Sexually transmitted infection testing awareness, uptake and diagnosis among urban refugee and displaced youth living in informal settlements in Kampala, Uganda: a cross-sectional study

Intersecting social-ecological vulnerabilities to and lived experiences of sexually transmitted infections among Syrian refugee women in Lebanon: A qualitative study

Conflict-affected women and girls living in protracted forced displacement settings are vulnerable to sexually transmitted infections (STIs). Yet, little is known about the risk factors for and lived experiences of STIs in complex humanitarian settings, particularly in the Middle East and North Africa, where STIs have long been understudied. This qualitative study adapts the social ecological model to characterize the multi-level risks for and lived experiences of STIs among Syrian refugee women resettled in an urban refugee camp in Beirut, Lebanon. Adopting a community-based sampling strategy, community health workers, who were refugee women from the camp, recruited and conducted in-depth interviews (IDIs) with 30 adult Syrian refugee women. Data were analyzed using an interpretative phenomenological approach and thematically organized according to the levels of the social ecological model. We identified a confluence of individual, interpersonal, community-based, and societal vulnerabilities to STIs, including extreme poverty and insecurity, patriarchal gender norms, stigma, sexual exploitation and trafficking, poor healthcare accessibility, intimate partner violence, including marital rape, transactional sex, sexual harassment, social isolation, and internalized stigma. Participants described experiencing bothersome symptoms and sequelae of advanced and untreated STIs in the setting of limited access to health services and challenges with engaging their partners in STI treatment, largely due to STI stigma. These novel findings suggest dynamic, interrelated social and health disparities across all social ecological levels influencing refugee women's sexual health, including their risk of STIs. Comprehensive, multi-sectorial interventions, which transcend traditional public health methods and which adopt a sexual well-being approach, are urgently needed to address systemic and intrapersonal violence against refugee women, examine and mitigate the burden of STIs, and ensure sexual justice and health equity in this protracted forced displacement setting.

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.

Getting knowledge to provide care: prevalence and factors associated with Sexually Transmitted Infections in immigrants from Goiás

OBJECTIVE

To estimate the prevalence of Sexually Transmitted Infections (STIs) in immigrants and refugees living in the metropolitan region of Goiânia, Goiás.

METHOD

This is a cross-sectional and analytical study. Data collection was carried out from July 2019 to January 2020 and 308 immigrants and refugees were included in the sample. All were underwent face-to-face interviews and were tested for HIV, Syphilis, and Hepatitis B, using rapid tests.

RESULTS

The general prevalence for any of the STIs investigated was 8.8% (95%CI 6.0% - 12.3%), being 5.8% (95%CI 3.6% - 8.9%) for Hepatitis B, 2.3% for Syphilis (95%CI 1.00% - 4.4%) and 0.7% for HIV (95%CI 0.1% - 2.1%). Multiple analysis, using logistic regression, showed that the variables male gender (OR = 2.7) and length of time living in Brazil (OR = 2.6) were significantly associated with STIs (p < 0.05).

CONCLUSION

The results of this study suggest that STIs are a health problem in immigrants/refugees, which appear to be enhanced with the length of migration in the country. Public policies that guarantee health care for this population shall be considered.

Sexual and reproductive health (SRH) needs for forcibly displaced adolescent girls and young women (10-24 years old) in humanitarian settings: a mixed-methods systematic review

BACKGROUND

Globally, there are 42 million women and girls estimated to be forcibly displaced. Adolescent girls and young women in humanitarian settings have their sexual and reproductive health (SRH) neglected. This systematic review aimed to describe SRH obstacles that adolescent girls and young women (10-24 years old) face in humanitarian settings in line with the Sustainable Development Goals.

METHODS

We conducted a mixed-methods systematic review in six databases, focusing on migrant women ages 10 - 24and their SRH outcomes. The mixed-methods appraisal tool was used to evaluate the quality of the studies. This review follows PRISMA and the Systematic Review Guidelines from the Centre for Reviews and Dissemination recommendations.

RESULTS

Among the 1290 studies screened by abstracts, 32 met the eligibility criteria: 15 were qualitative, 10 were quantitative and seven were mixed-methods studies. Most studies were performed in the last four years, in African countries. They discussed the increased frequency of adolescent pregnancies (16-23%), lack of contraceptive use and access (8-32%), poor menstrual hygiene management (lack of water, shortage of menstrual hygiene supplies), ignorance and stigma about sexually transmitted infections and HIV, a higher number of child, early and forced marriage or partnership and sexual and gender-based violence, challenging to obtain SRH information/knowledge/access, and unmet SRH needs.

CONCLUSION

Migration is a current issue. Although there is a growing number of studies on adolescent girls and young women's SRH in humanitarian settings, this population remains overlooked, and face several challenges in SRH. There is a need for targeting interventions on SRH.

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

BACKGROUND

Adverse socio-cultural factors compromise the implementation of HIV prevention strategies among displaced youth. While condoms are an affordable and effective HIV prevention strategy for youth, stigma and inequitable gender norms may constrain condom self-efficacy (i.e., knowledge, intentions, and relationship dynamics that facilitate condom negotiation) and use. Further, knowledge of contextually appropriate HIV prevention approaches are constrained by limited understanding of the socio-cultural conditions that affect condom self-efficacy and use among displaced youth. Guided by syndemics theory, we examine independent and joint effects of adverse socio-cultural factors associated with condom self-efficacy and use among displaced youth living in urban slums in Kampala, Uganda.

METHODS

We conducted a community-based cross-sectional survey of displaced youth aged 16-24 years living in five slums in Kampala. We used multivariable logistic regression and multivariate linear regression to assess independent and two-way interactions among adverse socio-cultural factors (adolescent sexual and reproductive health-related stigma [A-SRH stigma], perceived HIV-related stigma, and beliefs in harmful inequitable gender norms) on condom self-efficacy and recent consistent condom use. We calculated the prevalence and co-occurrence of adverse socio-cultural factors; conducted regression analyses to create unique profiles of adverse socio-cultural factors; and then assessed joint effects of adverse socio-cultural factors on condom self-efficacy and practices.

RESULTS

Among participants (mean age: 19.59 years; SD: 2.59; women: n = 333, men: n = 112), 62.5% were sexually active. Of these, only 53.3% reported recent consistent condom use. Overall, 42.73% of participants reported two co-occurring adverse socio-cultural factors, and 16.63% reported three co-occurring exposures. We found a joint effect of beliefs in harmful inequitable gender norms with high A-SRH stigma (β = - 0.20; p < 0.05) and high A-SRH stigma with high perceived HIV stigma (β = - 0.31; p < 0.001) on reduced condom self-efficacy. We found a multiplicative interaction between high A-SRH stigma with high perceived HIV stigma (aOR = 0.52; 95% CI 0.28, 0.96) on recent consistent condom use. Additionally, we found that condom self-efficacy (aOR = 1.01; 95% CI 1.05, 1.16) and safer sexual communication (aOR = 2.12; 95% CI 1.54, 2.91) acted as protective factors on inconsistent condom use.

CONCLUSIONS

Displaced youth living in urban slums exhibited low consistent condom use. Intersecting stigmas were associated with lower condom self-efficacy-a protective factor linked with increased consistent condom use. Findings highlight the importance of gender transformative and intersectional stigma reduction approaches to increase sexual agency and safer sex practices among Kampala's slum-dwelling displaced youth.

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.

Relational Factors and HIV Testing Practices: Qualitative Insights from Urban Refugee Youth in Kampala, Uganda

Despite the global phenomenon of refugee urbanization, little is known of relational contexts that shape HIV testing among urban refugee youth. We explored perspectives, experiences, and preferences for social support in HIV testing among refugee youth aged 16-24 in Kampala, Uganda. We conducted five focus groups with refugee youth (n = 44) and five in-depth key informant interviews. Participant narratives signaled relational contexts shaping HIV testing included informal sources (intimate partners and family members) and formal sources (peer educators and professionals). There was heterogeneity in perspectives based on relationship dynamics. While some felt empowered to test with partners, others feared negative relationship consequences. Participant narratives reflected kinship ties that could facilitate testing with family, while others feared coercion and judgment. Peer support was widely accepted. Professional support was key for HIV testing as well as conflict-related trauma. Findings emphasize bonding and bridging social capital as salient components of enabling HIV testing environments.

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.

"They will say you want to make their home die": A mixed methods study to assess modern family planning use in partnered South Sudanese refugee and host populations in Northern Uganda

The unmet need for family planning among conflict-affected populations is high globally, leaving girls and women vulnerable to unintended pregnancies and poor sexual and reproductive health outcomes. Ours is the first known mixed-methods study to assess the use of modern family planning (FP) methods amongst married or partnered South Sudanese refugee and host populations in Northern Uganda and to explore differences between them. We conducted a cross-sectional survey in July 2019 which included 1,533 partnered women of reproductive age (15-49 years) from host and South Sudanese refugee communities in Kiryandongo and Arua. Qualitative data were collected in October 2019-January 2020 via 34 focus group discussions and 129 key informant interviews with refugee and host populations, health workers, community and religious leaders, health workers, local authorities and humanitarian actors. Our study did not find large differences between South Sudanese refugee and host populations in regard to modern FP use, though refugees reported somewhat poorer FP knowledge, accessibility and utilisation compared to Ugandan women. Reported barriers to FP use relate to access, quality of services, health concerns and family/community opposition, all of which emphasise the importance of men's gendered roles in relationships, cultural and religious beliefs and lack of agency for most women to make their own decisions about reproductive health. Sexual and gender-based violence related to FP use was reported among both refugee and host populations. Additional barriers to FP use include lack of privacy at the public health facilities which reduces confidentiality, mistrust of health workers, and stockouts of FP commodities. Facilitating factors for FP use included: free government health services; the presence of well-trained health workers; and NGOs who give support to populations and conduct community outreaches. The findings of this study underscore the importance of developing and implementing tailored sexual and reproductive health information and services, especially for modern FP methods, in partnership with South Sudanese refugee and host populations in Northern Uganda.

Factors associated with low knowledge about sexually transmitted infections in subnormal agglomerate, in the Brazilian Amazon

BACKGROUND

Populations living in subnormal agglomerates in urban areas are more vulnerable to infections, including sexually transmitted infections (STIs). In these groups, inadequate knowledge about sexually transmitted infections can further increase the risk of contracting STIs.

AIM

We investigated the factors associated with low knowledge about STIs in a peripheral population in the Brazilian Amazon.

METHODS

This cross-sectional study was conducted in Belém, in the Amazon region that has a high percentage of subnormal agglomerates in an urban area and a high incidence of STIs. Random sampling was adopted which resulted in a sample of 320 participants. To assess knowledge about STIs, the self-administered Sexually Transmitted Disease Knowledge Questionnaire was used. To assess aspects of vulnerability, a questionnaire was constructed which is linked to individual, social, and programmatic factors. The chi-square test, G test, and ordinal regression analyses were all performed.

FINDINGS

The sample of this study was composed of 320 participants. The mean age of the participants was 46.09 years. 37.5% (120), 50.6% (162), and 11.9% (38) showed low, medium, and high knowledge, respectively. Multiple analysis revealed that the factors associated with higher chance of having smaller knowledge about sexually transmitted infections were single/separated/divorced/widow(er) marital status (AOR: 1.80, CI: 1.15-2.84, P = 0.01); income equal to or less than one minimum wage (1.98, CI: 1.21-3.17, P = 0.00); equal to or over than 52 years old (AOR: 1.99, CI: 1.25-3.17, P = 0.00); lack of guidance by a health professional (AOR: 1.59, CI: 1.01-2.51, P = 0.04). Our results show that this community suffer from suboptimal levels of knowledge on STIs, which are linked to individual, social, and programmatic factors. Characterising the risk and vulnerabilities factors allows for carrying out appropriate interventions for populations living in subnormal agglomerates in urban area.

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.

The role of context in shaping HIV testing and prevention engagement among urban refugee and displaced adolescents and youth in Kampala, Uganda: findings from a qualitative study

Objective

To explore experiences, preferences and engagement with HIV testing and prevention among urban refugee and displaced adolescents and youth in Kampala, Uganda, with a focus on the role of contextual factors in shaping access and uptake.

Methods

This qualitative community‐based study with urban refugee and displaced youth aged 16–24 living in Kampala’s informal settlements involved five focus groups (FG), including two with young women, two with young men, and one with sex workers from March to May 2019. We also conducted five in‐depth key informant interviews. We conducted thematic analysis informed by Campbell and Cornish’s conceptualisation of material and symbolic contexts.

Results

Refugee/displaced youth participants (n = 44; mean age: 20.25, SD: 2.19; men: n = 17; women: n = 27) were from the Democratic Republic of Congo (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1). Participant narratives reflected material and symbolic contexts that shaped HIV testing awareness, preferences and uptake. Material contextual factors that presented barriers to HIV testing and prevention engagement included transportation costs to clinics, overcrowded living conditions that limited access to private spaces, low literacy and language barriers. Symbolic contexts that constrained HIV testing engagement included medical mistrust of HIV testing and inequitable gender norms. Religion emerged as an opportunity to connect with refugee communities and to address conservative religious positions on HIV and sexual health.

Conclusion

Efforts to increase access and uptake along the HIV testing and prevention cascade can meaningfully engage urban refugee and displaced youth to develop culturally and contextually relevant services to optimise HIV and sexual health outcomes.

Uptake of and factors associated with testing for sexually transmitted infections in community-based settings among youth in Zimbabwe: a mixed-methods study

BACKGROUND

The prevalence of sexually transmitted infections (STIs) among youth is high in sub-Saharan Africa. We investigated the uptake of testing for and prevalence of Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhoea) infections among youth in community-based settings in Zimbabwe, and explored the facilitators and barriers to testing.

METHODS

This study was nested within a cluster randomised trial of community-based delivery of integrated HIV and sexual and reproductive health services for youth aged 16-24 years. Chlamydia and gonorrhoea testing via urine samples using the Xpert CT/NG test was offered in the four intervention clusters in Harare, Zimbabwe. Factors associated with testing uptake were investigated in a subset of participants (n=257) using hierarchical multivariate logistic regression. In-depth interviews with a separate purposively selected sample (n=26) explored facilitators and barriers to STI testing and partner notification and were analysed using thematic analysis.

FINDINGS

Between June 1, 2019, and Jan 31, 2020, there were 6200 attendances by 4440 participants (78·2% women, 21·8% men) median age 20·3 (IQR 17·9-22·8) years. 1478 participants had 1501 tests done, and 248 tests were positive and 1253 tests were negative for chlamydia or gonorrhoea, or both. STI test uptake was 33·3% (95% CI 31·9-34·7), increasing from 11·7% in June, 2019, to 37·1% in January, 2020. The prevalence of chlamydia or gonorrhoea, or both, was 16·5% (95% CI 14·7-18·5; 248 of 1501), with only seven participants (3%) showing symptoms. The overall yield of testing was 4·0% (95% CI 3·5-4·5; 248 of 6200). Uptake was associated with having symptoms (adjusted odds ratio [OR] 14·8, 95% CI 1·66-132·07) and negatively associated with being single (adjusted OR 0·33, 95% CI 0·13-0·84) or having a boyfriend or girlfriend (adjusted OR 0·19, 95% CI 0·087-0·43) compared with being married, and being a student compared with being employed (adjusted OR 0·26, 95% CI 0·10-0·68). Perceived risk and symptoms of STIs were motivators for testing whereas misinformation, anticipated stigma, and concern about confidentiality were barriers.

INTERPRETATION

The prevalence of chlamydia or gonorrhoea, or both, was high among youth but only a minority were symptomatic. Therefore most infections would remain untreated without access to STI testing. Provision of education, counselling, and confidentiality are essential to improve uptake and acceptability of STI testing.

FUNDING

Wellcome Trust.