"When you have no water, it means you have no peace": A mixed-methods, whole-population study of water insecurity and depression in rural Uganda

Caregiver preferences for physically harsh discipline of children in rural Uganda

Purpose

Physically harsh discipline is associated with poor developmental outcomes among children. These practices are more prevalent in areas experiencing poverty and resource scarcity, including in low- and middle-income countries. Designed to limit social desirability bias, this cross-sectional study in rural Uganda estimated caregiver preferences for physically harsh discipline; differences by caregiver sex, child sex, and setting; and associations with indicators of household economic stress and insecurity.

Method

Three-hundred-fifty adult caregivers were shown six hypothetical pictographic scenarios depicting children whining, spilling a drink, and kicking a caregiver. Girls and boys were depicted engaging in each of the three behaviors. Approximately half of the participants were shown scenes from a market setting and half were shown scenes from a household setting. For each scenario, caregivers reported the discipline strategy they would use (time out, beating, discussing, yelling, ignoring, slapping).

Results

Two thirds of the participants selected a physically harsh discipline strategy (beating, slapping) at least once. Women selected more physically harsh discipline strategies than men (b = 0.40; 95% confidence interval [CI], 0.26 to 0.54). Participants shown scenes from the market selected fewer physically harsh discipline strategies than participants shown scenes from the household (b = -0.51; 95% CI, -0.69 to -0.33). Finally, caregivers selected more physically harsh discipline strategies in response to boys than girls. Indicators of economic insecurity were inconsistently associated with preferences for physically harsh discipline.

Conclusions

The high prevalence of physically harsh discipline preferences warrant interventions aimed at reframing caregivers' approaches to discipline.

Water Supply Interruptions Are Associated with More Frequent Stressful Behaviors and Emotions but Mitigated by Predictability: A Multisite Study

Water supply interruptions contribute to household water insecurity. Unpredictable interruptions may particularly exacerbate water insecurity, as uncertainty limits households' ability to optimize water collection and storage or to modify other coping behaviors. This study used regression models of survey data from 2873 households across 10 sites in 9 middle-income countries to assess whether water supply interruptions and the predictability of interruptions were related to composite indicators of stressful behaviors and emotional distress. More frequent water service interruptions were associated with more frequent emotional distress (β = 0.49, SE = 0.05, P < 0.001) and stressful behaviors (β = 0.39, SE = 0.06, P < 0.001). Among households that experienced interruptions, predictability mitigated these respective relationships by approximately 25 and 50%. Where the provision of continuous water supplies is challenged by climate change, population growth, and poor management, water service providers may be able to mitigate some psychosocial consequences of intermittency through scheduled intermittency and communication about water supply interruptions. Service providers unable to supply continuous water should optimize intermittent water delivery to reduce negative impacts on users, and global monitoring regimes should account for intermittency and predictability in post-2030 water service metrics to better reflect household water insecurity experiences.

A qualitative analysis of self-management needs of adolescents and young adults living with perinatally acquired HIV in rural, southwestern Uganda

The number of adolescents living with HIV remains high in sub-Saharan Africa with poorer HIV treatment outcomes among adolescents and young adults compared to individuals in other age groups. For adolescents and young adults living with perinatally acquired HIV (AYLPHIV), the transition from pediatric to adult HIV care is a particularly high-risk period. We conducted a qualitative study to understand self-management needs of AYLPHIV in rural, southwestern Uganda as they prepare to transition to adult HIV care in order to inform relevant interventions that can enable AYLPHIV acquire the necessary skills to manage their illness as they age into adulthood. We conducted 60 in-depth interviews with AYLPHIV (n = 30), caregivers (n = 20) and health care providers (n = 10) from the HIV clinic at Mbarara Regional Referral Hospital. We used an interview guide that focused on perceptions about transition to adult HIV care, challenges with transitioning, navigating HIV care, and self-management needs for AYLPHIV (from the perspectives of AYLPHIV, their caregivers, and health care providers). We used thematic analysis to identify themes related to AYLPHIV's self-management skills. We identified several self-management needs that we grouped under two major themes; social support and empowerment for AYLPHIV to assume responsibility for their own health and to navigate adult HIV care independently. The sub-themes under social support were information support, instrumental support, and emotional support as the sub themes while sub-themes under empowerment included self-advocacy skills, interpersonal skills, self-care skills, and disclosure skills. Taken together, these findings indicate that AYLPHIV need to be supported and empowered to maximize their chances of successfully transitioning to adult HIV care. Support comes from peers and caregivers. AYLPHIV require knowledge about their HIV status and empowerment with different skills including: self-advocacy skills, interpersonal skills, self-care skills, and HIV status disclosure skills, in order to assume responsibilities related to independent HIV care.

Social networks and HIV treatment adherence among people with HIV initiating treatment in rural Uganda and peri-urban South Africa

Timely initiation of and adherence to antiretroviral therapy (ART) is critical for improving HIV outcomes and reducing HIV transmissibility. Social networks, or the social relationships individuals have with each other, have been linked with positive health outcomes, but less is known about the extent to which social network composition and structure are associated with improved ART adherence among people living with HIV (PLWH). We conducted an ego-centric network study among 828 previously ART-naïve PLWH presenting for ART initiation at 11 clinics in Mbarara, Uganda (rural population) and Gugulethu, South Africa (peri-urban population). We collected social network data using name generator and name interpreter questions. ART adherence was monitored over 12 months using wireless monitors (Wisepill). Our primary outcome of interest was ART adherence during the 12-month follow-up period. We used generalized linear models to estimate the associations between network measures and ART adherence. PLWH at the Uganda site (compared with the South Africa site) were less isolated, had larger social networks, and had more social ties providing sufficient social support; they were also more likely to bridge different social groups whereby not all social ties were connected to each other. In Uganda, social isolation was associated with a 5.5 percentage point reduction in ART adherence (95% confidence interval [CI] -9.95 to -1.13; p = 0.014), while having more same gender social ties was associated with higher ART adherence (b = 0.13, 95% CI 0.02-0.25, p = 0.025). In South Africa, there was no association between social isolation and ART adherence, and having more friendship ties (vs. family ties) was associated with lower ART adherence (b = -2.20, 95% CI -3.56 to -0.84; p = 0.002). Identifying and supporting PLWH who are isolated may facilitate optimal adherence, but understanding how networks differentially affect ART adherence by country context is important.

Water insecurity is associated with gender-based violence: A mixed-methods study in Indonesia

Gender Based Violence (GBV) is a global pandemic and water insecurity is increasing in intensity and extent. This study explores the association between these two global health threats. Cross-sectional, quantitative data were collected via surveys (n = 365 adult women) to measure household water insecurity (HWI) and women's experiences of GBV in the last year. Qualitative data were collected from semi-structured interviews (n = 24 men and women), two focus group discussions (n = 25 men and women) and a multi-stakeholder meeting (n = 35 men and women) to explore experiences, attitudes and risk factors associated with HWI and GBV. Multivariate logistic regression analysis showed that women in water insecure households were more than twice as likely to report experiencing GBV in the last year (OR = 2.2, CI: 1.0-4.9, p = 0.051). Examining household water insecurity scores as a continuous variable revealed an increased odds of reporting GBV with each increase in the HWISE score (OR = 1.1, CI: 1.0; 1.1, p < 0.001). Qualitative data indicates that the intersection between HWI, a patriarchal social organization and a caste system produced water-related conflicts between intimate partners, between daughters-in-law and their in-laws, and between masters and enslaved women. These results are presented using an integrated theoretical framework - a Feminist Political Ecology of Health (FPEH) - to illustrate the many ways women encounter and experience multi-dimensional forms of violence across scales in connection to water insecurity. The combination of robust qualitative and quantitative data presented in this study suggests that HWI may be causally related to GBV in this context.

Associations between water insecurity and mental health outcomes among lesbian, gay, bisexual, transgender and queer persons in Bangkok, Thailand and Mumbai, India: Cross-sectional survey findings

Background

Water insecurity disproportionally affects socially marginalized populations and may harm mental health. Lesbian, gay, bisexual, transgender and queer (LGBTQ) persons are at the nexus of social marginalization and mental health disparities; however, they are understudied in water insecurity research. Yet LGBTQ persons likely have distinct water needs. We explored associations between water insecurity and mental health outcomes among LGBTQ adults in Mumbai, India and Bangkok, Thailand.

Methods

This cross-sectional survey with a sample of LGBTQ adults in Mumbai and Bangkok assessed associations between water insecurity and mental health outcomes, including anxiety symptoms, depression symptoms, loneliness, alcohol misuse, COVID-19 stress and resilience. We conducted multivariable logistic and linear regression analyses to examine associations between water insecurity and mental health outcomes.

Results

Water insecurity prevalence was 28.9% in Mumbai and 18.6% in Bangkok samples. In adjusted analyses, in both sites, water insecurity was associated with higher likelihood of depression symptoms, anxiety symptoms, COVID-19 stress, alcohol misuse and loneliness. In Mumbai, water insecurity was also associated with reduced resilience.

Conclusion

Water insecurity was common among LGBTQ participants in Bangkok and Mumbai and associated with poorer well-being. Findings signal the importance of assessing water security as a stressor harmful to LGBTQ mental health.

"Gender-Based Water Violence": Cross-Cultural Evidence for Severe Harm Associated With Water Insecurity for Women and Girls

We examined how study participants in Indonesia and Peru viewed the relationship between water insecurity and women's health via thematic analysis of interviews and focus groups. Participants reported that water insecurity led to vaginal infections, miscarriage, premature births, uterine prolapse, poor nutrition, restricted economic opportunities, and intergenerational cycles of poverty. Participants in both countries stated that extreme burdens associated with water insecurity should be categorized as violence. Based on these findings, we developed the concept of "gender-based water violence," defined as the spectrum of stressors associated with water insecurity that are so severe as to threaten human health and well-being, particularly that of women and girls.

WaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region

BACKGROUND

Water, sanitation, and hygiene (WaSH) insecurity increases the risk of water-related diseases. However, limited research has been conducted on psychosocial distress as it relates to WaSH insecurity, especially among people who inject drugs (PWID). We examined the relationship between WaSH insecurity and related anxiety among PWID living in different housing conditions along the US-Mexico border region.

METHODS

From 2020-2021, a cross-sectional study was conducted among 585 people who injected drugs within the last month in Tijuana (N = 202), San Diego (N = 182), and in both Tijuana and San Diego (N = 201). Participants underwent interviewer-administered surveys related to WaSH access, substance use, and generalized anxiety disorder (GAD-7). Quasi-Poisson regressions were used to assess associations between WaSH insecurity and anxiety in the prior 6-months.

RESULTS

Participants were 75% male, 42% were unhoused and 91% experienced WaSH insecurity in the prior 6-months. After adjusting for housing status, gender, and age, lack of access to basic drinking water (Adj RR: 1.28; 95% CI: 1.02-1.58), sanitation (Adj RR:1.28; 95% CI: 1.07-1.55), and a daily bath/shower (Adj RR: 1.38; 95% CI: 1.15-1.66) were associated with mild-severe anxiety. The number of WaSH insecurities was independently associated with a 20% increased risk of experiencing anxiety per every additional insecurity experienced (Adj RR: 1.20; CI: 1.12-1.27). We also found a significant interaction between gender and housing status (p = 0.003), indicating that among people experiencing sheltered/unsheltered homelessness, women had a higher risk of mild-severe anxiety compared to men (Adj RR: 1.55; 95% CI: 1.27-1.89). At the same time, among women, those who are unhoused have 37% increased risk of anxiety than those who live in stable housing conditions (Adj RR: 1.37; 95% CI: 1.01-1.89).

CONCLUSION

The lack of specific WaSH services, particularly lack of drinking water, toilets, and daily showers were associated with higher levels of anxiety among PWID in the Tijuana-San Diego border region. Women experiencing homelessness were especially vulnerable. WaSH interventions that provide safe, 24-h access may help to reduce anxiety and health risks associated with WaSH insecurity.

Male circumcision uptake and misperceived norms about male circumcision: Cross-sectional, population-based study in rural Uganda

Background

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circumcision for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention. The prevalence of male circumcision in Uganda nearly doubled from 26% in 2011 to 43% in 2016, but remains below the 2020 target level. Little is known about how common male circumcision is perceived to be, how accurate such perceptions are, and whether they are associated with men's own circumcision uptake.

Methods

We conducted a cross-sectional study of all adult residents of eight villages in Rwampara District, southwestern Uganda in 2020-2022. We elicited their perceptions of the adult male circumcision prevalence within their village: >50% (most men), 10% to <50% (some), <10%, (few to none), or do not know. We compared their perceived norms to the aggregated prevalence of circumcision reported in these villages. We used a modified multivariable Poisson regression model to estimate the association between perceived norms and personal circumcision uptake among men.

Results

We surveyed 1566 participants (91% response rate): 698 men and 868 women. Among the men, 167 (27%) reported being circumcised, including 167/444 (38%) men <50 years of age. Approximately one-fourth of the population (189 (27%) men and 177 (20%) women) believed that few to no men in their own village had been circumcised. In a multivariable regression model, men who underestimated the prevalence of male circumcision were less likely to be circumcised themselves (adjusted relative risk (aRR) = 0.51; 95% confidence interval (CI) = 0.37-0.83).

Conclusions

In this population-based study in rural Uganda, one-fourth of men underestimated the prevalence of male circumcision. Men who underestimated the extent of circumcision uptake were themselves less likely to be circumcised. If the observed association is causal and underestimates within the population contribute to low uptake, then interventions correcting these misperceived norms could increase uptake of voluntary medical male circumcision.

The effects of climate change awareness on mental health: Comparison of climate anxiety and hopelessness levels in Turkish youth

BACKGROUND

Climate anxiety, one of the negative emotions created by climate change, is particularly prevalent among climate activists and young individuals who hold a more serious concern for environmental issues.

AIM

This study aims to determine the effects of climate change awareness on the mental health of young people in Turkey.

METHODS

Designed as a descriptive and two-group comparative study, the target population of this study comprises young individuals aged 15 to 24 who are climate activists and those who are not. The study data was collected through e-questionnaires administered between March 15 and May 10, 2023, using a demographic characteristics form, a climate change anxiety scale and the Beck Hopelessness Scale. The study was completed with a total of 306 participants, including 103 young individuals who are climate activists and 203 young individuals who are not climate activists.

RESULTS

We determined that young individuals who are climate activists have a high level of climate change anxiety, while those who are not climate activists have a moderate level of climate change anxiety. We found that the levels of hopelessness in both groups are at a mild level. Additionally, within the group of climate activists, we observed that individuals with a higher level of knowledge about climate change tend to exhibit greater levels of hopelessness.

CONCLUSIONS

We identified that as awareness and knowledge about climate change increase, climate change anxiety, and hopelessness also increase. There is a need for studies to determine youth-specific mental health interventions to address mental health issues related to climate change awareness.

Making waves: Mental health impacts of inadequate drinking water services - From sidenote to research focus

The paramount significance of the harmful impacts of poor drinking water services on physical health have been recognized for decades. Besides, over the past twenty years, an additional body of literature on their negative mental health impacts has emerged. With this brief review, we summarise the findings of the scholarship to advance addressing overall health (physical, mental, and social) in the water sector. We furthermore review the key policy documents of this field with a focus on mental health aspects and give recommendations for practitioners and decision-makers on addressing mental health in water service delivery. We reviewed the existing published works (42) assessing psychological impacts of deficient drinking water services in low-income settings. We then identified and compared the different mechanisms causing negative mental health outcomes described in them. For these purposes, we used a water insecurity experience -model and the vulnerability-stress model of clinical psychology. Next, we probed key international and national guiding documents of the water sector to analyse how mental health issues resulting from poor services are addressed today. We found that according to the literature, poor quality and quantity of water was predictably one of the most important psychosocial stressors to users. Surprisingly, however, various kinds of water-service-related inequalities (e.g. between genders, communities or socio-economic groups) showed up as equally significant stressors. Our analysis with the vulnerability-stress model furthermore indicates that insufficient drinking water services may predispose to common mental disorders particularly through external stress. Existing field guidelines have evolved to highlight the values of non-discrimination and participation, whilst mental health aspects remain ignored. This should not be the case. Therefore, practices for addressing mental health effectively in documentation and water service development should be further researched. But already in the light of the existing literature, we urge stakeholders to focus more on the negative mental health impacts of unequal service provision for users and nearby people left without improved services.

Maternal adverse childhood experiences, child mental health, and the mediating effect of maternal depression: A cross-sectional, population-based study in rural, southwestern Uganda

OBJECTIVES

This study aimed to examine the intergenerational effects of maternal adverse childhood experiences (ACEs) and child mental health outcomes in rural Uganda, as well as the potentially mediating role of maternal depression in this pathway. Additionally, we sought to test the extent to which maternal social group membership attenuated the mediating effect of maternal depression on child mental health.

METHODS

Data come from a population-based cohort of families living in the Nyakabare Parish, a rural district in southwestern Uganda. Between 2016 and 2018, mothers completed surveys about childhood adversity, depressive symptoms, social group membership, and their children's mental health. Survey data were analyzed using causal mediation and moderated-mediation analysis.

RESULTS

Among 218 mother-child pairs, 61 mothers (28%) and 47 children (22%) showed symptoms meeting cutoffs for clinically significant psychological distress. In multivariable linear regression models, maternal ACEs had a statistically significant association with severity of child conduct problems, peer problems, and total child difficulty scores. Maternal depression mediated the relationship between maternal ACEs and conduct problems, peer problems, and total difficulty, but this mediating effect was not moderated by maternal group membership.

CONCLUSIONS

Maternal depression may act as a potential mechanism linking maternal childhood adversity with poor child mental health in the next generation. Within a context of elevated rates of psychiatric morbidity, high prevalence of childhood adversity, and limited healthcare and economic infrastructures across Uganda, these results emphasize the prioritization of social services and mental health resources for rural Ugandan families.

Cigarette smoking and misperceived norms among adults in rural Uganda: a population-based study

BACKGROUND

Little is known about perceived norms about cigarette smoking in Uganda or the extent to which perceptions drive personal cigarette smoking behaviour.

METHODS

We conducted a cross-sectional study in 2016-2018 that targeted all adults who resided within eight villages in Rwampara District, southwestern Uganda. Personal cigarette smoking frequency was elicited by self-report. We also asked participants what they believed to be the cigarette smoking frequency of most other adult men and women in their villages (i.e., perceived norms). Frequent cigarette smoking was defined as 4+ times/week. We compared perceived norms to cigarette smoking frequency reports aggregated at the village level. We used multivariable Poisson regression to estimate the association between perceived norms and personal cigarette smoking behaviour.

RESULTS

Among 1626 participants (91% response rate), 92 of 719 men (13%) and 6 of 907 women (0.7%) reported frequent smoking. However, 1030 (63%) incorrectly believed most men in their villages smoked cigarettes frequently. Additionally, 116 (7%) incorrectly believed that most women in their villages smoked cigarettes frequently. These misperceptions were pervasive across social strata. Men who misperceived frequent cigarette smoking as the norm among other men in their villages were more likely to smoke frequently themselves (adjusted relative risk=1.49; 95% CI, 1.13 to 1.97).

CONCLUSIONS

Most adults overestimated cigarette smoking frequency among village peers. Men who incorrectly believed that frequent smoking was the norm were more likely to engage in frequent smoking themselves. Applying a 'social norms approach' intervention by promoting existing healthy norms may prevent smoking initiation or motivate reductions in smoking among men in rural Uganda.

Water, sanitation and depression in rural communities: evidence from nationally representative study data in South Africa

Clean water and sanitation provisions are essential for good hygiene and health, with rural South Africa facing a simultaneous access crisis of both, the direct health effect of restricted access to both on mental health remaining scarce and largely overlooked. This study investigated the association between access to clean water and sanitation on depression in rural South Africa utilizing the most recent data (year 2017) from the South African National Income Dynamics Study. Our study outcome was depression, based on the 10-item abridged version of the Center for Epidemiologic Studies Depression Scale (data available in SA-NIDS), the main exposures being access to clean water and adequate sanitation facilities (i.e. flushing toilets). Two types of analyses were conducted: first, adjusted logistic regression models were fitted to assess the relationship between lack of access to clean water and adequate sanitation to depression. Second, we conducted mediation analysis to investigate whether access to clean water mediated the relationship between lack of access to toilets and depression. A high proportion of rural participants lacked access to clean water (n = 6,188, 47.6%) and adequate toilets (n = 9,797, 81.6%). The regression analyses indicated that lack of access to both clean water (OR = 1.21, 95% CI: 1.06-1.39) and adequate sanitation (OR = 1.36, 95% CI: 1.10-1.69) were significantly associated with greater odds of depression. The mediation analysis indicated that access to clean water partially mediated the relationship between lack of access to adequate sanitation and depression, the total mediated effect being 18.2% (95% CI: 11.0%-51.0%). Most rural communities in South Africa lack access to basic services that are essential for human dignity and a decent quality of life, leading to opportunities for poor mental health, with its various consequences for socio-economic development and personal wellbeing, including avoidable depression.

Intrapersonal predictors of internalized stigma among school going adolescents living with HIV in southwestern Uganda

We assessed the association between internalized HIV stigma, resilience, health locus of control, coping self-efficacy and empowerment among adolescents living with HIV in Uganda. We conducted a cross-sectional study between August and October 2020 among 173 adolescents aged 13-18 years attending Mbarara Regional Referral Hospital's HIV clinic. We used linear regression to determine the association between HIV stigma and intrapersonal factors adjusting for sociodemographic characteristics. The median age of the participants was 16 (IQR 3) years. There was a negative correlation between HIV stigma and resilience (β= -0.03, p < 0.001), internal health locus of control (β= -0.095, p < 0.001) and coping self-efficacy (β= -0.02, p < 0.001), while empowerment was positively correlated (β = 0.07, p < 0.001) with HIV stigma. After adjusting for the intrapersonal factors (resilience, health locus of control, coping self-efficacy and empowerment) and socio-demographic characteristics (education level and boarding school), only internal health locus of control (β=-0.044, p = 0.016) and coping self-efficacy (β=-0.015, p < 0.001) remained significantly correlated with HIV stigma. The findings suggest that interventions focusing on intrapersonal factors such as internal locus of control, empowerment and resilience may contribute towards reduction of HIV stigma among adolescents in boarding schools.

Evidence on the links between water insecurity, inadequate sanitation and mental health: A systematic review and meta-analysis

BACKGROUND

Water insecurity and inadequate sanitation have adverse impacts on the mental health of individuals.

OBJECTIVE

To review and synthesize evidence on the relationship between water insecurity, inadequate sanitation, and mental health globally.

DATA SOURCES

Relevant studies were identified by searching PubMed, PsycINFO, and EMBASE databases from inception up to March 2023.

STUDY ELIGIBILITY CRITERIA

Only quantitative studies were included. The exposure was water insecurity and or inadequate sanitation. The outcome was common mental disorders (CMD: depression or anxiety), mental distress, mental health or well-being. There was no restriction on geographical location.

PARTICIPANTS

General population or people attending health facilities or other services.

EXPOSURE

Water insecurity and/ or inadequate sanitation.

RISK OF BIAS

The effective Public Health Practice Project (EPHPP) assessment tool was used to assess quality of selected studies.

SYNTHESIS OF RESULTS

A meta-analysis was conducted using a random effects statistical model.

RESULTS

Twenty-five studies were included, with 23,103 participants from 16 countries in three continents: Africa (Kenya, Ethiopia, Ghana, Uganda, South Africa, Malawi, Mozambique, and Lesotho), Asia (Nepal, Bangladesh, India, and Iran) and the Americas (Brazil, Haiti, Bolivia and Vietnam). There was a statistically significant association between water insecurity and CMD symptoms. Nine studies reported a continuous outcome (5,248 participants): overall standardized mean difference (SMD = 1.38; 95% CI = 0.88, 1.87). Five studies reported a binary outcome (5,776 participants): odds ratio 5.03; 95% CI = 2.26, 11.18. There was a statistically significant association between inadequate sanitation and CMD symptoms (7415 participants), overall SMD = 5.36; 95% CI = 2.51, 8.20.

LIMITATIONS

Most of the included studies were cross-sectional which were unable to examine temporal relationships.

CONCLUSIONS

Water insecurity and inadequate sanitation contribute to poorer mental health globally.

IMPLICATIONS OF KEY FINDINGS

Interventions to provide basic water, sanitation and psychosocial support, could substantially contribute to reducing the burden of CMD alongside other health and social benefits.

TRIAL REGISTRATION

PROSPERO registration number: CRD42022322528.

Perceived norms about male circumcision and personal circumcision status: a cross-sectional, population-based study in rural Uganda

Introduction

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men.

Methods

We conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women reported as the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men.

Results

Overall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors.

Conclusions

Across eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.

"If you have light, your heart will be at peace": A qualitative study of household lighting and social integration in southwestern Uganda

Background

Expanding electrification and access to other clean and affordable energy, such as solar energy, is a critical component of the Sustainable Development Goals, particularly in sub-Saharan Africa where 70% of people are energy insecure. Intervention trials related to access or less polluting household energy alternatives have typically focused on air quality and biological outcomes rather than on how an intervention affects the end user's lived experiences, a key determinant of uptake and adoption outside of a research setting. We explored perceptions of and experiences with a household solar lighting intervention in rural Uganda.

Methods

In 2019, we completed a one-year parallel group, randomized wait-list controlled trial of indoor solar lighting systems (ClinicalTrials.gov NCT03351504) in rural Uganda where participants are largely relying on kerosene and other fuel-based lighting received household indoor solar lighting systems. In this qualitative sub-study, we conducted one-on-one, in-depth qualitative interviews with all 80 female participants enrolled in the trial. Interviews explored how solar lighting and illumination impacted participants' lives. We applied a theoretical model linking social integration and health to analyse dynamic interactions across aspects of study participants' lived experiences. Sensors were used to measure daily lighting use before and after receipt of the intervention solar lighting system.

Results

Introduction of the solar lighting system increased daily household lighting use by 6.02 (95% confidence intervals (CI) = 4.05-8.00) hours a day. The solar lighting intervention had far-reaching social implications with improved social integration and, consequently, social health. Participants felt that lighting improved their social status, mitigated the stigma of poverty, and increased the duration and frequency of social interactions. Household relationships improved with access to lighting because of reduced conflicts over light rationing. Participants also described a communal benefit of lighting due to improved feelings of safety. At the individual-level, many reported improved self-esteem, sense of well-being, and reduced stress.

Conclusion

Improved access to lighting and illumination had far reaching implications for participants, including improved social integration. More empirical research, particularly in the light and household energy field, is needed that emphasizes the impacts of interventions on social health.

Registration

ClinicalTrials.gov No. NCT03351504.

Challenges and Fears of Adolescents and Young Adults Living with HIV Facing Transition to Adult HIV Care

Adolescents and young adults living with perinatally-acquired HIV (AYLPHIV) have poor outcomes along each step of the HIV care continuum due to challenges in seeking care and advocating for themselves. The transition from paediatric to adult HIV care is a particularly high-risk period for AYLPHIV in rural Uganda. We conducted in-depth interviews with AYLPHIV (n = 30), caregivers (n = 10), and healthcare providers (n = 10) to understand challenges facing AYLPHIV during the transition from paediatric to adult HIV care. Themes were identified by thematic content analysis. Transition-related challenges and fears included difficulty navigating the adult HIV clinic; loss of informational support; long wait times at the adult HIV clinic; lack of privacy, and fear of HIV status disclosure and stigma; and loss of support from caregivers, and health care providers. Before transitioning to adult HIV care, AYLPHIV should be adequately prepared and given appropriate information to help them navigate adult HIV care.

Associations of the COVID-19 pandemic with quality of life: A cross-sectional study of older-age people with and without HIV in rural Uganda

Background

COVID-19-related lockdowns and other public health measures may have differentially affected the quality of life (QOL) of older people with and without human immunodeficiency virus (HIV) in rural Uganda.

Methods

The Quality of Life and Aging with HIV in Rural Uganda study enrolled people with and without HIV aged over 49 from October 2020 to October 2021. We collected data on COVID-19-related stressors (behavior changes, concerns, interruptions in health care, income, and food) and the participants' QOL. We used linear regression to estimate the associations between COVID-19-related stressors and QOL, adjusting for demographic characteristics, mental and physical health, and time before vs after the lockdown during the second COVID-19 wave in Uganda. Interaction between HIV and COVID-19-related stressors evaluated effect modification.

Results

We analyzed complete data from 562 participants. Mean age was 58 (standard deviation (SD) = 7); 265 (47%) participants were female, 386 (69%) were married, 279 (50%) had HIV, and 400 (71%) were farmers. Those making ≥5 COVID-19-related behavior changes compared to those making ≤2 had worse general QOL (estimated linear regression coefficient (b) = - 4.77; 95% confidence interval (CI) = -6.61, -2.94) and health-related QOL (b = -4.60; 95% CI = -8.69, -0.51). Having access to sufficient food after the start of the COVID-19 pandemic (b = 3.10, 95% CI = 1.54, 4.66) and being interviewed after the start of the second lockdown (b = 2.79, 95% CI = 1.30, 4.28) were associated with better general QOL. Having HIV was associated with better health-related QOL (b = 5.67, 95% CI = 2.91,8.42). HIV was not associated with, nor did it modify the association of COVID-19-related stressors with general QOL.

Conclusions

In the context of the COVID-19 pandemic in an HIV-endemic, low-resource setting, there was reduced QOL among older Ugandans making multiple COVID-19 related behavioral changes. Nonetheless, good QOL during the second COVID-19 wave may suggest resilience among older Ugandans.

Multiple aspects of energy poverty are associated with lower mental health-related quality of life: A modelling study in three peri-urban African communities

Objective

Over 900 million people in sub-Saharan Africa (SSA) live in energy poverty, relying on cooking polluting fuels (e.g. wood, charcoal). The association between energy poverty and mental/physical health-related quality of life (HRQoL) among women in SSA, who are primarily tasked with cooking, is unknown.

Methods

Females (n ​= ​1,150) from peri-urban Cameroon, Kenya and Ghana were surveyed on their household energy use and mental/physical health status using the standardized Short-Form 36 (SF-36) questionnaire. Random effects linear regression linked household energy factors to SF-36 mental (MCS) and physical component summary (PCS) scores. A binary outcome of 'likely depression' was derived based on participants' MCS score. Random effects Poisson regression with robust error variance assessed the relationship between household energy factors and odds of likely depression.

Results

The prevalence of likely depression varied by a factor of four among communities (36%-Mbalmayo, Cameroon; 20%-Eldoret, Kenya; 9%-Obuasi, Ghana). In the Poisson model (coefficient of determination (R²) ​= ​0.28), females sustaining 2 or more cooking-related burns during the previous year had 2.7 (95%CI:[1.8,4.1]) times the odds of likely depression as those not burned. Females cooking primarily with charcoal and wood had 1.6 times (95%CI:[0.9,2.7]) and 1.5 times (95%CI:[0.8,3.0]) the odds of likely depression, respectively, as those primarily using liquefied petroleum gas. Women without electricity access had 1.4 (95%CI:[1.1,1.9]) times the odds of likely depression as those with access. In the MCS model (R² ​= ​0.23), longer time spent cooking was associated with a lower average MCS score in a monotonically increasing manner. In the PCS model (R² ​= ​0.32), women injured during cooking fuel collection had significantly lower (-4.8 95%CI:[-8.1,-1.4]) PCS scores.

Conclusion

The burden of energy poverty in peri-urban communities in SSA extends beyond physical conditions. Experiencing cooking-related burns, using polluting fuels for cooking or lighting and spending more time cooking are potential risk factors for lower mental HRQoL among women.

Social network correlates of free and purchased insecticide-treated bed nets in rural Uganda

BACKGROUND

Malaria is a major cause of mortality and morbidity in Uganda. Despite Uganda's efforts to distribute bed nets, only half of households have achieved the World Health Organization (WHO) Universal Coverage Criteria (one bed net for every two household members). The role of peer influence on bed net ownership remains underexplored. Data on the complete social network of households were collected in a rural parish in southwestern Uganda to estimate the association between household bed net ownership and peer household bed net ownership.

METHODS

Data on household sociodemographics, bed net ownership, and social networks were collected from all households across one parish in southwestern Uganda. Bed nets were categorized as either purchased or free. Purchased and free bed net ownership ratios were calculated based on the WHO Universal Coverage Criteria. Using network name generators and complete census of parish residents, the complete social network of households in the parish was generated. Linear regression models that account for network autocorrelation were fitted to estimate the association between households' bed net ownership ratios and bed net ownership ratios of network peer households, adjusting for sociodemographics and network centrality.

RESULTS

One thousand seven hundred forty-seven respondents were interviewed, accounting for 716 households. The median number of peer households to which a household was directly connected was 7. Eighty-six percent of households owned at least one bed net, and 41% of households met the WHO Universal Coverage Criterion. The median bed net ownership ratios were 0.67 for all bed nets, 0.33 for free bed nets, and 0.20 for purchased bed nets. In adjusted multivariable models, purchased bed net ownership ratio was associated with average household wealth among peer households (b = 0.06, 95% CI 0.03, 0.10), but not associated with average purchased bed net ownership ratio of peer households. Free bed net ownership ratio was associated with the number of children under 5 (b = 0.08, 95% CI 0.05, 0.10) and average free bed net ownership ratios of peer households (b = 0.66, 95% CI 0.46, 0.85).

CONCLUSIONS

Household bed net ownership was associated with bed net ownership of peer households for free bed nets, but not for purchased bed nets. The findings suggest that public health interventions may consider leveraging social networks as tools for dissemination, particularly for bed nets that are provided free of charge.

Mental disorders and lack of social support among refugees and Ugandan nationals screening for HIV at health centers in Nakivale refugee settlement in southwestern Uganda

Background

Exposure to potentially traumatic events and daily stressors in humanitarian settings puts refugees and asylum seekers (henceforth collectively referred to as refugees) at increased risk for mental disorders. Little is known about how mental disorder prevalence compares between refugees and national populations who live in the same settings and are exposed to many of the same daily challenges. We aimed to compare the proportions of refugees and Ugandan nationals screening positive for mental disorders in a Ugandan refugee settlement to inform targeted health interventions. Given displacement’s disruptive effect on social networks and the importance of social support for mental health, we also aimed to assess social support.

Methods

Refugees and Ugandan nationals voluntarily testing for HIV at health centers in Nakivale Refugee Settlement were screened for post-traumatic stress disorder (PTSD CheckList-6 – Civilian Version [PCL-6]), depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (General Anxiety Disorder-7 [GAD-7]), and lack of social support (Brief Social Support Scale [BS6]). The association between refugee versus Ugandan national status and the four outcomes was assessed using log-binomial regression.

Results

Screening surveys were completed by 5,513 participants, including 3,622 refugees and 1,891 Ugandan nationals. A positive screen for PTSD, depression, anxiety and lack of social support was found for 2,388 (44%), 1,337 (25%), 1,241 (23%) and 631 (12%) participants, respectively. Refugee status was associated with a higher prevalence of a positive screen for PTSD (prevalence ratio (PR)=1.15; 95% confidence interval (CI)=1.08-1.23), depression (PR=1.22; 95% CI=1.11-1.36), anxiety (PR=1.28; 95% CI=1.14-1.42), and lack of social support (PR=1.50; 95% CI=1.27-1.78). When adjusted for the other outcomes, the higher prevalence of a positive screen for PTSD, anxiety and lack of social support for refugees remained statistically significant.

Conclusions

Elevated symptoms of mental disorders are found among refugees and Ugandan nationals testing for HIV in Nakivale Refugee Settlement. The significant association between refugee status and PTSD, anxiety and lack of social support symptoms highlights the distinct needs of this population. To determine the prevalence of mental disorders in these populations, comprehensive assessment, including psychological and neuropsychological testing, is needed.

COVID-19 lockdowns: Employment and business disruptions, water access and hygiene practices in Nairobi's informal settlements

Host to one billion people around the world, informal settlements are especially vulnerable to COVID-19 lockdown measures as they already lack basic services such as water, toilets, and secure housing. Additionally, many residents work in informal labor markets that have been affected by the lockdowns, resulting in further reductions in access to resources, including clean water. This study uses a cross-sectional design (n = 532) to examine the vulnerabilities of households to employment and business disruptions, water access and hygiene practices during the COVID-19 lockdowns between April and June 2020 in three informal settlements in Nairobi, Kenya. We used survey questions from the Household Water Insecurity Experience Scale (HWISE) to investigate the relationship between employment and business disruptions, water access, and hygiene practices (i.e., hand washing, body washing, clothes washing, and being able to use or drink clean water). Of the sampled households, 96% were forced to reduce work hours during the lockdowns, and these households had 92% lower odds of being able to afford water than households who did not experience a work hour reduction (OR = 0.08, p < .001). Household challenges in affording water were likely due to a combination of reduced household income, increased water prices, and pre-existing poverty, and were ultimately associated with lower hygiene scores (Beta = 1.9, p < .001). Our results highlight a compounding tragedy of reduced water access in informal settlements that were already facing water insecurities at a time when water is a fundamental requirement for following hygiene guidelines to reduce disease burden during an ongoing pandemic. These outcomes emphasize the need for targeted investments in permanent water supply infrastructures and improved hygiene behaviors as a public health priority among households in informal settlements.

The Impact of Climate Change on Mental Health and Emotional Wellbeing: A Narrative Review of Current Evidence, and its Implications

Converging global evidence highlights the dire consequences of climate change for human mental health and wellbeing. This paper summarises literature across relevant disciplines to provide a comprehensive narrative review of the multiple pathways through which climate change interacts with mental health and wellbeing. Climate change acts as a risk amplifier by disrupting the conditions known to support good mental health, including socioeconomic, cultural and environmental conditions, and living and working conditions. The disruptive influence of rising global temperatures and extreme weather events, such as experiencing a heatwave or water insecurity, compounds existing stressors experienced by individuals and communities. This has deleterious effects on people's mental health and is particularly acute for those groups already disadvantaged within and across countries. Awareness and experiences of escalating climate threats and climate inaction can generate understandable psychological distress; though strong emotional responses can also motivate climate action. We highlight opportunities to support individuals and communities to cope with and act on climate change. Consideration of the multiple and interconnected pathways of climate impacts and their influence on mental health determinants must inform evidence-based interventions. Appropriate action that centres climate justice can reduce the current and future mental health burden, while simultaneously improving the conditions that nurture wellbeing and equality. The presented evidence adds further weight to the need for decisive climate action by decision makers across all scales.

Perceptions About Local ART Adherence Norms and Personal Adherence Behavior Among Adults Living with HIV in Rural Uganda

Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.

Associations between water, sanitation, and depression among older people in Ghana: empirical evidence from WHO-SAGE Wave 2 survey

BACKGROUND

While depression is the most frequent psychiatric disorder among the older adults, the use of water and sanitation has been associated with both physical and psychological adverse outcomes. We investigated the associations of water and sanitation with depressive symptoms among older adults in Ghana.

METHODS

The study used data from 4,735 participants in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 2 of adults aged ≥50 years. Major depressive episode (MDE) was assessed using the World Mental Health Survey version of the Composite International Diagnostic Interview and we classified water and sanitation sources based on the Joint Monitoring Program. Multivariate logistic regressions evaluated the associations.

RESULTS

Approximately 7.3% of respondents reported a MDE, 90% and 78% used improved water sources and sanitation facilities respectively, and 77% shared sanitation facilities. Individuals who used unimproved water sources and unimproved sanitation were 1.6 and 1.3 times more likely to report MDE respectively. Also, sex-based analysis showed that the effect of the use of unimproved water and sanitation on depression was much appreciable and more substantial among women compared to men.

CONCLUSIONS

The findings suggest the importance of water and sanitation to the well-being of older people, particularly among women. Policies targeted at improving the mental health in old age should include water and sanitation.

Perspectives About Transition Readiness Among Adolescents and Young People Living With Perinatally Acquired HIV in Rural, Southwestern Uganda: A Qualitative Study

ABSTRACT

Despite the availability of antiretroviral therapy, treatment outcomes are worse among adolescents and young adults living with perinatally acquired HIV (AYLPHIV). These disparities are magnified during the transition from pediatric to adult-based HIV care. We conducted in-depth interviews with AYLPHIV aged 15-24 years ( n = 30), their caregivers ( n = 10), and health care providers ( n = 10). All participants provided written assent and/or informed consent to enroll. Thematic content analysis was used to identify and analyze themes relevant to transition readiness. We grouped perspectives on transition readiness into 4 themes: preparation for transition, communication between stakeholders, social support, and timing of transition. AYLPHIV in sub-Saharan Africa who are facing a transition to adult HIV care should be equipped with relevant information about their illness, self-advocacy skills, and support from caregivers and health care providers to remain engaged in HIV care.

Development and validation of the Soweto Coping Scale: A mixed-methods, population-based study of adults living in Soweto, South Africa

Mental health disorders are amongst the leading contributors to the burden of disease and need to be prioritised in policy making and program implementation. In the absence of mental healthcare, people often navigate their own social support and activate individual coping mechanisms to sustain their emotional well-being. Few South African studies conceptualise and evaluate the strategies people use to manage adverse situations in non-clinical samples. We conducted two related ethnographic studies of stress and coping in Soweto (n = 107). We then used the studies to develop a novel scale to measure local forms of coping and evaluated its use in an epidemiological surveillance study (n = 933). In a split sample analysis, we first conducted exploratory factor analyses and then a comparative fit index assessment. In the exploratory factor analysis, we obtained a two-factor solution: problem-focused/emotional coping and religious coping. In the confirmatory factor analysis, both domains had good model fit above the conservative ≥ 0.95 cut-off, and both factors had adequate internal consistency (religious coping = 0.72; problem/emotion focused coping = 0.69). Both the problem-focused/emotional and the religious coping subscales were positively correlated with quality of life, except that the religious coping subscale was not correlated with social relationships. Total adverse childhood experiences were correlated with the problem-focused/emotional coping subscale but not with the religious coping subscale. We conclude that the Soweto Coping Scale provides a novel understanding of local forms of coping and can be used by mental healthcare researchers and providers who seek to develop interventions for promoting mental health and social well-being.

Perceived and misperceived norms about khat and/or cannabis use among adults in southwest Uganda

BACKGROUND

Studies from high-income contexts have found evidence that norms about substance use are misperceived. The accuracy of perceived norms about khat and cannabis use in Uganda have not previously been described.

METHODS

We conducted a population-based study targeting all resident adults across eight villages in southwestern Uganda. Personal khat and/or cannabis use frequency was based on self-report. We measured perceived norms about substance use by eliciting individuals' perceptions about how often most other adult men and most other adult women in their villages used these substances. We compared perceived norms to aggregated village rates of use to assess the extent to which norms were misperceived. We used multivariable Poisson regression to estimate correlates of misperceived norms.

RESULTS

Among 1626 participants (91% response rate), only 29 men (4%) and 9 women (1%) reported any lifetime use of khat and/or cannabis. However, 695 participants (43%) did not think lifetime abstinence was the norm among men in their villages, and 256 participants (16%) did not think lifetime abstinence was the norm among women. Moreover, 219 participants (13%) incorrectly believed most men in their village regularly used khat and/or cannabis (≥4 times per week). Misperceived norms were present across subgroups and were correlated with larger social networks, symptoms of depression, loneliness, and younger age.

CONCLUSION

In this study of all adults across 8 villages in rural Uganda, many participants misperceived norms about khat and/or cannabis use. Providing accurate information about prevailing norms in the local population may help prevent initiation of khat and/or cannabis use among adults in this context.

Climate justice is central to addressing the climate emergency’s psychological consequences in the Global South: a narrative review

The United Nations has signalled a ‘code red’, marking climate change as an existential threat for humanity. The world is rapidly warming, and the consequences of climate change include an increase and intensification in flooding, droughts, wildfires, and other traumatic exposures. Although countries in the Global South have contributed least to global warming, they are the most vulnerable owing to historical inequities. The concept of ‘climate justice’ recognises that historical racial discrimination, class disenfranchisement, political misrecognition, and other social injustices make surviving climate change and thriving within it more challenging. This narrative review considers the psychological consequences of the climate emergency through a climate justice lens. The article discusses the unequal exposures to psychological adversities, socio-historical barriers to adaptations and, finally, institutional betrayal that complicates the experience of psychological distress. The review concludes by pragmatically discussing how psychology could support climate justice ends.

Effect of a solar lighting intervention on fuel-based lighting use and exposure to household air pollution in rural Uganda: A randomized controlled trial

Solar lighting is an alternative to polluting kerosene and other fuel-based lighting devices relied upon by millions of families in resource-limited settings. Whether solar lighting provides sustained displacement of fuel-based lighting sources and reductions in personal exposure to fine particulate matter (PM₂ .₅ ) and black carbon (BC) has not been examined in randomized controlled trials. Eighty adult women living in rural Uganda who utilized fuel-based (candles and kerosene lamps) and/or clean (solar, grid, and battery-powered devices) lighting were randomized in a 1:1 ratio to receive a home solar lighting system at no cost to study participants (ClinicalTrials.gov NCT03351504). Among intervention group participants, kerosene lamps were completely displaced in 92% of households using them. The intervention led to an average exposure reduction of 36.1 μg/m³ (95% CI -70.3 to -2.0) in PM₂ .₅ and 10.8 μg/m³ (95% CI -17.6 to -4.1) in BC, corresponding to a reduction from baseline of 37% and 91%, respectively. Reductions were greatest among participants using kerosene lamps. Displacement of kerosene lamps and personal exposure reductions were sustained over 12 months of follow-up. Solar lighting presents an immediate opportunity for achieving sustained reductions in personal exposure to PM_2.5 and BC and should be considered in household air pollution intervention packages.

Ease of marital communication and depressive symptom severity among men and women in rural Uganda: cross-sectional, whole-population study

PURPOSE

Depression is a major contributor to the global burden of disease. The extent to which marital communication may influence depression in contexts with little mental health support is unknown.

METHODS

We conducted a whole-population study of married adult residents of eight villages in a rural region of southwestern Uganda. Depression symptom severity was measured using a modified version of the Hopkins Symptom Checklist for Depression, with > 1.75 classified as a positive screen for probable depression. Respondents were asked to report about ease of marital communication ('never easy', 'easy once in a while', 'easy most of the time' or 'always easy'). Sex-stratified, multivariable Poisson regression models were fit to estimate the association between depression symptom severity and marital communication.

RESULTS

Among 492 female and 447 male participants (response rate = 96%), 23 women and 5 men reported communication as 'never easy' and 154 women and 72 men reported it as 'easy once in a while'. Reporting communication as 'never easy' was associated with an increased risk of probable depression among women (adjusted relative risk [ARR], 2.06; 95% confidence interval [CI], 1.08-3.93, p = 0.028) and among men (ARR, 7.10; 95% CI 1.70-29.56, p = 0.007).

CONCLUSION

In this whole-population study of married adults in rural Uganda, difficulty of marital communication was associated with depression symptom severity. Additional research is needed to assess whether communication training facilitated by local leaders or incorporated into couples-based services might be a novel pathway to address mental health burden.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

Overestimation of alcohol consumption norms as a driver of alcohol consumption: a whole-population network study of men across eight villages in rural, southwestern Uganda

BACKGROUND AND AIMS

Little is known about how perceived norms about alcohol consumption may influence high alcohol consumption rates in Uganda. This study estimated the accuracy of perceived norms about men's alcohol consumption and estimated the association between perceived norms and personal alcohol consumption.

DESIGN

Cross-sectional, whole-population, sociocentric social network study.

SETTING

Eight rural villages in Rwampara District, southwestern Uganda in 2016-18.

PARTICIPANTS

A total of 719 men aged 18 years and older (representing 91% of permanent resident men).

MEASUREMENTS

Self-reported frequent (≥ 4 days per week) and heavy alcohol consumption (six or more drinks on one occasion, more than three occasions of intoxication, or spending an excessive amount on alcohol). Participants also reported whether they thought most other men in their village engaged in frequent and heavy alcohol consumption (perceived norms). Using the network study design, we calculated alcohol consumption behavior within villages and social networks. Perceived norms were compared with aggregated self-reports. Multivariable Poisson regression models were used to estimate the association between perceived norms and individual behavior.

FINDINGS

Throughout villages, frequent and heavy alcohol consumption ranged from 7 to 37%. However, 527 (74%) participants perceived, contrary to fact, that most other men in their villages frequently consumed alcohol, and 576 (81%) perceived that most others heavily consumed alcohol. Overestimation of alcohol consumption by others was pervasive among socio-demographic subgroups and was present irrespective of the actual consumption behavior at the village level and within social networks. Men who misperceived these alcohol consumption behaviors as being common were more likely to engage in frequent [adjusted relative risk (aRR) = 3.98; 95% confidence interval (CI) = 1.69-9.34) and heavy (aRR = 4.75; 95% CI = 2.33-9.69) alcohol consumption themselves.

CONCLUSIONS

Most men in eight rural Ugandan villages incorrectly thought that frequent and heavy alcohol consumption were common among men in their villages. These misperceived norms had a strong positive association with individual drinking behavior.

"Thinking Too Much": A Systematic Review of the Idiom of Distress in Sub-Saharan Africa

Idioms of distress have been employed in psychological anthropology and global mental health to solicit localized understandings of suffering. The idiom "thinking too much" is employed in cultural settings worldwide to express feelings of emotional and cognitive disquiet with psychological, physical, and social consequences on people's well-being and daily functioning. This systematic review investigates how, where, and among whom the idiom "thinking too much" within varied Sub-Saharan African contexts was investigated. We reviewed eight databases and identified 60 articles, chapters, and books discussing "thinking too much" across Sub-Saharan Africa. Across 18 Sub-Saharan African countries, literature on "thinking too much" focused on particular sub-populations, including clinical populations, including people living with HIV or non-communicable diseases, and women experiencing perinatal or postnatal depression; health workers and caregivers; and non-clinical populations, including refugees and conflict-affected communities, as well as community samples with and without depression. "Thinking too much" reflected a broad range of personal, familial, and professional concerns that lead someone to be consumed with "too many thoughts." This research demonstrates that "thinking too much" is a useful idiom for understanding rumination and psychiatric distress while providing unique insights within cultural contexts that should not be overlooked when applied in clinical settings.

The embodiment of water insecurity: Injuries and chronic stress in lowland Bolivia

Water is critical to health and wellbeing. Studies have theorized that problems with water can become embodied, yet few studies have quantified this. Therefore, we first sought to understand the lowland Bolivian water environment of Tsimane' forager-horticulturalists. We assessed the water environment holistically, using objective measures of water quality and water services (Joint Monitoring Programme's drinking water services ladder) and subjective measures, including perceived water safety and water insecurity experiences [Household Water Insecurity Experiences Scale (HWISE)]. We tested how water service levels, perceived water safety, and water fetching frequency were associated with HWISE scores using Tobit regression models among 270 households. We then tested if and how water becomes embodied via self-reported water-related injury and a chronic stress biomarker, hair cortisol concentration (HCC). Results demonstrated that, compared with households using surface water, households with basic water services had HWISE scores 1.59-pts lower (SE = 0.29; P < 0.001). Ingestion of water perceived to be "bad" and more daily water-fetching trips were associated with higher HWISE scores. Twenty percent of households reported prior water-related injuries, with women most commonly injured. In logistic regressions, each point higher HWISE score was associated with 28% (95%CI:1.16-1.41; P < 0.001) higher odds of injury. Basic water services compared to surface water was associated with 48% lower odds (OR = 0.52; 95%CI:0.33-0.82; P = 0.005) of injury. Finally, using linear regressions among 332 adults, HWISE scores were not associated with HCC. Past water-related injury was associated with higher HCC (Beta = 0.31; SE = 0.09; P = 0.029) among women, but not men. Relying on unimproved water services compared to surface was associated with 46.2% higher HCC for women (Beta=0.38; SE=0.14; P=0.048) and 55.3% higher HCC for men (Beta=0.44; SE=0.15; P=0.044), respectively. Overall, our findings demonstrate that water insecurity can become embodied through water-related injuries and elevated HCC. Improving water service levels through an equity lens may help ameliorate water insecurity and its accompanying negative health effects.

Understanding Rural Women's Domestic Work Experiences (DWE) in Ibadan, Nigeria: Development of a Measurement Tool Using Confirmatory Factor Analysis

Gender norms prescribe domestic labor as primarily a female's responsibility in developing countries. Many domestic tasks depend on access to water, so the physical, emotional, and time demands of domestic labor may be exacerbated for women living in water-insecure environments. We developed a set of domestic work experience (DWE) measures tailored to work in rural areas in developing countries, assessed rural Nigerian women's DWE, and examined relationships among the measures. Interviewer-administered survey data were collected between August and September from 256 women in four rural Nigerian communities. Latent factors of DWE were identified by analyzing survey items using confirmatory factor analysis. Pearson's correlation was used to examine relationships among latent factor scores, and multivariate linear regression models were used to determine if factor scores significantly differed across socio-demographic characteristics. The DWE measures consisted of latent factors of the physical domain (frequency of common domestic tasks, water sourcing and carriage, experience of water scarcity), the psychosocial domain (stress appraisal and demand-control), and the social domain (social support). Significant correlations were observed among the latent factors within and across domains. Results revealed the importance of measuring rural Nigerian women's DWE using multiple and contextual approaches rather than relying solely on one exposure measure. Multiple inter-related factors contributed to women's DWE. Water insecurity exacerbated the physical and emotional demands of domestic labor DWE varied across age categories and pregnancy status among rural Nigerian women.

Diverse Health, Gender and Economic Impacts from Domestic Transport of Water and Solid Fuel: A Systematic Review

(1) Background: Water and solid fuel collection and transport are domestic duties for millions of households across the globe. People in areas with limited or no access to safely managed sources of water and household energy must fetch these resources on a frequent basis. The health, gender, and economic impacts associated with water and solid fuel collection labor have not been systematically reviewed. (2) Methods: Studies were identified through database searches and included using a list of inclusion and exclusion criteria. Studies were summarized and grouped into one of eight thematic categories. (4) Conclusions: The findings suggest that a diverse and heavy health burden is associated with water and solid fuel collection and transport. The literature also suggests that the provision of safely managed and accessible water and improved fuel options can mitigate these negative outcomes. Filling research gaps and utilizing results to guide policy and funding would likely be an effective way to ensure low- and middle-income countries are not left behind as the world strives to meet the sustainable development goals.

Normative vs personal attitudes toward persons with HIV, and the mediating role of perceived HIV stigma in rural Uganda

Background

HIV stigma has well-documented negative impacts on HIV testing, transmission risk behavior, initiation of and adherence to antiretroviral therapy, and retention in care. We sought to assess the extent to which anticipated HIV stigma is based on misperceptions of normative attitudes toward persons with HIV, and to determine whether persons with HIV have stronger misperceptions compared with HIV-negative persons or persons of unknown serostatus. We also sought to estimate the association between normative attitudes about persons with HIV and personal attitudes about persons with HIV, and to determine the extent to which anticipated stigma mediates this association.

Methods

We conducted a whole-population survey of 1776 persons living in 8 rural villages in southwestern Uganda. Negative attitudes toward persons with HIV, and anticipated stigma, were measured using a newly validated 15-item scale measuring multiple dimensions of HIV stigma, including social distance, blaming attitudes, and concerns about reciprocity. We used multivariable regression to estimate the association between normative attitudes about persons with HIV and personal attitudes toward persons with HIV, and to determine the extent to which perceptions of normative attitudes (anticipated stigma) mediated this association.

Results

Study participants believed that negative attitudes toward persons with HIV were more pervasive than they actually are. Perceptions of the extent to which these negative attitudes are normative mediated more than one-third of the association between normative attitudes and their personal attitudes. In contrast to what we originally hypothesized, persons with HIV were less likely to misperceive these norms and perceived normative attitudes to be less stigmatizing than did others in the general population.

Conclusions

Interventions designed to accurately describe normative attitudes toward persons with HIV may reduce HIV stigma without directly focusing on the educational components that are typically embedded in anti-stigma interventions.

Towards an integrated theoretical framework for understanding water insecurity and gender-based violence in Low-and middle-income countries (LMICs)

Disparities in access to basic needs and resources such as water is largely borne out of power imbalance across scale. In examining these power dynamics in the context of health inequalities, scholars have deployed Feminist political ecology analytical framework to situate gender and other forms of vulnerability as emerging from unequal power relations, and political ecology of health to emphasise the health implications of inherent relational power in the distribution of resources. Although appealing, the two theoretical frameworks over time have proven to be limiting in the study of intersectional vulnerabilities such as gender-based violence and water insecurity which reflect multiple dimensions of unequal power structures. This study expands the theoretical space for the study of inequalities in health geography by demonstrating the utility of incorporating feminist political ecology with political ecology of health to form an integrated theoretical framework - Feminist Political Ecology of Health (FPEH). This proposed theoretical framework gives guidance for engaging with a suite of questions and methods related to multifaceted problems such as water insecurity and gender based-violence. The paper highlights these theoretical issues and then discusses how FPEH can enrich research on water security and gender-based violence in Low-and middle-income countries (LMICs).

Perspective: The Importance of Water Security for Ensuring Food Security, Good Nutrition, and Well-being

Water security is a powerful concept that is still in its early days in the field of nutrition. Given the prevalence and severity of water issues and the many interconnections between water and nutrition, we argue that water security deserves attention commensurate with its importance to human nutrition and health. To this end, we first give a brief introduction to water insecurity and discuss its conceptualization in terms of availability, access, use, and stability. We then lay out the empirical grounding for its assessment. Parallels to the food-security literature are drawn throughout, both because the concepts are analogous and food security is familiar to the nutrition community. Specifically, we review the evolution of scales to measure water and food security and compare select characteristics. We then review the burgeoning evidence for the causes and consequences of water insecurity and conclude with 4 recommendations: 1) collect more water-insecurity data (i.e., on prevalence, causes, consequences, and intervention impacts); 2) collect better data on water insecurity (i.e., measure it concurrently with food security and other nutritional indicators, measure intrahousehold variation, and establish baseline indicators of both water and nutrition before interventions are implemented); 3) consider food and water issues jointly in policy and practice (e.g., establish linkages and possibilities for joint interventions, recognize the environmental footprint of nutritional guidelines, strengthen the nutrition sensitivity of water-management practices, and use experience-based scales for improving governance and regulation across food and water systems); and 4) make findings easily available so that they can be used by the media, community organizations, and other scientists for advocacy and in governance (e.g., tracking progress towards development goals and holding implementers accountable). As recognition of the importance of water security grows, we hope that so too will the prioritization of water in nutrition research, funding, and policy.

Adverse childhood experiences and adult cardiometabolic risk factors and disease outcomes: Cross-sectional, population-based study of adults in rural Uganda

Background

Cardiovascular diseases (CVD) pose a major threat to public health in sub-Saharan African communities, where the burden of these classes of illnesses is expected to double by 2030. Growing research suggests that past developmental experiences and early life conditions may also elevate CVD risk throughout the life course. Greater childhood stress and adversity are consistently associated with a range of adult CVDs and associated risk factors, yet little research exists on the long-term effects of early life stress on adult physical health outcomes, especially CVD risk, in sub-Saharan African contexts. This study aims to evaluate the associations between adverse childhood experiences and adult cardiometabolic risk factors and health outcomes in a population-based study of adults living in Mbarara, a rural region of southwestern Uganda.

Methods

Data come from an ongoing, whole-population social network cohort study of adults living in the eight villages of Nyakabare Parish, Mbarara. A modified version of the Adverse Childhood Experiences-International Questionnaire (ACEs) assessed past exposure to physical, emotional, and sexual adversity. Participants also took part in a health fair where medical histories on cardiometabolic risk factors and cardiovascular diseases were gathered. Multiple logistic regression models estimated the associations between ACEs and cardiometabolic risk factors and health outcomes.

Results

Data were available on 545 adults. The average number of ACEs was 4.9 out of a possible 16. The cumulative number of ACEs were associated with having a history of heart attack and/or heart failure (adjusted odds ratio (AOR) = 1.11, 95% confidence interval (CI) = 0.999-1.234, P = 0.051), but the estimated association was not statistically significant. ACEs did not have statistically significant associations with any others measures of adult cardiometabolic risk and CVD.

Conclusions

Adverse childhood experiences are not associated with a range of adult cardiometabolic risk factors and health outcomes in this sample of rural Ugandan adults. Further research in this sample is necessary to identify the pathways that may motivate these null relationship and possibly protect against adverse cardiometabolic and cardiovascular health outcomes.

Re-examining the effects of drought on intimate-partner violence

Droughts are associated with several societal ills, especially in developing economies that rely on rainfed agriculture. Recently, researchers have begun to examine the effect of droughts on the risk of Intimate-Partner Violence (IPV), but so far this work has led to inconclusive results. For example, two large recent studies analyzed comparable data from multiple sub-Saharan African countries and drew opposite conclusions. We attempt to resolve this apparent paradox by replicating previous analyses with the largest data set yet assembled to study drought and IPV. Integrating the methods of previous studies and taking particular care to control for spatial autocorrelation, we find little association between drought and most forms of IPV, although we do find evidence of associations between drought and women's partners exhibiting controlling behaviors. Moreover, we do not find significant heterogeneous effects based on wealth, employment, household drinking water sources, or urban-rural locality.

Correlates of attendance at community engagement meetings held in advance of bio-behavioral research studies: A longitudinal, sociocentric social network study in rural Uganda

BACKGROUND

Community engagement is central to the conduct of health-related research studies as a way to determine priorities, inform study design and implementation, increase recruitment and retention, build relationships, and ensure that research meets the goals of the community. Community sensitization meetings, a form of community engagement, are often held prior to the initiation of research studies to provide information about upcoming study activities and resolve concerns in consultation with potential participants. This study estimated demographic, health, economic, and social network correlates of attendance at community sensitization meetings held in advance of a whole-population, combined behavioral, and biomedical research study in rural Uganda.

METHODS AND FINDINGS

Research assistants collected survey data from 1,630 adults participating in an ongoing sociocentric social network cohort study conducted in a rural region of southwestern Uganda. These community survey data, collected between 2016 and 2018, were linked to attendance logs from community sensitization meetings held in 2018 and 2019 before the subsequent community survey and community health fair. Of all participants, 264 (16%) attended a community sensitization meeting before the community survey, 464 (28%) attended a meeting before the community health fair, 558 (34%) attended a meeting before either study activity (survey or health fair), and 170 (10%) attended a meeting before both study activities (survey and health fair). Using multivariable Poisson regression models, we estimated correlates of attendance at community sensitization meetings. Attendance was more likely among study participants who were women (adjusted relative risk [ARR]health fair = 1.71, 95% confidence interval [CI], 1.32 to 2.21, p < 0.001), older age (ARRsurvey = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001; ARRhealth fair = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001), married (ARRsurvey = 1.74, 95% CI, 1.29 to 2.35, p < 0.001; ARRhealth fair = 1.41, 95% CI, 1.13 to 1.76, p = 0.002), and members of more community groups (ARRsurvey = 1.26 per group, 95% CI, 1.10 to 1.44, p = 0.001; ARRhealth fair = 1.26 per group, 95% CI, 1.12 to 1.43, p < 0.001). Attendance was less likely among study participants who lived farther from meeting locations (ARRsurvey = 0.54 per kilometer, 95% CI, 0.30 to 0.97, p = 0.041; ARRhealth fair = 0.57 per kilometer, 95% CI, 0.38 to 0.86, p = 0.007). Leveraging the cohort's sociocentric design, social network analyses suggested that information conveyed during community sensitization meetings could reach a broader group of potential study participants through attendees' social network and household connections. Study limitations include lack of detailed data on reasons for attendance/nonattendance at community sensitization meetings; achieving a representative sample of community members was not an explicit aim of the study; and generalizability may not extend beyond this study setting.

CONCLUSIONS

In this longitudinal, sociocentric social network study conducted in rural Uganda, we observed that older age, female sex, being married, membership in more community groups, and geographical proximity to meeting locations were correlated with attendance at community sensitization meetings held in advance of bio-behavioral research activities. Information conveyed during meetings could have reached a broader portion of the population through attendees' social network and household connections. To ensure broader input and potentially increase participation in health-related research studies, the dissemination of research-related information through community sensitization meetings may need to target members of underrepresented groups.

Water fetching burden: a qualitative study to examine how it differs by gender among rural households in the west region of Cameroon

Women act as gatekeepers in securing water for their households. Using this qualitative methodology, 35 participants were interviewed with the objectives to determine roles and responsibilities of different family members in fetching and managing water and examine differences in perceptions related to water access/use between men and women in households from rural areas of the Menoua Division, West Cameroon. We found that the household structure was key component in each family member's degree of involvement in water fetching and management. A significant gender gap was found among adults with fewer men than women experiencing coping strategies-related to water scarcity. Hence, women participation in designing water and food security initiatives is warranted.

A Social-Ecological Framework to Understand Barriers to HIV Clinic Attendance in Nakivale Refugee Settlement in Uganda: a Qualitative Study

The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting.

Nexus between Water Security Framework and Public Health: A Comprehensive Scientific Review

Water scarcity, together with the projected impacts of water stress worldwide, has led to a rapid increase in research on measuring water security. However, water security has been conceptualized under different perspectives, including various aspects and dimensions. Since public health is also an integral part of water security, it is necessary to understand how health has been incorporated as a dimension in the existing water security frameworks. While supply–demand and governance narratives dominated several popular water security frameworks, studies that are specifically designed for public health purposes are generally lacking. This research aims to address this gap, firstly by assessing the multiple thematic dimensions of water security frameworks in scientific disclosure; and secondly by looking into the public health dimensions and evaluating their importance and integration in the existing water security frameworks. For this, a systematic review of the Scopus database was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A detailed review analysis of 77 relevant papers was performed. The result shows that 11 distinct dimensions have been used to design the existing water security framework. Although public health aspects were mentioned in 51% of the papers, direct health impacts were considered only by 18%, and indirect health impacts or mediators were considered by 33% of the papers. Among direct health impacts, diarrhea is the most prevalent one considered for developing a water security framework. Among different indirect or mediating factors, poor accessibility and availability of water resources in terms of time and distance is a big determinant for causing mental illnesses, such as stress or anxiety, which are being considered when framing water security framework, particularly in developing nations. Water quantity is more of a common issue for both developed and developing countries, water quality and mismanagement of water supply-related infrastructure is the main concern for developing nations, which proved to be the biggest hurdle for achieving water security. It is also necessary to consider how people treat and consume the water available to them. The result of this study sheds light on existing gaps for different water security frameworks and provides policy-relevant guidelines for its betterment. Also, it stressed that a more wide and holistic approach must be considered when framing a water security framework to result in sustainable water management and human well-being.