Self care interventions could advance sexual and reproductive health in humanitarian settings

Climate change and extreme weather events and linkages with HIV outcomes: recent advances and ways forward

PURPOSE OF REVIEW

Discuss the recent evidence on climate change and related extreme weather events (EWE) and linkages with HIV prevention and care outcomes.

RECENT FINDINGS

We identified 22 studies exploring HIV prevention and care in the context of EWE. HIV prevention studies examined sexual practices that increase HIV exposure (e.g., condomless sex, transactional sex), HIV testing, and HIV recent infections and prevalence. HIV care-related outcomes among people with HIV included clinical outcomes (e.g., viral load), antiretroviral therapy adherence and access, HIV care engagement and retention, and mental and physical wellbeing. Pathways from EWE to HIV prevention and care included: structural impacts (e.g., health infrastructure damage); resource insecurities (e.g., food insecurity-related ART adherence barriers); migration and displacement (e.g., reduced access to HIV services); and intrapersonal and interpersonal impacts (e.g., mental health challenges, reduced social support).

SUMMARY

Studies recommended multilevel strategies for HIV care in the context of EWE, including at the structural-level (e.g. food security programs), health institution-level (e.g., long-lasting ART), community-level (e.g. collective water management), and individual-level (e.g., coping skills). Climate-informed HIV prevention research is needed. Integration of EWE emergency and disaster preparedness and HIV services offers new opportunities for optimizing HIV prevention and care.

Contextualizing HIV testing experiences within the HIV prevention cascade: qualitative insights from refugee youth in Bidi Bidi refugee settlement, Uganda

BACKGROUND

There remain key knowledge gaps regarding HIV testing needs and priorities among refugee youth in low and middle-income country (LMIC) humanitarian settings. The HIV prevention cascade framework focuses on three domains (motivation, access, effective use) central to prevention uptake, yet is understudied in relationship to HIV testing, particularly among refugee youth. Uganda is an exemplar context to explore refugee youth HIV testing needs and priorities as it hosts 1.5 million refugees and is Africa's largest refugee hosting nation. In this study, we explored perceptions and experiences regarding HIV testing among refugee youth living in Bidi Bidi refugee settlement, Uganda.

METHODS

We conducted a community-based research study in Bidi Bidi Refugee Settlement, one of the world's largest refugee settlements with over 195,000 residents. This qualitative study involved four focus groups (2 with young women, 2 with young men) with refugee youth aged 16-24 living in Bidi Bidi refugee settlement. We applied thematic analysis informed by the HIV prevention cascade to understand domains of motivation, access, and effective use that emerged as salient for HIV testing engagement.

RESULTS

Participants (n = 40; mean age: 20 years, standard deviation: 2.2) included refugee young women (n = 20) and young men (n = 20), of whom 88% had a lifetime HIV test and 58% had ever heard of HIV self-testing. Participant discussions described HIV testing motivation was influenced by dimensions of: HIV treatment and testing knowledge; risk perception; positive and negative consequences of use; and social norms regarding gender and age. Access to HIV testing was shaped by: limited availability; distance and language barriers; confidentiality concerns; and affordability. Effective use of and engagement with HIV testing was related to HIV serostatus knowledge self-efficacy and in/equitable partner dynamics.

CONCLUSIONS

Complex, multi-level factors shape motivation for, access to, and effective use of HIV testing among refugee youth in Bidi Bidi. Findings align with the HIV prevention cascade framework that helps to identify gaps to inform intervention development with youth in humanitarian settings. HIV testing approaches tailored for refugee youth in contexts such as Bidi Bidi can foster HIV prevention and treatment literacy, gender equity, gender-based violence prevention, and intersectional stigma reduction.

Self-care for maternal and reproductive health in conflict settings: qualitative case study in Nuba Mountains, Sudan

Introduction

Self-care is a critical component of Reproductive, Maternal, and Neonatal Health (RMNH), offering women the knowledge, skills, and autonomy needed for well-being throughout the reproductive cycle. This paper explores the significance of self-care in conflict-affected regions, where access to formal healthcare is limited. Such areas place pregnant women at higher risk due to increased incidents of adverse events during pregnancy and childbirth. Self-care interventions have the potential to enhance access to quality healthcare services.

Methods

Employing a qualitative approach, this study explores RMNH self-care practices among pregnant and post-natal women in the Nuba Mountains. The methods included in-depth semi-structured interviews with 24 participants, comprising pregnant women, recent mothers, and healthcare providers. Purposive sampling was used to capture the experiences of mothers, and thematic analysis identified key patterns and themes in self-care practices. The perspectives of healthcare professionals were included to understand the context of RMNH care in conflict settings.

Results

The study revealed the crucial role of community cohesion in providing emotional and practical support in pregnancy, childbirth, and in the post-natal period. Limited healthcare infrastructure and ongoing conflict-related challenges provided important drivers for self-care practices. A spectrum of self-care interventions ranged from personal hygiene practices to community-supported childbirth and postnatal care. Significant reliance on elder women's wisdom and traditional midwifery was observed, particularly in the absence of formal healthcare facilities. Some women moved to live with family close to the hospital in the weeks before their due dates in order to mitigate the risks of early deliveries, complications, or general insecurity in their home areas.

Discussion

The findings present a compelling narrative of communal self-care, challenging the conventional notion of self-care as solely individualistic. In this setting, the community's role is fundamental, with knowledge sharing and mutual support forming the bedrock of maternal health practices. Elder women, embodying repositories of perceived traditional wisdom, emerge as central figures, guiding pregnant and postpartum women through shared experiences and practices. This collective approach is not merely a cultural characteristic but a necessity born out of the region's limited healthcare infrastructure and ongoing conflict. The study underscores the need to recognize and integrate these communal self-care strategies into broader health interventions.

Exploring the uptake of sexual and reproductive health services for lesbians and bisexual women in Bulawayo, Zimbabwe. A quantitative enquiry

Background

Sexual and reproductive healthcare is essential for all individuals, including LGBTQ+ individuals. However, lesbians and bisexual women often lack tailored services, leading to underutilization. This study aimed to assess the availability and uptake of sexual and reproductive health services for lesbian and bisexual Bulawayo women.

Methods

A cross-sectional study surveyed 67 lesbian and bisexual women recruited through the Voice of the Voiceless Organization. The participants completed a structured questionnaire on available services, factors influencing their uptake, and access challenges. Cross-tabulation was used to examine the associations between variables. Data were analyzed using Microsoft Excel and STATA Version 15 S.E.

Results

Most respondents were bisexual women aged 35 years. Cross-tabulations revealed significant associations between delayed or avoided services and the absence of specific services for lesbians and bisexual women as well as the presence of gender identity nondiscrimination policies.

Conclusion

Sexual and reproductive health programs play a vital role in meeting lesbian and bisexual women's needs. Improving service uptake requires strengthening the linkages between clinics and sexual health education programs, providing lesbian and bisexual women-friendly clinical services, and ensuring access to comprehensive information.

Sexual and reproductive health among forcibly displaced persons in urban environments in low and middle-income countries: scoping review findings

BACKGROUND

Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC.

METHODS

Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs.

FINDINGS

The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles (n = 38) discussed sexual health domains including: GBV (n = 23); HIV/STI (n = 19); and CSE (n = 12). Over one-third (n = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care (n = 13); contraception (n = 13); fertility (n = 1); and safe abortion (n = 1). Eight included both reproductive and sexual health. Most grey literature (n = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels.

CONCLUSIONS

This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC. Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs.

Self-care interventions for women's health and well-being

The human right to health is universal and non-exclusionary, supporting health in full, and for all. Despite advances in health systems globally, 3.6 billion people lack access to essential health services. Women and girls are disadvantaged when it comes to benefiting from quality health services, owing to social norms, unequal power in relationships, lack of consideration beyond their reproductive roles and poverty. Self-care interventions, including medicines and diagnostics, which offer an additional option to facility-based care, can improve the autonomy and agency of women in managing their own health. However, tackling challenges such as stigma is essential to avoid scenarios in which self-care interventions provide more choice for those who already benefit from access to quality healthcare, and leave behind those with the greatest need. This Perspective explores the opportunities that self-care interventions offer to advance the health and well-being of women with an approach grounded in human rights, gender equality and equity.

Associations between climate change-related factors and sexual health: A scoping review

There is growing attention to the ways in which climate change may affect sexual health, yet key knowledge gaps remain across global contexts and climate issues. In response, we conducted a scoping review to examine the literature on associations between climate change and sexual health. We searched five databases (May 2021, September 2022). We reviewed 3,183 non-duplicate records for inclusion; n = 83 articles met inclusion criteria. Of these articles, n = 30 focused on HIV and other STIs, n = 52 focused on sexual and gender-based violence (GBV), and n = 1 focused on comprehensive sexuality education. Thematic analysis revealed that hurricanes, drought, temperature variation, flooding, and storms may influence HIV outcomes among people with HIV by constraining access to antiretroviral treatment and worsening mental health. Climate change was associated with HIV/STI testing barriers and worsened economic conditions that elevated HIV exposure (e.g. transactional sex). Findings varied regarding associations between GBV with storms and drought, yet most studies examining flooding, extreme temperatures, and bushfires reported positive associations with GBV. Future climate change research can examine understudied sexual health domains and a range of climate-related issues (e.g. heat waves, deforestation) for their relevance to sexual health. Climate-resilient sexual health approaches can integrate extreme weather events into programming.

Changing climates, compounding challenges: a participatory study on how disasters affect the sexual and reproductive health and rights of young people in Fiji

Pacific youth are at the forefront of the climate crisis, which has important implications for their health and rights. Youth in Fiji currently bear a disproportionate burden of poor experiences and outcomes related to their sexual and reproductive health and rights (SRHR). There is limited information about how the increasing climate impacts may affect their SRHR, and what the implications may be for climate action and disaster risk reduction. We aimed to explore the experiences of 21 Fijian youth in fulfilling their SRHR when living through multiple natural hazards. We conducted 2 workshops and 18 individual semistructured interviews using visual and storytelling methods. Irrespective of the type of hazard or context of disasters, participants identified limited agency as the main challenge that increased SRHR risks. Through reflexive thematic analysis, we identified four themes centred around 'youth SRHR agency'; (1) information and knowledge, (2) community and belonging, (3) needs and resources, and (4) collective risks. These themes encompassed multiple factors that limited youth agency and increased their SRHR risks. Participants highlighted how existing challenges to their SRHR, such as access to SRHR information being controlled by community gatekeepers, and discrimination of sexual and gender diverse youth, were exacerbated in disasters. In disaster contexts, immediate priorities such as water, food and financial insecurity increased risks of transactional early marriage and transactional sex to access these resources. Daily SRHR risks related to normalisation of sexual and gender-based violence and taboos limited youth agency and influenced their perceptions of disasters and SRHR risks. Findings offer important insights into factors that limited youth SRHR agency before, during and after disasters. We underscore the urgency for addressing existing social and health inequities in climate and disaster governance. We highlight four key implications for reducing youth SRHR risks through whole-of-society approaches at multiple (sociocultural, institutional, governance) levels.

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

INTRODUCTION

Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda.

METHODS

We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16-24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions.

RESULTS

We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up).

CONCLUSIONS

Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.

Considerations for Program Managers to Improve Sexual and Reproductive Health Services for Displaced Populations

Delivering sexual and reproductive health services to migrating and displaced populations is complex. The authors provide 4 recommendations drawing on their experience across Africa and Asia.

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

BACKGROUND

Graphic medicine formats, such as comic books in which health information is presented alongside images, may be a useful learning tool to improve post-rape care and youth-friendly service provision among health care providers in humanitarian contexts. We describe the development and pilot-testing of a workshop using a comic book to improve youth-friendly post-rape care with providers in Bidi Bidi refugee settlement, Uganda.

PROGRAM DEVELOPMENT AND PILOTING

We conducted 6 focus groups with refugee young men (n=3) and women (n=3) aged 16-24 years and 28 in-depth individual interviews (refugee youth: n=12; health care providers: n=8; elders: n=8). Findings informed the development of a workshop that included a participatory comic book on sexual and gender-based violence (SGBV) and youth, SGBV stigma, youth-friendly health care, and post-exposure prophylaxis. Comic book illustrations specifically addressed health care confidentiality and examples of being a supportive health care provider. Then, we conducted a 1-day workshop with health care providers (n=20) that included structured activities addressing SGBV impacts and related stigma and included comic book discussions. Open-ended survey data were collected 8 weeks after the workshop to explore health care providers' experiences with the workshop, perceived impact of the intervention on their work, and support required to implement youth-friendly services for SGBV survivors. Qualitative data were analyzed using thematic approaches. Open-ended response data indicated that: comic book methods were informative and interactive; health care providers felt more empowered to offer youth-friendly services and spaces; and health care providers want additional SGBV training and institutional support for youth-friendly spaces and community engagement.

IMPLICATIONS

A comic book intervention has the potential to meaningfully engage health care providers in humanitarian contexts to provide youth-friendly health care, acquire skills for engaging in SGBV prevention, create youth-friendly clinic spaces, and identify health care and community SGBV prevention needs.

Utilization of sexual and reproductive health services among young people in refugee settings in Uganda

There is a considerable high level of unmet need for reproductive health services among refugees. Yet, there is limited research about the provision and utilization of sexual and reproductive health (SRH) services among young people in refugee settings. Drawing on a sample of 575 young refugees (15-24 years) from a cross-sectional survey, this study aims to fill this gap by identifying the factors associated with SRH utilization among young people living in refugee settings in Northern Uganda. The utilization of SRH services at the health facilities was significantly different between female and male young people after adjusting for all other variables (aOR = 2.46, 95% CI, 1.58, 3.84). Young people who were not living in a marital union (aOR = 0.38, 95% CI, 0.20, 0.71), or held inequitable gender norms about services (aOR = 0.28, 95% CI, 0.12, 0.66) had about a third of the odds of utilizing SRH services. Young women with comprehensive knowledge about contraception, modern contraceptives, and HIV and STI prevention, had more than twice the odds of utilizing SRH services (aOR = 2.23, 95% CI, 2.67, 6.90). There is need to integrate social norm measurements and social norm change strategies in strategies for promoting utilization of SRH services among refugees in low-income countries especially in Uganda.

Todurujo na Kadurok (empowering youth): study protocol of an HIV self-testing and edutainment comic cluster randomised trial among refugee youth in a humanitarian setting in Uganda

INTRODUCTION

Refugees experience HIV vulnerabilities due to the confluence of displacement, violence and poverty. HIV self-testing, understudied with refugees, is a promising method to increase testing uptake, yet challenges remain with linkages to confirmatory testing following a positive HIV self-test. This study aims to evaluate the effectiveness of HIV self-testing kits and 'edutainment' comics in increasing HIV testing and HIV status knowledge among refugee youth aged 16-24 years in Bidi Bidi Refugee Settlement, Uganda.

METHODS AND ANALYSIS

This study will be conducted in Bidi Bidi. We conducted a qualitative formative phase with focus groups (n=40) to generate knowledge of barriers and facilitators of HIV prevention, testing and care among refugee youth (aged 16-24) in Bidi Bidi. These findings were used to create comic scenarios aligning with edutainment approaches to health promotion and inform a four-arm cluster randomised controlled trial in Bidi Bidi using a 2×2 factorial design: (1) HIV self-testing alongside edutainment comics, (2) HIV self-testing alone, (3) edutainment comic alone and (4) standard of care. The target sample size will be 120 youth (30 per arm), who will be enrolled in the trial and followed for 3 months. Data will be collected at baseline and 3 months after enrolment. The primary outcomes (HIV testing frequency, HIV status knowledge) and secondary outcomes (linkage to confirmatory HIV testing, HIV care linkage, HIV self-test kit use, HIV-related stigma, HIV knowledge, safer sex efficacy, condom use, adolescent sexual and reproductive health (SRH) stigma, sexual relationship power, access to SRH services) will be evaluated using descriptive statistics and regression analyses.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board, Mildmay Uganda Research Ethics Committee and the Uganda National Council for Science and Technology. Results will be shared in peer-reviewed publications and community knowledge sharing.

TRIAL REGISTRATION NUMBER

NCT05213689.

Left behind on the path to 90-90-90: understanding and responding to HIV among displaced people

INTRODUCTION

In 2021, the number of people affected by displacement worldwide reached the highest on record, with an estimated 30.5 million refugees and 4.6 million asylum seekers seeking safety across international borders and further 53.2 million people displaced within their countries of origin. Most forcibly displaced persons come from or relocate to lower- and middle-income countries (LMICs) and many of those countries have large HIV epidemics. In this commentary, we describe some of the challenges at the intersection of HIV and displacement vulnerabilities that cannot be easily addressed in resource-limited environments.

DISCUSSION

HIV transmission and prevention and treatment efforts in the context of displacement are affected by myriad behavioural, social and structural factors across different stages of the displacement journey. For example, structural barriers faced by people experiencing displacement in relation to HIV prevention and care include funding constraints and legal framework deficiencies. Such barriers prevent all forced migrants, and particularly those whose sexual identities or practices are stigmatized against, access to prevention and care equal to local residents. Xenophobia, racism and other social factors, as well as individual risky behaviours facilitated by experiences of forced migration, also affect the progress towards 90-90-90 targets in displaced populations. Current evidence suggests increased HIV vulnerability in the period before displacement due to the effect of displacement drivers on medical supplies and infrastructure. During and after displacement, substantial barriers to HIV testing exist, though following resettlement in stable displacement context, HIV incidence and viral suppression are reported to be similar to those of local populations.

CONCLUSIONS

Experiences of often-marginalized displaced populations are diverse and depend on the context of displacement, countries of origin and resettlement, and the nature of the crises that forced these populations to move. To address current gaps in responses to HIV in displacement contexts, research in LMIC, particularly in less stable resettlement settings, needs to be scaled up. Furthermore, displaced populations need to be specifically addressed in national AIDS strategies and HIV surveillance systems. Finally, innovative technologies, such as point-of-care viral load and CD4 testing, need to be developed and introduced in settings facing displacement.

Contraceptive self-injection through routine service delivery: Experiences of Ugandan women in the public health system

Contraceptive self-injection (SI) is a new self-care practice with potential to transform women's family planning access by putting a popular method, injectable contraception, directly into the hands of users. Research shows that SI is feasible and acceptable; evidence regarding how to design and implement SI programs under real-world conditions is still needed. This evaluation examined women's experiences when self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was introduced in Uganda alongside other contraceptive options in the context of informed choice. We conducted structured survey interviews with 958 randomly selected SI clients trained in three districts in 2019. SI clients demonstrated their injection technique on a model to permit an assessment of injection proficiency. A randomly selected subset of 200 were re-interviewed 10-17 months post-training to understand resupply experiences, waste disposal practices and continuation. Finally, we conducted survey interviews with a random sample of 200 clients who participated in training but declined to self-inject. Data were analyzed using Stata IC/14.2. Differences between groups were measured using chi square and t-tests. Multivariate analyses predicting injection proficiency and SI adoption employed mixed effects logistic regression. Nearly three quarters of SI clients (73%) were able to demonstrate injection proficiency without additional instruction from a provider. Years of education, having received a complete training, practicing, and taking home a job aid were associated with higher odds of proficiency. Self-reported satisfaction and continuation were high, with 93% reinjecting independently 3 months post-training. However, a substantial share of those trained opted not to self-inject. Being single, having a partner supportive of family planning use, training with a job aid, practicing, witnessing a demonstration and exposure to a full training were associated with higher odds of becoming an SI client; conversely, those trained in a group had reduced odds of becoming an SI client. The self-care program was successful for the majority of women who became self-injectors, enabling most women to demonstrate SI proficiency. Nearly all those who opted to self-inject reinjected independently, and the majority continued self-injecting for at least 1 year. Additional research should identify strategies to facilitate adoption by women who wish to self-inject but face challenges.

Self-care interventions for sexual and reproductive health in humanitarian and fragile settings: a scoping review

BACKGROUND

Self-care is the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and manage illness and disability with or without a health care provider. In resource-constrained settings with disrupted sexual and reproductive health (SRH) service coverage and access, SRH self-care could play a critical role. Despite SRH conditions being among the leading causes of mortality and morbidity among women of reproductive age in humanitarian and fragile settings, there are currently no reviews of self-care interventions in these contexts to guide policy and practice.

METHODS

We undertook a scoping review to identify the design, implementation, and outcomes of self-care interventions for SRH in humanitarian and fragile settings. We defined settings of interest as locations with appeals for international humanitarian assistance or identified as fragile and conflict-affected situations by the World Bank. SRH self-care interventions were described according to those aligned with the Minimum Initial Services Package for Reproductive Health in Crises. We searched six databases for records using keywords guided by the PRISMA statement. The findings of each included paper were analysed using an a priori framework to identify information concerning effectiveness, acceptability and feasibility of the self-care intervention, places where self-care interventions were accessed and factors relating to the environment that enabled the delivery and uptake of the interventions.

RESULTS

We identified 25 publications on SRH self-care implemented in humanitarian and fragile settings including ten publications on maternal and newborn health, nine on HIV/STI interventions, two on contraception, two on safe abortion care, one on gender-based violence, and one on health service provider perspectives on multiple interventions. Overall, the findings show that well-supported self-care interventions have the potential to increase access to quality SRH for crisis-affected communities. However, descriptions of interventions, study settings, and factors impacting implementation offer limited insight into how practical considerations for SRH self-care interventions differ in stable, fragile, and crisis-affected settings.

CONCLUSION

It is time to invest in self-care implementation research in humanitarian settings to inform policies and practices that are adapted to the needs of crisis-affected communities and tailored to the specific health system challenges encountered in such contexts.

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

Background

Urban refugee youth may live in social contexts characterized by structural drivers of HIV such as poverty and violence. Knowledge gaps remain regarding HIV testing practices among urban refugee youth, despite the increasing trend toward refugee settlement in urban contexts. This study examined social contextual factors associated with lifetime HIV testing among urban refugee youth in Kampala, Uganda.

Methods

We conducted a community-based study with a peer-recruited cohort of urban refugee youth aged 16–24 years living in Kampala’s informal settlements, and present baseline cross-sectional findings. We conducted descriptive statistics and logistic regression to examine socio-demographic (e.g., gender and age), material (e.g., income insecurity and education), relational (e.g., social support), and symbolic contexts (e.g., HIV-related stigma and intimate partner violence (IPV]) associated with lifetime HIV testing.

Results

Participants (n = 450) had a mean age of 20.4 years (standard deviation: 2.4 years), most lived in Uganda for 1–5 years (53.2%), and less than half reported lifetime HIV testing (43.4%). In multivariable analyses, odds of lifetime HIV testing were higher among youth with secondary school education or higher (adjusted odds ratio (aOR]: 2.30, 95% confidence interval (CI]: 1.27–4.17), currently employed (aOR: 1.79, 95% CI: 1.03–3.10), and reporting IPV (aOR: 3.61, 95% CI: 1.43–9.10). Having children was marginally associated with HIV testing (aOR: 2.17, 95% CI: 0.98–4.81, p = 0.052).

Conclusions

Findings demonstrate suboptimal HIV testing and the importance of tailored strategies to reach urban refugee youth who are unemployed and have limited formal education. There is a need to meaningfully engage urban refugee youth to create enabling environments for sexual health.

Uptake and provision of self-care interventions for sexual and reproductive health: findings from a global values and preferences survey

Self-care interventions hold the potential to improve sexual and reproductive health (SRH) and well-being. Yet key knowledge gaps remain regarding how knowledge and uptake vary across different types of self-care interventions. There is also limited understanding of health workers’ confidence in promoting SRH self-care interventions, and how this may differ based on personal uptake experiences. To address these knowledge gaps, we conducted a web-based cross-sectional survey among health workers and laypersons from July to November 2018. We investigated the following information about SRH self-care interventions: knowledge and uptake; decisions for use; and associations between health workers’ uptake and providing prescriptions, referrals, and/or information for these interventions. Participants (n = 837) included laypersons (n = 477) and health workers (n = 360) from 112 countries, with most representation from the WHO European Region (29.2%), followed by the Americas (28.4%) and African (23.2%) Regions. We found great heterogeneity in knowledge and uptake by type of SRH self-care intervention. Some interventions, such as oral contraception, were widely known in comparison with interventions such as STI self-sampling. Across interventions, participants perceived benefits of privacy, convenience, and accessibility. While pharmacies and doctors were preferred access points, this varied by type of self-care intervention. Health workers with knowledge of the self-care intervention, and who had themselves used the self-care intervention, were significantly more likely to feel confident in, and to have provided information or referrals to, the same intervention. This finding signals that health workers can be better engaged in learning about self-care SRH interventions and thereby become resources for expanding access.

Developmental origins of disease highlight the immediate need for expanded access to comprehensive prenatal care

The prenatal environment plays a critical role in shaping fetal development and ultimately the long-term health of the child. Here, we present data linking prenatal health, via maternal nutrition, comorbidities in pregnancy (e.g., diabetes, hypertension), and infectious and inflammatory exposures, to lifelong health through the developmental origins of disease framework. It is well-established that poor maternal health puts a child at risk for adverse outcomes in the first 1,000 days of life, yet the full health impact of the in utero environment is not confined to this narrow window. The developmental origins of disease framework identifies cognitive, neuropsychiatric, metabolic and cardiovascular disorders, and chronic diseases in childhood and adulthood that have their genesis in prenatal life. This perspective highlights the enormous public health implications for millions of pregnancies where maternal care, and therefore maternal health and fetal health, is lacking. Despite near universal agreement that access to antenatal care is a priority to protect the health of women and children in the first 1,000 days of life, insufficient progress has been achieved. Instead, in some regions there has been a political shift toward deprioritizing maternal health, which will further negatively impact the health and safety of pregnant people and their children across the lifespan. In this article we argue that the lifelong health impact attributed to the perinatal environment justifies policies aimed at improving access to comprehensive antenatal care globally.

The Potential of Self-Managed Abortion to Expand Abortion Access in Humanitarian Contexts

Refugees and displaced people face uniquely challenging barriers to abortion access, including the collapse of health systems, statelessness, and a lack of prioritization of sexual and reproductive health services by humanitarian agencies. This article summarizes the evidence around abortion access in humanitarian contexts, and highlights the opportunities for interventions that could increase knowledge and support around self-managed abortion. We explore how lessons learned from other contexts can be applied to the development of effective interventions to reduce abortion-related morbidity and mortality, and may improve access to information about safe methods of abortion, including self-management, in humanitarian settings. We conclude by laying out a forward-thinking research agenda that addresses gaps in our knowledge around abortion access and experiences in humanitarian contexts.

Adolescent sexual behaviour in a refugee setting in Uganda

Background

Children under 18 years old constituted more than half (52%) of the refugee population in 2017. Adolescent Sexual and reproductive health is an essential component of primary health care. Yet, not every refugee adolescent is able to access sexual and reproductive health services.

Methods

Using quantitative data from 356 refugee adolescents and qualitative data (17 in-depth interviews and nine key informant interviews), we examine refugee adolescent sexual behaviour in Bidibidi settlement—the largest refugee settlement in Uganda using a binary logistic regression model.

Results

The results show that 25% of refugee adolescents in Bidibidi refugee settlement had ever had sex. After controlling for all factors, results show that refugee adolescents aged 16–18 years (OR  =  3.47; 95% CI  =  1.09–10.94), males (OR  =  17.59; 95% CI  =  4.48–69.07), not in school (OR  =  14.57; 95% CI  =  2.20–96.35) were more likely to engage in sexual behaviour than their counterparts. Refugee adolescents who do not agree that a girl cannot get pregnant if she has sex while standing up (knowledge about getting pregnant) were significantly less associated with sexual behaviour (OR  =  0.30; 95% CI  =  0.10–0.85).

Conclusions

Results from this study show that keeping refugee adolescents in school and providing sexual and reproductive health information are likely to delay refugee adolescents’ engagement in sexual behaviour. Therefore, there is need to promote keeping refugee adolescents in school in order to improve sexual and reproductive health of adolescent refugees living in low-income countries such as Uganda.

Sexual and reproductive health is an essential component of primary health care. Limited access to sexual and reproductive health (SRH) services for adolescent refugees particularly in low income countries can affect their reproductive health. Similarly, limited knowledge of the determinants of sexual behaviour of adolescent refugees in low income countries puts them at risk of SRH challenges.

This study uses quantitative data from 356 adolescent refugees and qualitative (17 in-depth interviews with adolescent refugees and nine key informant interviews with service providers) to examine the factors that influence the sexual behaviour of adolescent refugees in Bidibidi refugee settlement.

The findings show that older age, male sex, not being in school and having knowledge of getting pregnant were associated with sexual behaviour among adolescent refugees in Bidibidi refugee settlement in Uganda.

There is need to promote keeping refugee adolescents in school and providing them with relevant SRH information to contribute to improving sexual and reproductive health of adolescent refugees living in low-income countries such as Uganda.

Sexual and reproductive health self-care interventions in the Eastern Mediterranean Region: findings from a cross-sectional values and preferences survey to inform WHO normative guidance on self-care interventions

Background

Self-care strategies for sexual and reproductive health (SRH) include practices, tools, and strategies for people to manage their health. Access to SRH services has increased in the Eastern Mediterranean Region (EMR) in the past decade. The objective of this manuscript is to provide a preliminary assessment of self-care SRH interventions focusing on access, knowledge, perceived challenges, and recommendations for the future. We aim to contribute to the evidence base on knowledge and uptake of self-care SRH strategies in the EMR.

Methods

We conducted an online cross-sectional Global Values and Preferences Survey (GVPS) to inform WHO guideline development on self-care interventions for SRH. Recruitment was web-based and included hosting the survey on the WHO Department of Reproductive Health and Research website, and sharing the survey link to diverse SRH websites. Analyses included the subsample of respondents living in EMR countries. We first conducted descriptive statistics of sociodemographic and self-care intervention responses. We then conducted bivariate analyses to examine statistically significant differences in knowledge for each intervention between EMR and non-EMR regions. We extracted open-text responses and applied thematic analysis techniques.

Results

There were 53 respondents from the EMR spanning 14 countries, including16 health care providers (HCP) and 37 laypersons. Qualitative responses (n = 16) suggest that (a) perceived benefits of self-care SRH strategies include enhanced SRH access, knowledge, and improved SRH outcomes; (b) perceived concerns include misuse and safety; (c) linkage to care following self-care SRH interventions can consider mobile phone apps, hotlines, health care liaisons, and community outreach; (d) HCP want additional training on strengthening therapeutic alliances with patients and practical information on interventions; and (e) future research can focus on reproductive health, condom use, service barriers, and implementation. EMR respondents reported lower knowledge levels than non-EMR respondents on the following strategies: diaphragm/cervical cap, contraceptive patch, web-based SRH information, post-exposure prophylaxis, re-exposure prophylaxis, and HIV treatment.

Conclusions

Knowledge of self-care SRH strategies varies by intervention type in the EMR. Future research with larger and more representative samples can inform regional self-care SRH implementation. Knowledge dissemination, stigma reduction, accessibility, and training of health care professionals are key domains for advancing access to self-care SRH strategies in the EMR.

Sexual and reproductive health self-care in humanitarian and fragile settings: where should we start?

Recent crises have accelerated global interest in self-care interventions. This debate paper aims to raise the issue of sexual and reproductive health (SRH) self-care and invites members of the global community operating in crisis-affected settings to look at potential avenues in mainstreaming SRH self-care interventions. We start by exploring self-care interventions that could align with well-established humanitarian standards, such as the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Crises, point to the potential of digital health support for SRH self-care in crisis-affected settings, and discuss related policy, programmatic, and research considerations. These considerations underscore the importance of self-care as part of the care continuum and within a whole-system approach. Equally critical is the need for self-care in crisis-affected settings to complement other live-saving SRH interventions-it does not eliminate the need for provider-led services in health facilities. Further research on SRH self-care interventions focusing distinctively on humanitarian and fragile settings is needed to inform context-specific policies and practice guidance.

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

Introduction

HIV‐related risks may be exacerbated in humanitarian contexts. Uganda hosts 1.3 million refugees, of which 60% are aged under 18. There are knowledge gaps regarding HIV testing facilitators and barriers, including HIV and intersecting stigmas, among urban refugee youth. In response, we explored experiences and perspectives towards HIV testing strategies, including HIV self‐testing, with urban refugee youth in Kampala, Uganda.

Methods

We implemented a qualitative study with refugee cisgender youth aged 16 to 24 living in Kampala's informal settlements from February‐April 2019. We conducted five focus groups with refugee youth, including two with adolescent boys and young men, two with adolescent girls and young women and one with female sex workers. We also conducted five key informant (KI) interviews with government, non‐government and community refugee agencies and HIV service providers. We conducted thematic analyses to understand HIV testing experiences, perspectives and recommendations.

Results

Participants (n = 49) included young men (n = 17) and young women (n = 27) originally from the Democratic Republic of Congo [DRC] (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1), in addition to five KI (gender: n = 3 women, n = 2 men; country of origin: n = 2 Rwanda, n = 2 Uganda, n = 1 DRC). Participant narratives revealed stigma drivers included fear of HIV infection; misinformation that HIV is a “Ugandan disease”; and blame and shame for sexual activity. Stigma facilitators included legal precarity regarding sex work, same‐sex practices and immigration status, alongside healthcare mistreatment and confidentiality concerns. Stigma experiences were attributed to the social devaluation of intersecting identities (sex work, youth, refugees, sexual minorities, people living with HIV, women). Participants expressed high interest in HIV self‐testing. They recommended HIV self‐testing implementation strategies to be peer supported and expressed concerns regarding sexual‐ and gender‐based violence with partner testing.

Conclusions

Intersecting stigma rooted in fear, misinformation, blame and shame, legal precarity and healthcare mistreatment constrain current HIV testing strategies with urban refugee youth. Findings align with the Health Stigma and Discrimination Framework that conceptualizes stigma drivers and facilitators that devalue intersecting health conditions and social identities. Findings can inform multi‐level strategies to foster enabling HIV testing environments with urban refugee youth, including tackling intersecting stigma and leveraging refugee youth peer support.

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

BACKGROUND

HIV is the leading cause of mortality among youth in sub-Saharan Africa. Uganda hosts over 1.43 million refugees, and more than 83,000 live in Kampala, largely in informal settlements. There is limited information about HIV testing uptake and preferences among urban refugee and displaced youth. HIV self-testing is a promising method for increasing testing uptake. Further, mobile health (mHealth) interventions have been effective in increasing HIV testing uptake and could be particularly useful among youth.

OBJECTIVE

This study aims to evaluate the feasibility and effectiveness of two HIV self-testing implementation strategies (HIV self-testing intervention alone and HIV self-testing combined with an mHealth intervention) in comparison with the HIV testing standard of care in terms of HIV testing outcomes among refugee/displaced youth aged 16 to 24 years in Kampala, Uganda.

METHODS

A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomization will be performed with a 1:1:1 method. Approximately 450 adolescents (150 per cluster) will be enrolled and followed for 12 months. Data will be collected at the following three time points: baseline enrollment, 8 months after enrollment, and 12 months after enrollment. Primary outcomes (HIV testing frequency, HIV status knowledge, linkage to confirmatory testing, and linkage to HIV care) and secondary outcomes (depression, condom use efficacy, consistent condom use, sexual relationship power, HIV stigma, and adolescent sexual and reproductive health stigma) will be evaluated.

RESULTS

The study has been conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (June 14, 2019), Mildmay Uganda (November 11, 2019), and the Uganda National Council for Science and Technology (August 3, 2020). The Tushirikiane trial launched in February 2020, recruiting a total of 452 participants. Data collection was paused for 8 months due to COVID-19. Data collection for wave 2 resumed in November 2020, and as of December 10, 2020, a total of 295 participants have been followed-up. The third, and final, wave of data collection will be conducted between February and March 2021.

CONCLUSIONS

This study will contribute to the knowledge of differentiated HIV testing implementation strategies for urban refugee and displaced youth living in informal settlements. We will share the findings in peer-reviewed manuscripts and conference presentations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04504097; https://clinicaltrials.gov/ct2/show/NCT04504097.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26192.

Sexual and reproductive health mobile apps: results from a cross-sectional values and preferences survey to inform World Health Organization normative guidance on self-care interventions

Mobile application (app) platforms have the potential to advance sexual and reproductive health (SRH). Yet there is a dearth of knowledge regarding global perspectives from healthcare providers on how SRH mobile apps are being leveraged in their healthcare practice. In 2019 the World Health Organization (WHO) developed a consolidated guideline on self-care interventions for SRH. To inform this guideline, we conducted a global values and preferences survey. This study aimed to (a) understand the awareness, access, and uptake of SRH mobile apps; (b) examine how many healthcare provider (HCP) participants provided linkages, referrals and information to clients regarding SRH mobile apps; and (c) among HCP, assess how many felt confident and informed regarding SRH mobile apps. We hosted a cross-sectional web-based survey on the WHO Department of Reproductive Health and Research website and shared the survey with SRHR listservs. There were 825 survey participants, 360 whom identified as healthcare providers (HCP). Approximately one-third of HCP participants had provided a referral/information to their clients about sexual or reproductive health apps. While 40.8% of HCP felt confident and informed about sexual health apps, half (47.4%) reported needing more information, and 15.6% expressed interest in receiving training to use in practice. While 42.6% of HCPs felt confident and informed about reproductive health apps, 45.7% needed more information, and 15.1% were interested in further training. There was also an open-ended question for HCP to share their thoughts about self-care SRH interventions. Specifically regarding SRH apps, HCP responses revealed the importance of considering: (a) security and confidentiality; (b) potential benefits of SRH apps for underserved groups (i.e. youth, rural communities); (c) community engagement; (d) health benefits; and (e) and online training for HCP on SRH mobile apps. Findings signal interest and opportunities for training and engaging HCP in using mobile apps to advance SRH.

Self-care interventions for sexual and reproductive health and rights for advancing universal health coverage

WHO's normative guidance on self-care interventions for sexual and reproductive health and rights (SRHR) promotes comprehensive, integrated and people-centred approaches to health service delivery. Implementation of self-care interventions within the context of human rights, gender equality, and a life course approach, offers an underused opportunity to improve universal health coverage (UHC) for all. Results from an online global values and preferences survey provided lay persons' and healthcare providers' perspectives on access, acceptability, and implementation considerations. This analysis examines 326 qualitative responses to open-ended questions from healthcare providers (n = 242) and lay persons (n = 70) from 77 countries. Participants were mostly women (66.9%) and were from the Africa (34.5%), America (32.5%), South-East Asia (5.6%), European (19.8%), Eastern Mediterranean (4.8%), and Western Pacific regions (2.8%). Participants perceived multiple benefits of self-care interventions for SRHR, including: reduced exposure to stigma, discrimination and access barriers, increased confidentiality, empowerment, self-confidence, and informed decision-making. Concerns include insufficient knowledge, affordability, and possible side-effects. Implementation considerations highlighted the innovative approaches to linkages with health services. Introduction of self-care interventions is a paradigm shift in health care delivery bridging people and communities through primary health care to reach UHC. Self-care interventions can be leveraged by countries as gateways for reaching more people with quality, accessible and equitable services that is critical for achieving UHC. The survey results underscored the urgent need to reduce stigma and discrimination, increase access to and improve knowledge of self-care interventions for SRHR for laypersons and healthcare providers to advance SRHR.

Exploring associations between adolescent sexual and reproductive health stigma and HIV testing awareness and uptake among urban refugee and displaced youth in Kampala, Uganda

Uganda, hosting over 1.3 million refugees, is a salient context for exploring HIV testing with urban refugee and displaced youth. We examined associations between stigma (HIV-related and adolescent sexual and reproductive health [SRH]-related) and HIV testing services awareness and HIV testing uptake among urban refugee and displaced youth in Kampala, Uganda. We implemented a cross-sectional survey with refugee and displaced adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM) aged 16-24. We conducted exploratory and confirmatory factor analysis of an adolescent SRH stigma scale and identified a two-factor structure (“Sexual activity & pregnancy stigma”,”Modern family planning & abortion stigma”). We conducted multivariable logistic regression analysis to determine the adjusted risk ratio for HIV testing services awareness and testing uptake. Among participants (n=445; mean age=19.59, SD=2.60; AGYW: n=333; 74.7%), two-thirds were aware of HIV testing services in their community and over half (56.0%) had received a lifetime HIV test. In adjusted multivariable regression analysis findings with AGYW: (a) higher sexual activity & pregnancy stigma and modern family planning & abortion stigma were associated with reduced odds of HIV testing services awareness, and (b) modern family planning & abortion stigma was associated with reduced lifetime HIV testing odds. Stigma was not associated with HIV testing awareness/uptake among ABYM. HIV testing services awareness among AGYW was lower than among ABYM, yet AGYW were more likely to have been tested and to experience adolescent SRH stigma as a testing barrier. Addressing adolescent SRH stigma may optimise AGYW's HIV testing.

Social ecological factors associated with experiencing violence among urban refugee and displaced adolescent girls and young women in informal settlements in Kampala, Uganda: a cross-sectional study

BACKGROUND

Research on violence targeting urban forcibly displaced adolescent girls and young women (AGYW) is limited, particularly regarding polyvictimization (exposure to multiple forms of violence). Yet there is a global trend of refugee urbanization, and urban AGYW are at the nexus of violence disparities among adolescents, forcibly displaced persons, and slum dwellers. This study explored factors associated with young adulthood violence (> 16 years) (YAV) and intimate partner violence (IPV) among forcibly displaced AGYW in Kampala, Uganda.

METHODS

We conducted a cross-sectional survey with forcibly displaced AGYW aged 16-24 from five informal settlement (slum) communities across Kampala (Kabalagala, Rubaga, Kansanga, Katwe, Nsambya) using peer network sampling. We assessed YAV (experienced at age 16 or above) (sexual, physical, emotional violence) and recent (past 12-month) IPV (physical, sexual, control violence). We conducted descriptive statistics, followed by multinomial logistic regression analyses to explore social ecological factors (e.g., intrapersonal: depression; interpersonal: sexual relationship power, community: food insecurity) associated with experiencing YAV and YAV polyvictimization, and IPV and IPV polyvictimization.

RESULTS

Over half of participants (n = 333; mean age = 19.31; SD = 2.56, range = 16-24) reported YAV (n = 179; 53.7%) and 9.3% (n = 41) reported YAV polyvictimization. Most participants that were in an intimate relationship in the last 12 months (n = 200; 85.8%) reported IPV, among these, 45.5% reported one form of IPV and 54.5% reported IPV polyvictimization. In adjusted analyses, experiencing any YAV was significantly associated with: adolescent sexual and reproductive health (SRH) stigma; sexual relationship power; mobile app usage; depressive symptoms; childhood abuse; and childhood polyvictimization. In adjusted analyses YAV polyvictimization was associated with: depressive symptoms; childhood polyvictimization; sexual relationship power; and food insecurity. Recent IPV polyvictimization in adjusted analyses was associated with owning/using a mobile phone and depressive symptoms. Participants with higher sexual relationship power had lower odds of recent IPV polyvictimization.

CONCLUSION

Findings suggest that YAV and IPV polyvictimization require urgent attention among forcibly displaced AGYW in Kampala. Multi-level strategies are required to address intrapersonal e.g. (depression), interpersonal (e.g. childhood abuse, sexual relationship power) and community (e.g. adolescent SRH stigma, food insecurity) factors associated with experiencing violence. Future research can tailor approaches to advance health, agency and human rights among urban forcibly displaced AGYW.