Massy Mutumba

Sexual and reproductive health: Progress and outstanding needs

We examine progress towards the 1994 International Conference on Population and Development (ICPD) commitment to provide universal access to sexual and reproductive health (SRH) services by 2014, with an emphasis on changes for those living in poor and emerging economies. Accomplishments include a 45% decline in the maternal mortality ratio (MMR) between 1990 and 2013; 11.5% decline in global unmet need for modern contraception; ~21% increase in skilled birth attendance; and declines in both the case fatality rate and rate of abortion. Yet aggregate gains mask stark inequalities, with low coverage of services for the poorest women. Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 80 developing countries highlight persistent disparities in skilled birth attendance by household wealth: in 70 of 80 countries (88%), ≥80% of women in the highest quintile were attended by a skilled provider at last birth; in only 23 of the same countries (29%) was this the case for women in the lowest wealth quintile. While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor.

Disclosure of HIV status to perinatally infected adolescents in urban Uganda: a qualitative study on timing process and outcomes.

&NA; Disclosure of HIV status to children and adolescents living with HIV remains a challenge in pediatric HIV care. Many of the current disclosure guidelines from national and international bodies recommend that perinatally infected children be informed of their HIV status prior to adolescence, but rates of disclosure in both high‐ and low‐income countries remains low. The applicability of the recommendations to low‐income countries remains largely unknown, as few studies have explored the disclosure process in these settings. Our purpose was to explore disclosure experiences of HIV‐infected adolescents in Uganda. Disclosure was a largely one‐time event conducted by health care providers. The average age at disclosure was 13 years. Disclosure elicited a diverse array of positive and negative reactions, including suicidal ideation; reactions were closely associated with participant age, gender, knowledge about HIV, and health status at time of disclosure. Interventions to promote locally effective, process‐oriented approaches to early disclosure are needed.

The Social Legacy of AIDS: Fertility Aspirations Among HIV-Affected Women in Uganda

OBJECTIVES We investigated the impact of HIV status on fertility desires in Uganda. METHODS We surveyed 1594 women aged 18 to 49 years visiting outpatient services at Mbarara Regional Hospital, from May through August 2010. Of these, 59.7% were HIV-positive; 96.4% of HIV-positive women were using antiretroviral therapy (ART). We used logistic regression models to examine relationships between HIV status and fertility desires, marital status, household structure, educational attainment, and household income. RESULTS Among married women, HIV-positive status was significantly associated with a lower likelihood of desiring more children (27.7% vs 56.4% of HIV-negative women; χ(2) = 39.97; P < .001). The difference remained highly significant net of age, parity, son parity, foster children, education, or household income. HIV-positive women were more likely to be poor, unmarried, single heads of household, in second marriages (if married), living with an HIV-positive spouse, and supporting foster children. CONCLUSIONS We found a strong association between positive HIV status and lower fertility aspirations among married women in Uganda, irrespective of ART status. Although the increasing availability of ART is a tremendous public health achievement, women affected by HIV have numerous continuing social needs.

Mental health and support among young key populations: an ecological approach to understanding and intervention

The patterning of the HIV epidemic within young key populations (YKPs) highlights disproportionate burden by mental disorders in these populations. The mental wellbeing of YKPs is closely associated with biological predispositions and psychosocial factors related to YKPs’ sexual and gender identities and socio‐economic status. The purpose of this paper is to highlight sources of risk and resilience, as well as identify treatment and supports for mental health disorders (MHDs) among YKPs.

Psychometric properties of instruments for assessing depression among African youth: A systematic review

Objective This study aimed to systematically review the psychometric properties of instruments used to screen for major depressive disorder or assess depression symptom severity among African youth. Methods Systematic search terms were applied to seven bibliographic databases: African Journals Online, the African Journal Archive, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Medical Literature Analysis and Retrieval System Online (MEDLINE), PsycINFO, and the World Health Organization (WHO) African Index Medicus. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on data collected from youth (any author definition) in an African member state of the United Nations. We extracted data on study population characteristics, sampling strategy, sample size, the instrument assessed, and the type of reliability and/or validity evidence provided. Results Of 1 027 records, we included 23 studies of 10 499 youth in 10 African countries. Most studies reported excellent scale reliability, but there was much less evidence of equivalence or criterion-related validity. No measures were validated in more than two countries. Conclusions There is a paucity of evidence on the reliability or validity of depression assessment among African youth. The field is constrained by a lack of established criterion standards, but studies incorporating mixed methods offer promising strategies for guiding the process of cross-cultural development and validation.

Examining the relationship between psychological distress and adherence to anti-retroviral therapy among Ugandan adolescents living with HIV.

ABSTRACT Psychological distress is common among adolescents living with HIV (ALHIV) worldwide, and has been associated with non-adherence to anti-retroviral therapy (ART), leading to poor virologic suppression, drug resistance, and increased risk for AIDS morbidity and mortality. However, only a few studies have explored the relationship between psychological distress and ART adherence among adolescents in sub-Saharan Africa. The paper examines the relationship between psychological distress and ART adherence, and effect of psychosocial resources on ART adherence. We conducted a cross-sectional survey of 464 ALHIV (aged 12–19; 53% female) seeking HIV care at a large HIV treatment center in Kampala, Uganda. ALHIV were recruited during routine clinic visits. Three self-reported binary adherence measures were utilized: missed pills in the past three days, non-adherence to the prescribed medical regimen, and self-rated adherence assessed using a visual analog scale. Psychological distress was measured as a continuous variable, and computed as the mean score on a locally developed and validated 25-item symptom checklist for Ugandan ALHIV. Psychosocial resources included spirituality, religiosity, optimism, social support, and coping strategies. After adjusting for respondents’ socio-demographic characteristics and psychosocial resources, a unit increase in psychological distress was associated with increased odds of missing pills in past 3 days (Odds Ratio(OR) = 1.75; Confidence Interval (CI): 1.04–2.95), not following the prescribed regimen (OR = 1.63; CI: 1.08–2.46), and lower self-rated adherence (OR = 1.79; CI: 1.19–2.69). Psychosocial resources were associated with lower odds for non-adherence on all three self-report measures. There is a need to strengthen the psychosocial aspects of adolescent HIV care by developing interventions to identify and prevent psychological distress among Ugandan ALHIV.

Community influences on modern contraceptive use among young women in low and middle-income countries: a cross-sectional multi-country analysis

BackgroundDespite investment in family planning programs and education, unmet need for family planning remains high among young women (aged 15–24) in low and middle-income countries, increasing the risk for unwanted pregnancies and adverse social and reproductive health outcomes. There is a dearth of cross-national research that identifies the differential impact of community level factors among youth in low and middle-income countries (LMICs), which is imperative for the design of structural level interventions aimed at increasing family planning use.MethodsGrounded in the socio-ecological framework, this paper utilizes Demographic and Health Survey (DHS) from 52 LMICs to examine the influence of community level reproductive, gender, fertility, literacy and economic indicators on modern contraceptive use among female youth. Analyses are conducted using multi-level logistic regressions with random community-level effects.ResultsOur findings highlight the positive influence of community level education attainment and negative influence of gender and fertility related norms on young women’s contraceptive use. Additionally, increased exposure to mass media did not positively influence young women’s uptake of modern contraceptive methods.ConclusionsTaken together, findings indicate that young women’s contraceptive decision-making is greatly shaped by their social contexts. The commonalities and regional variations in community level influences provide support for both structural level interventions and tailored regional approaches to family planning interventions.

Psychological distress among Ugandan adolescents living with HIV: Examining stressors and the buffering role of general and religious coping strategies

ABSTRACT HIV infection increases the risk of psychological distress among adolescents living with HIV (ALHIV), which, in turn, increases risky behaviours such as medication non-adherence, substance use, and sexual risk-taking. The majority of studies on psychological distress among ALHIV have been conducted in high-income countries; data on the prevalence and correlates of psychological distress among ALHIV in sub-Saharan Africa (SSA) are scarce, yet over two-thirds of the global population of ALHIV resides in SSA. The purpose of this study was to identify the contextually relevant correlates of psychological distress among Ugandan ALHIV. Utilizing the stress and coping framework, we explored the risk and protective factors for psychological distress in cross-sectional sample of 464 ALHIV (aged 12–19; 53% female) at a large HIV treatment centre in Kampala, Uganda. The stressors associated with psychological distress included daily hassles, major negative life events, HIV-related quality of life, and stigma. Protective factors included psychosocial resources such as religious coping, satisfaction with social support, and general coping style and behaviours. Social support and optimism were significantly associated with psychological distress. Findings underscore the need for mental health services for ALHIV in Uganda and other resource-limited settings.