Being an 'adolescent': The consequences of gendered risks for young people in rural Uganda

“We are experiencing pain on our own”: mental health care to prevail over impacts of cultural silence on HIV

Purpose

This qualitative case study aims to investigate how current services meet the emotional needs of young women growing up with perinatally acquired human immunodeficiency virus (HIV). Young women (15–19 years old), caregivers and service providers were recruited through three multidisciplinary HIV management centres in Malawi.

Design/methodology/approach

In-depth interviews were used to collect data for 14 “cases” (each “case” involved a young woman, a caregiver and a service provider, for a total of 42 participants). The interviews with adolescents were conducted using an innovative visual method known as the “my story” book.

Findings

Thematic analysis revealed that young women experienced traumatic experiences and emotional neglect after being diagnosed as HIV positive. Lack of adult support networks and social isolation were identified as intersecting factors contributing to their mental distress. According to the findings of this study, HIV care should more explicitly include comprehensive mental health-care services. This provision should include ongoing individualised counselling sessions, supplemented by communication skills training to help break the prevalent cultural silence on HIV issues. Young people living with HIV, in general, and young women, are more likely to experience mental health issues than their non-infected peers. Integrating comprehensive mental health evaluation and treatment into HIV care for young people can be beneficial.

Practical implications

Mental health issues are critical and underserved challenges among young people living with perinatally acquired HIV. Women experience a higher prevalence of mental challenges than men. Integrating comprehensive mental health evaluation and treatment into HIV care for young people can be beneficial. Therefore, interventions to assist young people with mental health issues are needed within the context of HIV management in Malawi.

Originality/value

Many studies on mental health and HIV/AIDS have been conducted. However, there is very little information as regards the emotional needs of young women growing up with perinatally acquired HIV. This study fills the void.

Exploring adolescent engagement in sexual and reproductive health research in Kenya, Rwanda, Tanzania, and Uganda: A scoping review

Adolescent sexual and reproductive health (ASRH) in East Africa has prioritized research on the barriers to care, communication, and ASRH knowledge, attitudes, and practices. However, there is little research examining the extent to which meaningful adolescent engagement in research is achieved in practice and how this influences the evidence available to inform ASRH services. This review offers a critical step towards understanding current approaches to adolescent engagement in ASRH research and identifying opportunities to build a strengthened evidence base with adolescent voices at the centre. This scoping review is based on Arksey and O'Malley's (2005) framework, employing a keyword search of four databases via OVID: Medline, Global Health, Embase and PsycINFO. Two reviewers screened title, abstract and full text to select articles examining ASRH in Tanzania, Rwanda, Kenya, and Uganda, published between 2000 and 2020. After articles were selected, data was extracted, synthesized, and thematically organized to highlight emerging themes and potential opportunities for further research. The search yielded 1201 results, 34 of which were included in the final review. Results highlight the methods used to gather adolescent perspectives of ASRH (qualitative), the content of those perspectives (knowledge, sources of information, gaps in information and adolescent friendly services), and the overall narratives that frame discussions of ASRH (risky sexual behaviour, stigma, and gender norms). Findings indicate the extent of adolescent engagement in ASRH research is limited, resulting in a lack of comprehensive evidence, consistent challenges with stigma, little information on holistic concepts and a narrow framing of ASRH. In conclusion, there is opportunity for more meaningful engagement of adolescents in ASRH research. This engagement can be achieved by involving adolescents more comprehensively throughout the research cycle and by expanding the range of ASRH topics explored, as identified by adolescents.

Proximate and distal factors associated with the stall in the decline of adolescent pregnancy in Uganda

Background

Adolescent pregnancy in Uganda declined from 31% in 2000–01 to 25% in 2006 but thereafter stalled at 25% from 2006 to 2016. This paper investigates the factors associated with the recent stall in the rate of decline of adolescent pregnancy in Uganda.

Methods

We used logistic regression models for 4 years (2000–01, 2006, 2011 and 2016) of data from the Uganda Demographic Health Survey to explore proximate and distal factors of adolescent pregnancy in Uganda. We carried out Blinder-Oaxaca decomposition models to explore the contributions of different factors in explaining the observed decline in adolescent pregnancy between 2001 and 2006, and the subsequent stall between 2006 and 2016.

Results

We found that marriage among women aged 15–19 years, and early sexual debut, were strongly associated with adolescent pregnancy. These declined substantially between 2000 and 01 and 2006, leading to a decline in adolescent pregnancy. Their decline was in turn associated with rising levels of female education and household wealth. After 2006, education levels and household wealth gains stalled, with associated stalls in the decline of marriage among women aged 15–19 years and sexual debut, and a stall in the decline of adolescent pregnancy.

Conclusions

The stall in the decline of adolescent pregnancies in Uganda was linked to a stall in the reduction of adolescent marriage, which in turn was associated with limited progress in female educational attainment between 2006 and 2016. We emphasize the need for a renewed focus on girl’s education and poverty reduction to reduce adolescent pregnancy in Uganda and subsequently improve health outcomes for adolescent girls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11403-6.

'This is what is going to help me': Developing a co-designed and theoretically informed harm reduction intervention for mobile youth in South Africa and Uganda

ABSTRACTYoung migrants in sub-Saharan Africa are particularly vulnerable to HIV-acquisition. Despite this, they are consistently under-served by services, with low uptake and engagement. We adopted a community-based participatory research approach to conduct longitudinal qualitative research among 78 young migrants in South Africa and Uganda. Using repeat in-depth interviews and participatory workshops we sought to identify their specific support needs, and to collaboratively design an intervention appropriate for delivery in their local contexts. Applying a protection-risk conceptual framework, we developed a harm reduction intervention which aims to foster protective factors, and thereby nurture resilience, for youth 'on the move' within high-risk settings. Specifically, by establishing peer supporter networks, offering a 'drop-in' resource centre, and by identifying local adult champions to enable a supportive local environment. Creating this supportive edifice, through an accessible and cohesive peer support network underpinned by effective training, supervision and remuneration, was considered pivotal to nurture solidarity and potentially resilience. This practical example offers insights into how researchers may facilitate the co-design of acceptable, sustainable interventions.

Long-Term Outcomes of the Good School Toolkit Primary School Violence Prevention Intervention Among Adolescents: Protocol for a Nonrandomized Quasi-Experimental Study

Background

Violence against children in schools is a global public health problem. There is growing evidence that school-based interventions can be effective in reducing violence against children in schools. However, there is little evidence on the long-term impact of such interventions. The Good School Toolkit, developed by Raising Voices, a Uganda-based nonprofit organization, is a whole-school violence prevention intervention that aims to change the operational culture of primary schools. In 2014, the Good School Toolkit was evaluated through a cluster randomized controlled trial (Good Schools Study) and found to reduce teacher-to-student and student-to-student violence.

Objective

This protocol describes quantitative analyses to explore long-term outcomes of the Good School Toolkit intervention among adolescents in Uganda, including the extent to which it is associated with peer-violence victimization (primary outcome) and peer-violence perpetration, intimate-partner violence, acceptance of teacher-violence, equitable gender attitudes, agency, self-regulation, peer connectedness, social assets, psychological assets, and retention in school (secondary outcomes).

Methods

This is a nonrandomized quasi-experimental 4-year follow-up study of adolescents who attended the 42 Good Schools Study primary schools in 2014; 21 schools initiated the Good School Toolkit intervention during the trial from 2012, and 19 schools initiated the intervention after the trial (during the later delivery phase) from 2015; 2 schools did not implement the intervention. Students in the final school grade (Primary 7) during 2014 of the 19 primary schools in the later delivery phase are expected to have left school prior to toolkit delivery in 2015. Wave 1 data were collected in 2014 from 3431 grade Primary 5 to Primary 7 school students aged 11-14 years; these students were followed up in 2018-2019 when aged 16-19 years and invited to participate in the Wave 2 survey. Data were collected in face-to-face interviews by trained Ugandan field researchers. Toolkit exposure groups are defined as exposed during the Good Schools Study trial (from 2012), as exposed during later delivery (from 2015), or not exposed including those expected to have completed Primary 7 prior to later delivery or from the 2 schools that did not implement the toolkit. Associations between outcomes at Wave 2 and toolkit exposure groups will be analyzed using mixed-effect multivariable logistic and linear regression models for binary and continuous outcomes, respectively. This analysis is exploratory and aims to generate hypotheses on if, and under what circumstances, the toolkit influences later adolescent outcomes.

Results

Data collection was completed in August 2019.

Conclusions

To our knowledge, this is the first long-term follow-up study of adolescents exposed to a school-based violence-prevention intervention in sub-Saharan Africa. If the intervention reduces violence and improves other outcomes in later adolescence, then this study supports primary school interventions as key to achieving long-term population impacts. The pattern of effects will inform where reinforced or additional interventions are needed.

International Registered Report Identifier (IRRID)

DERR1-10.2196/20940

Scaling up peer-led community-based differentiated support for adolescents living with HIV: keeping the needs of youth peer supporters in mind to sustain success

INTRODUCTION

Low rates of viral suppression among adolescents living with HIV (ALHIV) indicate that more effective support is urgently required at scale. The provision of peer support has generated considerable enthusiasm because it has the potential to ameliorate the complex social and relational challenges which underpin suboptimal adherence. Little is known about the impact on young peer supporters themselves, which is the focus of this paper.

METHODS

We present qualitative findings from the Zvandiri trial investigating the impact of a peer support intervention on the viral load for beneficiaries (ALHIV, aged 13 to 19 years) in Zimbabwe. The Zvandiri peer supporters aged 18 to 24 years, known as community adolescent treatment supporters (CATS), are themselves living with HIV. Individual in-depth interviews were conducted in late 2018 with 17 CATS exploring their experiences of delivering peer support and their own support needs. Interviews were analysed iteratively using thematic analysis.

RESULTS

The CATS reported that being peer supporters improved their own adherence behaviour and contributed to an improved sense of self-worth. The social connections between the CATS were a source of comfort and enabled them to develop skills to manage the challenging aspects of their work. Two substantial challenges were identified. First, their work may reveal their HIV status. Second, managing the emotional labour of this caring work; given how commonly the complexity of the beneficiaries' needs mirrored the circumstances of their own difficult lives. Both challenges were ameliorated by the support the CATS provided to each other and ongoing supervision from the adult mentor. There was variation in whether they felt their roles were appropriately valued through the remuneration they received and within the health system. There was a consensus that their experience meant that they would graduate from being a CATS with transferable skills that could enhance their employability.

CONCLUSIONS

Their experiences illustrate the advantages and opportunities of being a CATS. To minimize potential harms, it is vital to ensure that they feel valued in their role, which can be demonstrated by the provision of appropriate remuneration, recognition and respect, and that there is continued investment in ongoing support through ongoing training and mentoring.

Adolescents at risk of self-harm in Ghana: a qualitative interview study exploring the views and experiences of key adult informants

BACKGROUND

In Ghana, rates of self-harm in young people are as high as they are in high income countries. Self-reported interpersonal, familial and societal stressors form the most important background, and self-harm is seen by young people as a way of responding to that stress. In the present study, we obtained the views of key adult informants about self-harm among adolescents in Ghana - what they thought as possible reasons for self-harm in young people and what actions might be needed at an individual or population level to respond to the problem.

METHODS

We interviewed face-to-face 11 adults, using a semi-structured interview guide. We used an experiential thematic analysis technique to analyse the transcribed interviews.

RESULTS

The analysis identified five themes: "underestimating the prevalence of self-harm in adolescents", "life on the streets makes self-harm less likely", "self-harm in adolescents is socially and psychologically understandable", "ambivalence about responding to adolescent self-harm", and "few immediate opportunities for self-harm prevention in Ghana". Adolescent self-harm was acknowledged but its scale was underestimated. The participants offered explanations for adolescent self-harm in social and psychological terms that are recognisable from accounts in high income countries. Low rates among street-connected young people were explained by their overarching orientation for survival. Participants agreed that identification was important, but they expressed a sense of inadequacy in identifying and supporting adolescents at risk of self-harm. Again, the participants agreed that self-harm in adolescents should be prevented, but they recognised that relevant policies were not in place or if there were policies they were not implemented - mental health and self-harm were not high on public or political priorities.

CONCLUSIONS

The adults we interviewed about young people who self-harm see themselves as having a role in identifying adolescents at risk of self-harm and see the organisations in which they work as having a role in responding to individual young people in need. These are encouraging findings that point to at least one strand of a policy in Ghana for addressing the problem of self-harm in young people.

A reflection on ethical and methodological challenges of using separate interviews with adolescent-older carer dyads in rural South Africa

Background

This article discusses our reflections on ethical and methodological challenges when conducting separate interviews with individuals in dyads in the uMkhanyakude district, South Africa. Our work is embedded in an ethnographic study exploring care relationships between adolescents and their older carers in the context of a large-donor funded HIV programme. We use these reflections to discuss some of the challenges and present possible management strategies that may be adopted in conducting dyadic health research in resource-poor settings.

Methods

Drawing from the relational agency, three rounds of separate interviews and participant observation were undertaken with dyads of adolescents aged between 13 and 19 and their older carers aged 50+ from October 2017 to September 2018. A reflexive journal was kept to record the interviewer's experiences of the whole research process. We identified methodological and ethical challenges from these data during the thematic analysis.

Results

A total of 36 separate interviews were conducted with six pairs of adolescent-older carer dyads (n = 12 participants). Five themes emerged: recruitment of dyads, consenting dyads, confidentiality, conducting separate interviews with adolescents and older carers, and interviewer-dyad interaction. We also illustrated how we dealt with these challenges.

Conclusions

Results from this study can guide the recruitment, consenting and collecting data for health studies that employ a similar form of enquiry in LMICs. However, ethical and methodological challenges should be recognised as features of the relationships between cross-generation dyads rather than weaknesses of the method.