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Logie CH, Okumu M, Loutet M, Coelho M, McAlpine A, MacKenzie F, Lukone SO, Kisubi N, Kalungi H, Lukone OJ, Kyambadde P. Contextualizing HIV testing experiences within the HIV prevention cascade: qualitative insights from refugee youth in Bidi Bidi refugee settlement, Uganda. BMC Public Health 2024; 24:2599. [PMID: 39334074 PMCID: PMC11429596 DOI: 10.1186/s12889-024-20135-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 09/19/2024] [Indexed: 09/30/2024] Open
Abstract
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.
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Affiliation(s)
- Carmen Helen Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada.
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.
- United Nations University Institute for Water, Environment, and Health, Hamilton, Canada.
- Centre for Gender & Sexual Health Equity, Vancouver, Canada.
| | - Moses Okumu
- School of Social Work, University of Illinois at Urbana Champaign, Urbana, USA
- School of Social Sciences, Uganda Christian University, Mukono, Uganda
| | - Miranda Loutet
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Alyssa McAlpine
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | - Frannie MacKenzie
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada
| | | | - Nelson Kisubi
- Uganda Refugee and Disaster Management Council (URDMC), Arua, Uganda
| | | | | | - Peter Kyambadde
- National AIDS Coordinating Program, Ugandan Ministry of Health, Kampala, Uganda
- Most at Risk Population Initiative (MARPI), Kampala, Uganda
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Klabbers RE, Muwonge TR, Ajidiru S, Borthakur S, Mujugira A, Sharma M, Vinck P, Pham P, Celum C, Parkes-Ratanshi R, O'Laughlin KN. Understanding the barriers and facilitators of COVID-19 risk mitigation strategy adoption and COVID-19 vaccination in refugee settlements in Uganda: a qualitative study. BMC Public Health 2023; 23:1401. [PMID: 37474936 PMCID: PMC10360310 DOI: 10.1186/s12889-023-16320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 07/16/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Perspectives on COVID-19 risk and the willingness and ability of persons living in refugee settlements to adopt COVID-19 prevention strategies have not been rigorously evaluated. The realities of living conditions in Ugandan refugee settlements may limit the extent to which refugees can uptake strategies to mitigate COVID-19 risk. METHODS In-depth qualitative interviews were conducted between April 2021 and April 2022 to assess COVID-19 knowledge, risk perception, prevention strategy adoption including COVID-19 vaccination, and COVID-19 impact on living conditions in refugee settlements in Uganda. Interview participants included 28 purposively selected refugees who called into "Dial-COVID", a free telephone COVID-19 information collection and dissemination platform that was advertised in refugee settlements by community health workers. Interviews were analyzed using a combination of deductive and inductive content analysis. Emerging themes were mapped onto the Theoretical Domains Framework to identify domains influencing prevention behavior. Results were synthesized to provide intervention and policy recommendations for risk mitigation in refugee settlements for COVID-19 and future infectious disease outbreaks. RESULTS The COVID-19 pandemic detrimentally impacted economic and food security as well as social interactions in refugee settlements. Youth were considered especially impacted, and participants reported incidents of child marriage and teenage pregnancy following school closures. Participants displayed general knowledge of COVID-19 and expressed willingness to protect themselves and others from contracting COVID-19. Risk mitigation strategy uptake including COVID-19 vaccination was influenced by COVID-19 knowledge, emotions surrounding COVID-19, the environmental context and resources, personal goals, beliefs about the consequences of (non)adoption, social influences, and behavior reinforcement. Resource constraints, housing conditions, and competing survival needs challenged the adoption of prevention strategies and compliance decreased over time. CONCLUSIONS Contextual challenges impact the feasibility of COVID-19 risk mitigation strategy uptake in refugee settlements. Pre-existing hardships in this setting were amplified by the COVID-19 pandemic and related lockdowns. Targeted dispelling of myths, alignment of information across communication mediums, supporting survival needs and leveraging of respected role models are strategies that may hold potential to mitigate risk of infectious diseases in this setting. REGISTRATION DETAILS World Pandemic Research Network - 490,652.
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Affiliation(s)
- Robin E Klabbers
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | - Scovia Ajidiru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Patrick Vinck
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA
| | - Phuong Pham
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Rosalind Parkes-Ratanshi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Kelli N O'Laughlin
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Logie CH, Okumu M, Loutet MG, Coelho M, Berry I, Gittings L, Odong Lukone S, Kisubi N, Atama M, Kyambadde P. 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. BMJ Open 2022; 12:e065452. [PMID: 36418143 PMCID: PMC9685005 DOI: 10.1136/bmjopen-2022-065452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
- United Nations University Institute for Water, Environment and Health (UNU-INWEH), Hamilton, Ontario, Canada
- Centre for Gender & Sexual Health Equity, Vancouver, British Columbia, Canada
| | - Moses Okumu
- School of Social Work, University of Illinois-Champaign, Urbana, Illinois, USA
- School of Social Sciences, Uganda Christian University, Mukono, Uganda
| | - Miranda G Loutet
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Madelaine Coelho
- Department of Sociology, University of Toronto, Toronto, Ontario, Canada
| | - Isha Berry
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lesley Gittings
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- University of Cape Town, Rondebosch, South Africa
- School of Health Studies, Faculty of Health Sciences, Western University, London, ON, Canada
| | | | - Nelson Kisubi
- Uganda Refugee and Disaster Management Council, Yumbe, Uganda
| | - Malon Atama
- Yumbe Regional Referral Hospital, Yumbe, Uganda
| | - Peter Kyambadde
- Most at Risk Population Initiative, Mulago Hospital, Kampala, Uganda
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Logie CH, Okumu M, Latif M, Parker S, Hakiza R, Kibuuka Musoke D, Mwima S, Batte S, Kyambadde P. Relational Factors and HIV Testing Practices: Qualitative Insights from Urban Refugee Youth in Kampala, Uganda. AIDS Behav 2022; 26:2191-2202. [PMID: 35098391 PMCID: PMC9162965 DOI: 10.1007/s10461-021-03567-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/01/2022]
Abstract
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.
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Palattiyil G, Kisaakye P, Mwenyango H, Katongole S, Mulekya F, Sidhva D, Nair H, Bukuluki P. Access to HIV/AIDS or TB care among refugees in Kampala, Uganda: exploring the enablers and barriers during the COVID-19 pandemic. J Migr Health 2022; 5:100098. [PMID: 35403075 PMCID: PMC8979625 DOI: 10.1016/j.jmh.2022.100098] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/27/2022] [Accepted: 04/02/2022] [Indexed: 10/26/2022] Open
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Social Support and Linkage to HIV Care Following Routine HIV Testing in a Ugandan Refugee Settlement. AIDS Behav 2022; 26:2738-2745. [PMID: 35175438 PMCID: PMC9252961 DOI: 10.1007/s10461-022-03608-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 01/21/2023]
Abstract
We aimed to identify factors associated with linkage to care for individuals newly diagnosed with HIV in a refugee settlement. This study was conducted from October 2018 through January 2020 in Nakivale Refugee Settlement in Uganda. We conducted a cross-sectional survey among individuals accessing routine HIV testing services. The survey included questions on demographic factors, physical and mental health conditions, social support, and HIV-related stigma. We collected GPS coordinates of the homes of individuals newly diagnosed with HIV. Associations with linkage to care were assessed using bivariate and multivariable analyses. Linkage to care was defined as clinic attendance within 90 days of a positive HIV test, not including the day of testing. Network analysis was used to estimate the travel distance between participants' homes and HIV clinic and to spatially characterize participants living with HIV and their levels of social support. Of 219 participants diagnosed with HIV (out of 5,568 participants screened), 74.4% linked to HIV care. Those who reported higher social support had higher odds of linking to care compared with those who reported lower social support. On spatial analysis, lower levels of social support were most prevalent in Nakivale Refugee Settlement itself, with more robust social support southeast and west of the study area. Social support is a salient correlate of linkage to care for individuals living in refugee settlements and could be the focus of an intervention for improving uptake of HIV care services.
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Logie CH, Okumu M, Berry I, Loutet M, Hakiza R, Kibuuka Musoke D, Mwima S, Kiera UM, MacNamee C, Kyambadde P. Social contextual factors associated with lifetime HIV testing among the Tushirikiane urban refugee youth cohort in Kampala, Uganda: Cross-sectional findings. Int J STD AIDS 2022; 33:374-384. [PMID: 35125037 PMCID: PMC8958564 DOI: 10.1177/09564624211069236] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Carmen H Logie
- Factor-Iwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, ON, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, BC, Canada
- United Nations University Institute for Water, Environment & Health (UNU-INWEH), Hamilton, ON, Canada
| | - Moses Okumu
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Isha Berry
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Miranda Loutet
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Robert Hakiza
- Young African Refugees for Integral Development, Kampala, Uganda
| | | | - Simon Mwima
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, USA
- National AIDS Coordinating Program, Ugandan Ministry of Health, Kampala, Uganda
- Bukedi Prevention Institute, Kampala, Uganda
| | - Uwase Mimy Kiera
- Young African Refugees for Integral Development, Kampala, Uganda
- Bukedi Prevention Institute, Kampala, Uganda
| | - Clara MacNamee
- Factor-Iwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Peter Kyambadde
- National AIDS Coordinating Program, Ugandan Ministry of Health, Kampala, Uganda
- Most At Risk Population Initiative, Mulago Hospital, Kampala, Uganda
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Klabbers RE, Muwonge TR, Ayikobua E, Izizinga D, Bassett IV, Kambugu A, Tsai AC, Ravicz M, Klabbers G, O’Laughlin KN. Health Worker Perspectives on Barriers and Facilitators of Assisted Partner Notification for HIV for Refugees and Ugandan Nationals: A Mixed Methods Study in West Nile Uganda. AIDS Behav 2021; 25:3206-3222. [PMID: 33884511 PMCID: PMC8416880 DOI: 10.1007/s10461-021-03265-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 01/29/2023]
Abstract
Assisted partner notification (APN) is recommended by the World Health Organization to notify sexual partners of HIV exposure. Since 2018, APN has been offered in Uganda to Ugandan nationals and refugees. Distinct challenges faced by individuals in refugee settlements may influence APN utilization and effectiveness. To explore APN barriers and facilitators, we extracted index client and sexual partner data from APN registers at 11 health centers providing care to refugees and Ugandan nationals in West Nile Uganda and conducted qualitative interviews with health workers (N = 32). Since APN started, 882 index clients participated in APN identifying 1126 sexual partners. Following notification, 95% (1025/1126) of partners tested for HIV; 22% (230/1025) were diagnosed with HIV with 14% (139/1025) of tested partners newly diagnosed. Fear of stigma and disclosure-related violence limit APN utilization and effectiveness. Prospective research involving index clients and sexual partners is needed to facilitate safe APN optimization in refugee settlements.
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Affiliation(s)
- Robin E. Klabbers
- Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Timothy R. Muwonge
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Ayikobua
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Diego Izizinga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ingrid V. Bassett
- Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Andrew Kambugu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alexander C. Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Miranda Ravicz
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA USA
| | - Gonnie Klabbers
- Department of Health, Ethics and Society, Faculty of Health, Medicine, and Life
Sciences, Maastricht University, Maastricht, the Netherlands
| | - Kelli N. O’Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA USA
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Munezero E, Manoukian S. The social determinants of health and health seeking behaviour in populations affected by armed conflict: a qualitative systematic review. Med Confl Surviv 2021; 37:293-318. [PMID: 34544291 DOI: 10.1080/13623699.2021.1971824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This systematic review explored the relationship between the social determinants of health and health seeking behaviour of individuals affected by armed conflicts. A systematic search of all available evidence was conducted through well-known academic databases. Seven studies met the inclusion criteria and were quality assessed. The synthesis revealed that the social determinants of health in times of conflict also determine the level of health seeking in these individuals. The social determinants were grouped in three main themes a) individual and economic b) sociocultural c) political and health systems. The three themes show that armed conflicts affect health seeking behaviour of individuals in a multi-layered manner with strong connections across the social determinants. This review shows that individuals are forced to choose between fulfilling their basic needs and attending health services. This is further compounded by the lack of health provision in conflict settings. Future research must address the social determinants of health when examining health seeking behaviour of conflict affected populations.
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Affiliation(s)
- Elsa Munezero
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
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O'Laughlin KN, Greenwald K, Rahman SK, Faustin ZM, Ashaba S, Tsai AC, Ware NC, Kambugu A, Bassett IV. A Social-Ecological Framework to Understand Barriers to HIV Clinic Attendance in Nakivale Refugee Settlement in Uganda: a Qualitative Study. AIDS Behav 2021; 25:1729-1736. [PMID: 33263892 PMCID: PMC8081685 DOI: 10.1007/s10461-020-03102-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/21/2022]
Abstract
The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting.
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Affiliation(s)
- Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Kelsy Greenwald
- Harvard Affiliated Emergency Medicine Residency, Boston, MA, USA
| | | | | | | | - Alexander C Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Norma C Ware
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew Kambugu
- Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Ingrid V Bassett
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Ravicz M, Muhongayire B, Kamagaju S, Klabbers RE, Faustin Z, Kambugu A, Bassett I, O'Laughlin K. Using Intervention Mapping methodology to design an HIV linkage intervention in a refugee settlement in rural Uganda. AIDS Care 2021; 34:446-458. [PMID: 33749418 PMCID: PMC8452793 DOI: 10.1080/09540121.2021.1900532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Displaced populations, including refugees, face health challenges such as resource shortages, food and housing insecurity, violence, and disrupted social support. People living with HIV in refugee settings have decreased engagement with HIV services compared to non-refugee populations, and interventions are needed to enhance linkage to care. However, designing health interventions in humanitarian settings is challenging. We used Intervention Mapping (IM), a six-step method for developing theory- and evidence-based health interventions, to design a program to increase linkage to HIV care for refugees and Ugandan nationals in Nakivale Refugee Settlement in Uganda. We engaged a diverse group of stakeholders (N = 14) in Nakivale, including community members and humanitarian actors, in an interactive workshop focusing on IM steps 1–4. We developed a chronic care program that would integrate HIV care with services for hypertension and diabetes at accessible community sites, thereby decreasing stigma around HIV treatment and improving access to care. IM provided an inclusive, efficient method for integrating community members and program implementers in the intervention planning process, and can be used as a method-driven approach to intervention design in humanitarian settings.
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Affiliation(s)
- Miranda Ravicz
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Robin E Klabbers
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | | | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ingrid Bassett
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kelli O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA, USA
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Naal H, Mendelsohn R, Brome D, Noubani A, Nabulsi D, Muhieddine D, Saleh S. Evaluating a capacity building program on women's health for displaced community health workers in fragile settings in Lebanon. HUMAN RESOURCES FOR HEALTH 2021; 19:37. [PMID: 33743708 PMCID: PMC7981387 DOI: 10.1186/s12960-021-00585-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/15/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Displaced populations in fragile settings experience health disparities that are seldom attended to. Task-shifting, which involves training non-specialized community health workers (CHW) to deliver basic education and health services is a favorable strategy to address this problem, however very little data exist on this topic in the Middle East region. We conducted a long-term evaluation of the Women's Health Certificate delivered to Syrian refugees and host community in informal tented settlements in Lebanon under the Mobile University for Health (MUH) program. The training was delivered through a mobile classroom approach that incorporated a blended learning modality. METHODS We collected short-term data from the 42 trained CHW (knowledge assessments and satisfaction measures) during the delivery of the intervention between March and August 2019, and long-term data (semi-structured interviews with 8 CHW and focus group discussion with 9 randomly selected community members) one year later between July and August 2020. The evaluation approach was informed by the Kirkpatrick evaluation model, and the qualitative data were analyzed using qualitative content analysis. RESULTS Data from the CHWs and community members were triangulated, and they showed that the training enhanced access to education due to its mobile nature and provided opportunities for CHWs to engage and interact with learning material that enhanced their knowledge and favorable behaviors regarding women's health. In turn, CHWs were empowered to play an active role in their communities to transfer the knowledge they gained through educating community members and providing women's health services and referrals. Community members benefited from the CHWs and called for the implementation of more similar training programs. CONCLUSION This is one of few studies reporting a long-term community-level evaluation of a task-shifting program on women's health among displaced populations in Lebanon. Our findings support the need to increase funding for similar programs, and to focus on delivering programs for a variety of health challenges. It is also essential to enhance the reach and length of recruitment to wider communities, to design concise, interactive, and engaging sessions, and to provide tools to facilitate circulation of learning material, and resources for referrals to health services.
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Affiliation(s)
- Hady Naal
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Rebecca Mendelsohn
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, USA
| | - Dayana Brome
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Aya Noubani
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Dana Nabulsi
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Dina Muhieddine
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Shadi Saleh
- Global Health Institute, American University of Beirut, Beirut, Lebanon.
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
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Logie CH, Okumu M, Kibuuka Musoke D, Hakiza R, Mwima S, Kyambadde P, Abela H, Gittings L, Musinguzi J, Mbuagbaw L, Baral S. Intersecting stigma and HIV testing practices among urban refugee adolescents and youth in Kampala, Uganda: qualitative findings. J Int AIDS Soc 2021; 24:e25674. [PMID: 33713571 PMCID: PMC7955780 DOI: 10.1002/jia2.25674] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/06/2021] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Moses Okumu
- School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | | | - Robert Hakiza
- Young African Refugees for Integral Development (YARID), Kampala, Uganda
| | - Simon Mwima
- National AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Peter Kyambadde
- National AIDS Control Program, Ministry of Health, Kampala, Uganda.,Most At Risk Population Initiative Clinic, Mulago Hospital, Kampala, Uganda
| | - Heather Abela
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Lesley Gittings
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada.,Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Joshua Musinguzi
- National AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Stefan Baral
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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14
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Logie CH, Okumu M, Kibuuka Musoke D, Hakiza R, Mwima S, Kacholia V, Kyambadde P, Kiera UM, Mbuagbaw L. 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. Trop Med Int Health 2021; 26:572-581. [PMID: 33560587 PMCID: PMC8248412 DOI: 10.1111/tmi.13560] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Moses Okumu
- School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | | | - Robert Hakiza
- Young African Refugees for Integral Development (YARID), Kampala, Uganda
| | - Simon Mwima
- National AIDS Control Program, Ministry of Health, Kampala, Uganda.,Bukedi Prevention Institute, Kampala, Uganda
| | - Vibhuti Kacholia
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Peter Kyambadde
- National AIDS Control Program, Ministry of Health, Kampala, Uganda.,Most At Risk Population Initiative (MARPI), Mulago Hospital, Kampala, Uganda
| | - Uwase Mimy Kiera
- Young African Refugees for Integral Development (YARID), Kampala, Uganda
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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15
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O'Laughlin KN, Xu A, Greenwald KE, Kasozi J, Parker RA, Bustamante N, Parmar P, Faustin ZM, Walensky RP, Bassett IV. A cohort study to assess a communication intervention to improve linkage to HIV care in Nakivale Refugee Settlement, Uganda. Glob Public Health 2020; 16:1848-1855. [PMID: 33222633 DOI: 10.1080/17441692.2020.1847310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Communication interventions to enhance linkage to HIV care have been successful in sub-Saharan Africa but have not been assessed among refugees. Refugees and Ugandan nationals participating in HIV testing in Nakivale Refugee Settlement were offered weekly phone call and short message service (SMS) reminders. We assessed linkage to care and predictors of linkage within 90 days of testing, comparing Intervention participants to those unwilling or ineligible to participate (Non-Intervention). Of 208 individuals diagnosed with HIV, 101 (49%) participated in the intervention. No difference existed between Intervention and Non-intervention groups in linkage to care (73 [72%] vs. 76 [71%], p = 0.88). Excluding those who linked prior to receipt of intervention, the intervention improved linkage (69 [68%] vs. 50 [47%], p = 0.002). Participants were more likely to link if they were older (aOR 2.39 [1.31, 4.37], p = 0.005) or Ugandan nationals (aOR 3.76 [1.12, 12.66], p = 0.033). Although the communication intervention did not significantly improve linkage to HIV care, the linkage was improved when excluding those with same-day linkage. Excluding participants without a phone was a significant limitation; these data are meant to inform more rigorous designs moving forward. Innovative methods to improve linkage to HIV care for this vulnerable population are urgently needed.
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Affiliation(s)
- Kelli N O'Laughlin
- Department of Emergency Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Julius Kasozi
- United Nations High Commissioner for Refugees, Representation in Uganda, Kampala, Uganda
| | - Robert A Parker
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nirma Bustamante
- Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Parveen Parmar
- Division of Global Emergency Medicine, Department of Emergency Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Rochelle P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Brigham & Women's Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ingrid V Bassett
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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16
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Logie CH, Khoshnood K, Okumu M, Rashid SF, Senova F, Meghari H, Kipenda CU. Self care interventions could advance sexual and reproductive health in humanitarian settings. BMJ 2019; 365:l1083. [PMID: 30936067 PMCID: PMC6441869 DOI: 10.1136/bmj.l1083] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Forcibly displaced people often lack access to adequate sexual and reproductive health services. Carmen Logie and colleagues examine the role of self care interventions in filling the gap
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | | | - Moses Okumu
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Sabina Faiz Rashid
- James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Fidan Senova
- Çukurova University Faculty of Medicine, Balcalı Hospital, Adana, Turkey
| | - Hamza Meghari
- Institute for Global Health, University College London, London, UK
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17
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Khatoon S, Budhathoki SS, Bam K, Thapa R, Bhatt LP, Basnet B, Jha N. Socio-demographic characteristics and the utilization of HIV testing and counselling services among the key populations at the Bhutanese Refugees Camps in Eastern Nepal. BMC Res Notes 2018; 11:535. [PMID: 30064508 PMCID: PMC6069810 DOI: 10.1186/s13104-018-3657-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 07/27/2018] [Indexed: 11/29/2022] Open
Abstract
Objectives This cross-sectional study was conducted to describe the socio-demographic characteristics, assess the utilization of HIV testing and counselling services, and to explore the reasons for the non-utilization of HIV testing and counselling services among the key populations at the Bhutanese refugee camps in eastern Nepal. Results The HIV testing and counselling services are utilized by less than a third (29%) of the key population among the Bhutanese Refugees. The prime source of information about the HIV testing and counselling sites has been health workers followed by peer/outreach educators and neighbors. Common self-reported barriers for utilization of HIV testing and counselling services by the Bhutanese refugees were self-perceived stigma about HIV, the fear of being discriminated and the lack of knowledge about HIV testing and counselling services. There is a need to analyze the gap between availability and utilization through more qualitative approaches in order to identify interventions to increase the uptake of the HIV testing and counselling services.
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Affiliation(s)
- Salina Khatoon
- United Nations High Commissioner for Refugees, Sub-Office, Damak, Nepal
| | - Shyam Sundar Budhathoki
- School of Public Health and Community Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Kiran Bam
- Local Action for Global Health and Environment (LAGHE)-Nepal, Dhangadhi 5, Kailali, Nepal
| | - Rajshree Thapa
- AMDA Nepal Primary Health Care Project for Bhutanese Refugees, Damak, Nepal
| | - Lokesh P Bhatt
- Association of Medical Doctors of Asia-HIV/AIDS for Migrants (AMDA-HAMI), Kathmandu, Nepal
| | - Bidhya Basnet
- Birat Health College and Research Center, Biratnagar, Nepal
| | - Nilambar Jha
- School of Public Health and Community Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
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Feasibility and acceptability of home-based HIV testing among refugees: a pilot study in Nakivale refugee settlement in southwestern Uganda. BMC Infect Dis 2018; 18:332. [PMID: 30012110 PMCID: PMC6048800 DOI: 10.1186/s12879-018-3238-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 07/05/2018] [Indexed: 12/28/2022] Open
Abstract
Background Refugees in sub-Saharan Africa face both the risk of HIV infection and barriers to HIV testing. We conducted a pilot study to determine the feasibility and acceptability of home-based HIV testing in Nakivale Refugee Settlement in Uganda and to compare home-based and clinic-based testing participants in Nakivale. Methods From February–March 2014, we visited homes in 3 villages in Nakivale up to 3 times and offered HIV testing. We enrolled adults who spoke English, Kiswahili, Kinyarwanda, or Runyankore; some were refugees and some Ugandan nationals. We surveyed them about their socio-demographic characteristics. We evaluated the proportion of individuals encountered (feasibility) and assessed participation in HIV testing among those encountered (acceptability). We compared characteristics of home-based and clinic-based testers (from a prior study in Nakivale) using Wilcoxon rank sum and Pearson’s chi-square tests. We examined the relationship between a limited number of factors (time of visit, sex, and number of individuals at home) on willingness to test, using logistic regression models with the generalized estimating equations approach to account for clustering. Results Of 566 adults living in 319 homes, we encountered 507 (feasibility = 90%): 353 (62%) were present at visit one, 127 (22%) additional people at visit two, and 27 (5%) additional people at visit three. Home-based HIV testing participants totaled 378 (acceptability = 75%). Compared to clinic-based testers, home-based testers were older (median age 30 [IQR 24–40] vs 28 [IQR 22–37], p < 0.001), more likely refugee than Ugandan national (93% vs 79%, < 0.001), and more likely to live ≥1 h from clinic (74% vs 52%, < 0.001). The HIV prevalence was lower, but not significantly, in home-based compared to clinic-based testing participants (1.9 vs 3.4% respectively, p = 0.27). Testing was not associated with time of visit (p = 0.50) or sex (p = 0.66), but for each additional person at home, the odds of accepting HIV testing increased by over 50% (OR 1.52, 95%CI 1.12–2.06, p = 0.007). Conclusions Home-based HIV testing in Nakivale Refugee Settlement was feasible, with 90% of eligible individuals encountered within 3 visits, and acceptable with 75% willing to test for HIV, with a yield of nearly 2% individuals tested identified as HIV-positive.
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O'Laughlin KN, Rouhani SA, Kasozi J, Greenwald KE, Perkons NR, Faustin ZM, Bassett IV, Ware NC. A qualitative approach to understand antiretroviral therapy (ART) adherence for refugees living in Nakivale Refugee Settlement in Uganda. Confl Health 2018; 12:7. [PMID: 29545828 PMCID: PMC5846232 DOI: 10.1186/s13031-018-0145-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 01/12/2018] [Indexed: 01/24/2023] Open
Abstract
Background Refugees living with HIV in sub-Saharan Africa suffer unique hardships that may increase their vulnerability to interruptions in antiretroviral therapy (ART). Methods To investigate refugees’ experiences adhering to ART, we conducted inperson interviews with refugees on ART (n = 73) and HIV clinic staff (n = 4) in Nakivale Refugee Settlement in southwest Uganda from March to July 2011. Three analysts used a conventional content analysis approach to evaluate these data. Results Refugees described profound motivation to adhere to ART and employed adherence strategies to facilitate success despite the austere setting. However, refugees spoke of specific hardships living in Nakivale that served as barriers to ART adherence, including difficulty accessing clinic when ill, food insecurity, drug stockouts, and violence and unrest in the settlement. For some refugees, need for ART inextricably linked them to the HIV clinic and prevented them from transitioning permanently away from the settlement. Conclusions By learning about refugees’ experiences we can design informed interventions to enhance ART adherence, thus minimizing morbidity and mortality, preventing transmission of HIV, and supporting refugees’ abilities to move freely toward repatriation, resettlement or integration in their host country.
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Affiliation(s)
- Kelli N O'Laughlin
- 1Division of International Emergency Medicine and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,2Medical Practice Evaluation Center, Department of Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Shada A Rouhani
- 1Division of International Emergency Medicine and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Julius Kasozi
- United Nations High Commissioner for Refugees, P.O. Box 3813, Kampala, Uganda
| | - Kelsy E Greenwald
- 3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA.,11Harvard Affiliated Emergency Medicine Residency, 75 Francis Street, Boston, MA 02115 USA
| | | | | | - Ingrid V Bassett
- 2Medical Practice Evaluation Center, Department of Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA.,7Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA.,8Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 0213 USA
| | - Norma C Ware
- 9Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,10Department of Global Health & Social Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
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O'Laughlin KN, Kasozi J, Rabideau DJ, Parker RA, Mulogo E, Faustin ZM, Greenwald KE, Doraiswamy S, Walensky RP, Bassett IV. The cascade of HIV care among refugees and nationals in Nakivale Refugee Settlement in Uganda. HIV Med 2017; 18:513-518. [PMID: 28070923 DOI: 10.1111/hiv.12476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Refugees living in Uganda come from HIV-endemic countries, and many remain in refugee settlements for over a decade. Our objective was to evaluate the HIV care cascade in Nakivale Refugee Settlement and to assess correlates of linkage to care. METHODS We prospectively enrolled individuals accessing clinic-based HIV testing in Nakivale Refugee Settlement from March 2013 to July 2014. Newly HIV-diagnosed clients were followed for 3 months post-diagnosis. Clients underwent a baseline survey. The following outcomes were obtained from HIV clinic registers in Nakivale: clinic attendance ('linkage to HIV care'), CD4 testing, antiretroviral therapy (ART) eligibility, and ART initiation within 90 days of testing. Descriptive data were reported as frequency with 95% confidence interval (CI) or median with interquartile range (IQR). The impact of baseline variables on linkage to care was assessed with logistic regression models. RESULTS Of 6850 adult clients tested for HIV, 276 (4%; CI: 3-5%) were diagnosed with HIV infection, 148 (54%; CI: 47-60%) of those were linked to HIV care, 54 (20%; CI: 15-25%) had a CD4 test, 22 (8%; CI: 5-12%) were eligible for ART, and 17 (6%; CI: 3-10%) initiated ART. The proportions of refugees and nationals at each step of the cascade were similar. We identified no significant predictors of linkage to care. CONCLUSIONS Less than a quarter of newly HIV-diagnosed clients completed ART assessment, considerably lower than in other reports from sub-Saharan Africa. Understanding which factors hinder linkage to and engagement in care in the settlement will be important to inform interventions specific for this environment.
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Affiliation(s)
- K N O'Laughlin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard Humanitarian Initiative, Cambridge, MA, USA
| | - J Kasozi
- Representation in Uganda, United Nations High Commissioner for Refugees, Kampala, Uganda
| | - D J Rabideau
- Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA
| | - R A Parker
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - E Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Z M Faustin
- Kasese Campus, Bugema University, Kampala, Uganda
| | | | - S Doraiswamy
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - R P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - I V Bassett
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
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21
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O'Laughlin KN, Rabideau DJ, Kasozi J, Parker RA, Bustamante ND, Faustin ZM, Greenwald KE, Walensky RP, Bassett IV. Predictors of HIV infection: a prospective HIV screening study in a Ugandan refugee settlement. BMC Infect Dis 2016; 16:695. [PMID: 27881099 PMCID: PMC5120554 DOI: 10.1186/s12879-016-2021-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 11/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The instability faced by refugees may place them at increased risk of exposure to HIV infection. Nakivale Refugee Settlement in southwestern Uganda hosts 68,000 refugees from 11 countries, many with high HIV prevalence. We implemented an HIV screening program in Nakivale and examined factors associated with new HIV diagnosis. METHODS From March 2013-November 2014, we offered free HIV screening to all clients in the Nakivale Health Center while they waited for their outpatient clinic visit. Clients included refugees and Ugandan nationals accessing services in the settlement. Prior to receiving the HIV test result, participants were surveyed to obtain demographic information including gender, marital status, travel time to reach clinic, refugee status, and history of prior HIV testing. We compared variables for HIV-infected and non-infected clients using Pearson's chi-square test, and used multivariable binomial regression models to identify predictors of HIV infection. RESULTS During the HIV screening intervention period, 330 (4%) of 7766 individuals tested were identified as HIV-infected. Refugees were one quarter as likely as Ugandan nationals to be HIV-infected (aRR 0.27 [0.21, 0.34], p < 0.0001). Additionally, being female (aRR 1.43 [1.14, 1.80], p = 0.002) and traveling more than 1 h to the clinic (aRR 1.39 [1.11, 1.74], p = 0.003) increased the likelihood of being HIV-infected. Compared to individuals who were married or in a stable relationship, being divorced/separated/widowed increased the risk of being HIV-infected (aRR 2.41 [1.88, 3.08], p < 0.0001), while being single reduced the risk (aRR 0.60 [0.41, 0.86], p < 0.0001). Having been previously tested for HIV (aRR 0.59 [0.47, 0.74], p < 0.0001) also lowered the likelihood of being HIV-infected. CONCLUSIONS In an HIV screening program in a refugee settlement in Uganda, Ugandan nationals are at higher risk of having HIV than refugees. The high HIV prevalence among clients seeking outpatient care, including Ugandan nationals and refugees, warrants enhanced HIV screening services in Nakivale and in the surrounding region. Findings from this research may be relevant for other refugee settlements in Sub-Saharan Africa hosting populations with similar demographics, including the 9 other refugee settlements in Uganda.
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Affiliation(s)
- Kelli N O'Laughlin
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA. .,Harvard Humanitarian Initiative, Cambridge, MA, USA.
| | - Dustin J Rabideau
- MGH Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
| | - Julius Kasozi
- United Nations High Commissioner for Refugees, Representation in Uganda, PO Box 3813, Kampala, Uganda
| | - Robert A Parker
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,MGH Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nirma D Bustamante
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Rochelle P Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Brigham & Women's Hospital, Boston, MA, USA
| | - Ingrid V Bassett
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
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22
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Rouhani SA, O'Laughlin KN, Faustin ZM, Tsai AC, Kasozi J, Ware NC. The role of social support on HIV testing and treatment adherence: A qualitative study of HIV-infected refugees in southwestern Uganda. Glob Public Health 2016; 12:1051-1064. [PMID: 26783835 DOI: 10.1080/17441692.2015.1132472] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Little is known about the factors that encourage or discourage refugees to test for HIV, or to access and adhere to HIV care. In non-refugee populations, social support has been shown to influence HIV testing and utilisation of services. The present study enrolled HIV-infected refugees on anti-retroviral therapy (ART) in Uganda, who participated in qualitative interviews on HIV testing, treatment, and adherence. Interviews were analysed for themes about four types of social support: emotional, informational, instrumental, and appraisal support. A total of 61 interviews were analysed. Four roles for these types of social support were identified: (1) informational support encouraged refugees to test for HIV; (2) emotional support helped refugees cope with a diagnosis of HIV; (3) instrumental support facilitated adherence to ART and (4) after diagnosis, HIV-infected refugees provided informational and emotional support to encourage other refugees to test for HIV. These results suggest that social support influences HIV testing and treatment among refugees. Future interventions should capitalise on social support within a refugee settlement to facilitate testing and treatment.
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Affiliation(s)
- Shada A Rouhani
- a Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA.,b Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
| | - Kelli N O'Laughlin
- a Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA.,b Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA.,c Medical Practice Evaluation Center , Massachusetts General Hospital , Boston , MA , USA
| | | | - Alexander C Tsai
- e Massachusetts General Hospital (MGH) , MGH Global Health , Boston , MA , USA.,f Harvard Center for Population and Development Studies , Cambridge , MA , USA
| | - Julius Kasozi
- g United Nations High Commissioner for Refugees , Kampala , Uganda
| | - Norma C Ware
- h Department of Global Health and Social Medicine , Harvard Medical School , Boston , MA , USA
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23
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OʼLaughlin KN, Kasozi J, Walensky RP, Parker RA, Faustin ZM, Doraiswamy S, Owino CO, Bassett IV. Clinic-based routine voluntary HIV testing in a refugee settlement in Uganda. J Acquir Immune Defic Syndr 2015; 67:409-13. [PMID: 25162817 DOI: 10.1097/qai.0000000000000317] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We implemented and evaluated a clinic-based routine voluntary HIV testing intervention in Nakivale Refugee Settlement in Uganda. Comparing the standard of care period (40 d) with the intervention period (168 d), the mean HIV-infected clients identified per week increased from 0.9 to 5.6, and there was no significant difference between the HIV prevalence in the 2 periods (standard of care: 3.3%; intervention: 4.5%; P > 0.5). Clinic-based routine HIV testing in a refugee settlement is effective and should be considered for implementation in refugee settlements in other high-prevalence regions in sub-Saharan Africa.
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Affiliation(s)
- Kelli N OʼLaughlin
- *Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; †Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA; ‡Harvard Medical School, Boston, MA; §Harvard Humanitarian Initiative, Cambridge, MA; ‖United Nations High Commissioner for Refugees, Representation in Uganda, Kampala, Uganda; ¶Division of General Medicine, Massachusetts General Hospital, Boston, MA; #Division of Infectious Disease, Massachusetts General Hospital, Boston, MA; **Harvard University Center for AIDS Research, Boston, MA; ††Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA; ‡‡MGH Biostatistics Center, Massachusetts General Hospital, Boston, MA; §§Bugema University, Kampala, Uganda; ‖‖United Nations High Commissioner for Refugees, Geneva, Switzerland; and ¶¶Medical Teams International, Mbarara, Uganda
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