health problems among caregivers. Given the paucity of culturally adapted mental health interventions, this provides support for adaptation and scale-up in Uganda and other low-resource settings. CLINICAL TRIAL REGISTRATION INFORMATION: SMART Africa (Strengthening Mental Health Research and Training); https://clinicaltrials.gov/: NCT03081195.

The Relationship Between Family Cohesion and Depression Among School-Going Children With Elevated Symptoms of Behavioral Challenges in Southern Uganda.

PURPOSE: Depression is among the leading causes of disability and contributes significantly to the overall disease burden affecting children. Family cohesion has been identified as a protective factor against depression. Examining this relationship is necessary in sub-Saharan Africa, specifically in Uganda-a country characterized by a high prevalence of HIV/AIDS, and high rates of chronic poverty, all of which stress family functioning and elevate child behavioral challenges. This study examined the relationship between family cohesion and depression among school-going children with elevated symptoms of behavioral challenges in southern Uganda. METHODS: At baseline, 2089 children were enrolled in the National Institutes of Health-funded Strengthening Mental Health and Research Training Africa study in Southwestern Uganda. This article analyzed data from 626 children aged 8-13 years with elevated behavioral challenges. We conducted multilevel mixed-effects Poisson regression to determine the association between family cohesion and depression. We controlled for sociodemographic and household characteristics. RESULTS: The mean age was 10.3 years. The overall mean depression score was 3.2 (standard deviation = 2.7, range = 0-15). Family cohesion (ß = -0.03, 95% confidence interval [CI]: -0.04, -0.02, p < .001) and owning essential items by the child (ß = -0.13, 95% CI: -0.23, -0.04, p = .005) were protective against depression among children. Additionally, we observed being a single orphan (ß = -0.44, 95% CI: -0.03, -0.86, p = .036) and having both parents (ß = -0.43, 95% CI: -0.06, -0.81, p = .023) were associated with depression among children. DISCUSSION: Findings from this study reveal that family cohesion was protective against depression. Therefore, it is vital to strengthen family support systems by developing programs aimed at strengthening family relationships as a catalyst for addressing depression among children.

Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS): Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: East and Southern Africa have the highest HIV incidence and prevalence in the world, with adolescents and young adults being at the greatest risk. Despite effective combination prevention tools, including the recently available pre-exposure prophylaxis (PrEP), HIV incidence among adolescents and young adults in Uganda remains high, and PrEP use remains low. Mental health and substance use (behavioral health) play a role in sexual behavior and decision-making, contributing to an increase in the risk for acquiring HIV. Interventions that target multiple HIV risk factors, including sexual and mental health and problematic substance use, are crucial to ending the HIV epidemic. Yet few interventions addressing HIV related health disparities and comorbidities among adolescents and young adults in East and Southern Africa currently exist. OBJECTIVE: This study aims to evaluate the acceptability and feasibility of Kirabo, an SMS text message intervention informed by the information, motivation, and behavior model and to be disseminated through secondary schools. The study will gather preliminary estimates of Kirabo's effectiveness in increasing HIV testing and linking users to mental health counselors. METHODS: We identified Mobile 4 Reproductive Health for adaptation using the assessment, decision, administration, production, topical experts, integration, training, testing (ADAPT-ITT) framework. Mobile 4 Reproductive Health is an evidence-based automated 2-way SMS text messaging and interactive voice response platform that offers sexual and reproductive health information and links users to HIV clinics in East Africa. Through ADAPT-ITT we refined our approach and created Kirabo, an SMS text message-based intervention for linking adolescents and young adults to health services, including HIV testing and mental health counseling. We will conduct a 2-arm randomized controlled trial in Masaka, Uganda. Adolescents (N=200) will be recruited from local schools. Baseline sociodemographic characteristics, HIV test history, and behavioral health symptoms will be assessed. We will evaluate acceptability and feasibility using surveys, interviews, and mobile phone data. The preliminary efficacy of Kirabo in increasing HIV testing and linking users to mental health counselors will be evaluated immediately after the intervention and at the 3-month follow-up. We will also assess the intervention's impact on self-efficacy in testing for HIV, adopting PrEP, and contacting a mental health counselor. RESULTS: Intervention adaptation began in 2019. A pretest was conducted in 2021. The randomized controlled trial, including usability and feasibility assessments and effectiveness measurements, commenced in August 2023. CONCLUSIONS: Kirabo is a tool that assists in the efforts to end the HIV epidemic by targeting the health disparities and comorbidities among adolescents in Uganda. The intervention includes local HIV clinic information, PrEP information, and behavioral health screening, with referrals as needed. Increasing access to prevention strategies and mitigating factors that make adolescents and young adults susceptible to HIV acquisition can contribute to global efforts to end the HIV epidemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT05130151; https://clinicaltrials.gov/study/NCT05130151. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49352.

Impact of Family-Based Economic Empowerment Intervention, Suubi+Adherence (2012-2018) on Multidimensional Poverty for Adolescents Living with HIV (ALWHIV) in Uganda.

Children growing up in poverty are disproportionately affected by diseases, including HIV. In this study, we use data from Suubi+Adherence, a longitudinal randomized control trial (2012-2018) with 702 adolescents living with HIV (ALWHIV), to examine the effectiveness of a family-based multifaceted economic empowerment (EE) intervention in addressing economic instability and multidimensional poverty among ALWHIV in Southern Uganda. We constructed a Multidimensional Poverty Index of individual and household indicators, including health, assets, housing and family dynamics. We computed the proportion of multidimensionally poor children (H), estimated poverty intensity (A) and adjusted headcount ratio (M0). Using repeated measures at five-time points (baseline, years 1, 2, 3 and 4-post baseline) across two study arms: treatment (receiving the EE intervention) vs. control arm (not receiving EE), we find that both the incidence and proportion of multidimensional poverty decreased in the treatment arm vs. the control arm. Given that there is a direct link between economic instability and poor health outcomes, these findings are informative. They point to the potential for family EE interventions to decrease multidimensional poverty among vulnerable children, including ALWHIV, impacting their overall wellbeing and ability to meet their treatment needs and improve HIV care continuum outcomes.

Suubi4StrongerFamilies: A study protocol for a clustered randomized clinical trial addressing child behavioral health by strengthening financial stability and parenting among families in Uganda.

Background: Children in Sub-Saharan Africa are burdened by significant unmet mental health needs. Across the region, high rates of poverty, HIV/AIDS, food insecurity, stigma, and an inadequate health safety net system exacerbate serious child behavioral health needs and impede an effective response. Disruptive behavioral disorders are particularly concerning as they persist through adolescence and adulthood. Hence, addressing the context-specific social influences on child behavioral health is critical given that children in the region comprise more than half of the total regional population. Against this backdrop, this study protocol describes a randomized clinical trial that will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial, and context-specific drivers affect the mental health of children in Uganda. Methods: The study uses an experimental, longitudinal design across 30 cluster-randomized primary schools to compare single and combination intervention options; influences of economic empowerment and family strengthening on economic, perceptual, and functioning mediators; and context-specific moderators. The study will be conducted with 900 Ugandan children in mid-upper primary school (10-14 years). The three study conditions (n = 300 each) are: (1) economic empowerment only (EE only), (2) multiple family group-based family strengthening only (MFG-based FS only), and (3) combined EE + MFG-based FS. The interventions will be provided for 12 months; and assessments will occur at baseline, 12, 24, and 36 months. Conclusion: Children in Sub-Saharan Africa are burdened by significant unmet mental health needs, including disruptive behavior disorders that persist through adolescence and adulthood if left untreated. The proposed study will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial and context-specific drivers affect the mental health of children in mid-upper primary schools in Uganda. Findings from this study can inform group, community, and population approaches that are needed for scalable solutions to address the social drivers negatively impacting child behavioral health in low-resource settings, including in Sub-Saharan Africa. Clinical trial registration: [https://clinicaltrials.gov/], identifier [NCT053 68714].

Costing of a Multiple Family Group Strengthening Intervention (SMART-Africa) to Improve Child and Adolescent Behavioral Health in Uganda.

Reliable cost estimates are key to assessing the feasibility, affordability, and cost-effectiveness of interventions. We estimated the economic costs of a multiple family group (MFG) intervention-child and adolescent mental health evidence-based practices (CAMH-EBP) implemented under the SMART-Africa study, seeking to improve family functioning and reduce child and adolescent behavior problems-delivered through task-shifting by community health workers (CHWs) or parent peers (PPs) in school settings in Uganda. This prospective microcosting analysis was conducted from a provider perspective as part of a three-armed randomized controlled trial of the MFG intervention involving 2,391 participants aged 8-13 years and their caregivers in 26 primary schools. Activity-specific costs were estimated and summed, and divided by actual participant numbers in each study arm to conservatively calculate total per-child costs by arm. Total per-child costs of the MFG-PP and MFG-CHW arms were estimated at US$346 and US$328, respectively. The higher per-child cost of the MFG-PP arm was driven by lower than anticipated attendance by participants recruited to this arm. Personnel costs were the key cost driver, accounting for approximately 70% of total costs because of intensive supervision and support provided to MFG facilitators and intervention quality assurance efforts. This is the first study estimating the economic costs of an evidence-based MFG intervention provided through task-shifting strategies in a low-resource setting. Compared with the costs of other family-based interventions ranging between US$500 and US$900 in similar settings, the MFG intervention had a lower per-participant cost; however, few comparisons are available in the literature. More costing studies on CAMH-EBPs in low-resource settings are needed.