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PURPOSE: Depression is a major contributor to the global burden of disease. The extent to which marital communication may influence depression in contexts with little mental health support is unknown. METHODS: We conducted a whole-population study of married adult residents of eight villages in a rural region of southwestern Uganda. Depression symptom severity was measured using a modified version of the Hopkins Symptom Checklist for Depression, with >1.75 classified as a positive screen for probable depression. Respondents were asked to report about ease of marital communication (‘never easy’, ‘easy once in a while’, ‘easy most of the time’ or ‘always easy’). Sex-stratified, multivariable Poisson regression models were fit to estimate the association between depression symptom severity and marital communication. RESULTS: Among 492 female and 447 male participants (response rate = 96%), 23 women and 5 men reported communication as ‘never easy’ and 154 women and 72 men reported it as ‘easy once in a while’. Reporting communication as ‘never easy’ was associated with an increased risk of probable depression among women (adjusted relative risk [ARR], 2.06; 95% confidence interval [CI], 1.08–3.93, p = 0.028) and among men (ARR, 7.10; 95% CI, 1.70–29.56, p = 0.007). CONCLUSION: In this whole-population study of married adults in rural Uganda, difficulty of marital communication was associated with depression symptom severity. Additional research is needed to assess whether communication training facilitated by local leaders or incorporated into couples-based services might be a novel pathway to address mental health burden.

Background and aimsLittle is known about how perceived norms about alcohol consumption may influence high alcohol consumption rates in Uganda. This study estimated the accuracy of perceived norms about men's alcohol consumption and estimated the association between perceived norms and personal alcohol consumption.DesignCross-sectional, whole-population, sociocentric social network study.SettingEight rural villages in Rwampara District, southwestern Uganda in 2016-18.ParticipantsA total of 719 men aged 18years and older (representing 91% of permanent resident men).MeasurementsSelf-reported frequent (≥4days per week) and heavy alcohol consumption (six or more drinks on one occasion, more than three occasions of intoxication, or spending an excessive amount on alcohol). Participants also reported whether they thought most other men in their village engaged in frequent and heavy alcohol consumption (perceived norms). Using the network study design, we calculated alcohol consumption behavior within villages and social networks. Perceived norms were compared with aggregated self-reports. Multivariable Poisson regression models were used to estimate the association between perceived norms and individual behavior.FindingsThroughout villages, frequent and heavy alcohol consumption ranged from 7 to 37%. However, 527 (74%) participants perceived, contrary to fact, that most other men in their villages frequently consumed alcohol, and 576 (81%) perceived that most others heavily consumed alcohol. Overestimation of alcohol consumption by others was pervasive among socio-demographic subgroups and was present irrespective of the actual consumption behavior at the village level and within social networks. Men who misperceived these alcohol consumption behaviors as being common were more likely to engage in frequent [adjusted relative risk (aRR)=3.98; 95% confidence interval (CI)=1.69-9.34) and heavy (aRR=4.75; 95% CI=2.33-9.69) alcohol consumption themselves.ConclusionsMost men in eight rural Ugandan villages incorrectly thought that frequent and heavy alcohol consumption were common among men in their villages. These misperceived norms had a strong positive association with individual drinking behavior.

Background Chronic obstructive pulmonary disease (COPD) is a leading cause of global mortality. In high-income settings, the presence of cardiovascular disease among people with COPD increases mortality and complicates longitudinal disease management. An estimated 26 million people are living with COPD in sub-Saharan Africa, where risk factors for co-occurring pulmonary and cardiovascular disease may differ from high-income settings but remain uncharacterized. As non-communicable diseases have become the leading cause of death in sub-Saharan Africa, defining multimorbidity in this setting is critical to inform the required scale-up of existing healthcare infrastructure. Methods We measured lung function and carotid intima media thickness (cIMT) among participants in the UGANDAC Study. Study participants were over 40 years old and equally divided into people living with HIV (PLWH) and an age- and sex-similar, HIV-uninfected control population. We fit multivariable linear regression models to characterize the relationship between lung function (forced expiratory volume in one second, FEV1) and pre-clinical atherosclerosis (cIMT), and evaluated for effect modification by age, sex, smoking history, HIV, and socioeconomic status. Results Of 265 participants, median age was 52 years, 125 (47%) were women, and 140 (53%) were PLWH. Most participants who met criteria for COPD were PLWH (13/17, 76%). Median cIMT was 0.67 mm (IQR: 0.60 to 0.74), which did not differ by HIV serostatus. In models adjusted for age, sex, socioeconomic status, smoking, and HIV, lower FEV1 was associated with increased cIMT (β = 0.006 per 200 mL FEV1 decrease; 95% CI 0.002 to 0.011, p = 0.01). There was no evidence that age, sex, HIV serostatus, smoking, or socioeconomic status modified the relationship between FEV1 and cIMT. Conclusions Impaired lung function was associated with increased cIMT, a measure of pre-clinical atherosclerosis, among adults with and without HIV in rural Uganda. Future work should explore how co-occurring lung and cardiovascular disease might share risk factors and contribute to health outcomes in sub-Saharan Africa.

Background Although ≈70% of the world's population of people living with HIV reside in sub‐Saharan Africa, there are minimal prospective data on the contributions of HIV infection to atherosclerosis in the region. Methods and Results We conducted a prospective observational cohort study of people living with HIV on antiretroviral therapy >40 years of age in rural Uganda, along with population‐based comparators not infected with HIV. We collected data on cardiovascular disease risk factors and carotid ultrasound measurements annually. We fitted linear mixed effects models, adjusted for cardiovascular disease risk factors, to estimate the association between HIV serostatus and progression of carotid intima media thickness (cIMT). We enrolled 155 people living with HIV and 154 individuals not infected with HIV and collected cIMT images at 1045 visits during a median of 4 annual visits per participant (interquartile range 3–4, range 1–5). Age (median 50.9 years) and sex (49% female) were similar by HIV serostatus. At enrollment, there was no difference in mean cIMT by HIV serostatus (0.665 versus 0.680 mm, P =0.15). In multivariable models, increasing age, blood pressure, and non–high‐density lipoprotein cholesterol were associated with greater cIMT ( P P =0.25). Conclusions In rural Uganda, treated HIV infection was not associated with faster cIMT progression. These results do not support classification of treated HIV infection as a risk factor for subclinical atherosclerosis progression in rural sub‐Saharan Africa. Registration URL: https://www.ClinicalTrials.gov ; Unique identifier: NCT02445079.

We sought to describe changes in blood pressure and estimate the effect of HIV on blood pressure (BP) over 4 years of observation in a cohort of 155 HIV-infected adults (≥40 years) on antiretroviral therapy (ART) and 154 sex- and age-quartile matched, population-based, HIV-uninfected controls for four years in in rural Uganda, we compared changes in blood pressure (BP) by HIV serostatus, and tested whether body mass index and inflammation (high sensitivity C-reactive protein and Interleukin-6) and immune activation (sCD14 and sCD163) mediated the effects of HIV on BP using hierarchical multisvariate and two-stage parametric regression models. Overall HIV-uninfected participants had higher mean BP than HIV-infected counterparts (differences in trend p

Background Mosquito net use is an essential part of malaria prevention. Although previous research has shown that many people sleep under a mosquito net in endemic areas, it is unknown whether people underestimate how common it is to sleep under a net every night. Furthermore, perceived social norms about whether most others sleep under a mosquito net every night may contribute to personally sleeping under a net, given decades of research showing that people often mimic others’ behaviours. Methods Population-based data were collected from 1669 adults across eight villages in one rural parish in southwestern Uganda. Individuals’ perception about whether most adults in their community sleep under a mosquito net every night was compared with whether daily mosquito net use was the actual norm in their community to identify the extent of norm misperception. The association between whether an individual perceived daily mosquito net use to be the norm and personal mosquito net use was assessed while adjusting for the ratio of nets:people in the household and other factors. Results Although the majority (65%) of participants reported sleeping under a mosquito net every night (and 75% did so among the 86% of people with at least one net), one-quarter of participants thought that most adults in their community did not sleep under a mosquito net every night. Another 8% were unsure how many nights per week most adults in their community sleep under a mosquito net. Participants who perceived that daily mosquito net use was the norm were 2.94 times more likely to report personally sleeping under a mosquito net every night (95% CI 2.09–4.14, p

Background Depression is recognized globally as a leading cause of disability. Early-life adverse childhood experiences (ACEs) have been shown to have robust associations with poor mental health during adulthood. These effects may be cumulative, whereby a greater number of ACEs are progressively associated with worse outcomes. This study aimed to estimate the associations between ACEs and adult depression and suicidal ideation in a cross-sectional, population-based study of adults in Uganda. Methods and findings Between 2016 and 2018, research assistants visited the homes of 1,626 adult residents of Nyakabare Parish, a rural area in southwestern Uganda. ACEs were assessed using a modified version of the Adverse Childhood Experiences-International Questionnaire, and depression symptom severity and suicidal ideation were assessed using the Hopkins Symptom Checklist for Depression (HSCL-D). We applied a validated algorithm to determine major depressive disorder diagnoses. Overall, 1,458 participants (90%) had experienced at least one ACE, 159 participants (10%) met criteria for major depressive disorder, and 28 participants (1.7%) reported suicidal ideation. We fitted regression models to estimate the associations between cumulative number of ACEs and depression symptom severity (linear regression model) and major depressive disorder and suicidal ideation (Poisson regression models). In multivariable regression models adjusted for age, sex, primary school completion, marital status, self-reported HIV status, and household asset wealth, the cumulative number of ACEs was associated with greater depression symptom severity (b = 0.050; 95% confidence interval [CI], 0.039–0.061, p < 0.001) and increased risk for major depressive disorder (adjusted relative risk [ARR] = 1.190; 95% CI, 1.109–1.276; p < 0.001) and suicidal ideation (ARR = 1.146; 95% CI, 1.001–1.311; p = 0.048). We assessed the robustness of our findings by probing for nonlinearities and conducting analyses stratified by age. The limitations of the study include the reliance on retrospective self-report as well as the focus on ACEs that occurred within the household. Conclusions In this whole-population, cross-sectional study of adults in rural Uganda, the cumulative number of ACEs had statistically significant associations with depression symptom severity, major depressive disorder, and suicidal ideation. These findings highlight the importance of developing and implementing policies and programs that safeguard children, promote mental health, and prevent trajectories toward psychosocial disability., In a cross-sectional, population based study of adults in rural Uganda, Emily Satinsky and colleagues investigate adverse childhood experiences and associations with depression and suicidal ideation., Author summary Why was this study done? Depression is recognized globally as a leading cause of disability. Studies from high-income countries have shown robust associations between adverse childhood experiences (ACEs) and depression during adulthood. While studies from sub-Saharan Africa have demonstrated associations between ACEs and depression and suicidality among children, adolescents, and young adults, no study from this region has yet estimated the associations between ACEs and major depressive disorder and suicidal ideation within a whole-population sample of adults. What did the researchers do and find? We conducted a cross-sectional, population-based study of 1,626 adults in rural Uganda, eliciting ACEs, current depression, and suicidal ideation through face-to-face interviews. The cumulative number of ACEs that occurred before age 18 had statistically significant associations with adult depression symptom severity, major depressive disorder, and suicidal ideation. Depression symptom severity and major depressive disorder had statistically significant associations with each of the 9 types of ACEs. Suicidal ideation also had statistically significant associations with living with an adult who was sent to jail or prison during childhood and experiencing food and/or water insecurity during childhood. What do these findings mean? Our interpretation of these findings raises implications for the development of policies and programs that support children, adolescents, and their families, and promote mental health. We are not able to determine the extent to which these associations are causal, and our analysis is susceptible to potential bias from the use of retrospective self-report of ACEs.

Background Community engagement is central to the conduct of health-related research studies as a way to determine priorities, inform study design and implementation, increase recruitment and retention, build relationships, and ensure that research meets the goals of the community. Community sensitization meetings, a form of community engagement, are often held prior to the initiation of research studies to provide information about upcoming study activities and resolve concerns in consultation with potential participants. This study estimated demographic, health, economic, and social network correlates of attendance at community sensitization meetings held in advance of a whole-population, combined behavioral, and biomedical research study in rural Uganda. Methods and findings Research assistants collected survey data from 1,630 adults participating in an ongoing sociocentric social network cohort study conducted in a rural region of southwestern Uganda. These community survey data, collected between 2016 and 2018, were linked to attendance logs from community sensitization meetings held in 2018 and 2019 before the subsequent community survey and community health fair. Of all participants, 264 (16%) attended a community sensitization meeting before the community survey, 464 (28%) attended a meeting before the community health fair, 558 (34%) attended a meeting before either study activity (survey or health fair), and 170 (10%) attended a meeting before both study activities (survey and health fair). Using multivariable Poisson regression models, we estimated correlates of attendance at community sensitization meetings. Attendance was more likely among study participants who were women (adjusted relative risk [ARR]health fair = 1.71, 95% confidence interval [CI], 1.32 to 2.21, p < 0.001), older age (ARRsurvey = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001; ARRhealth fair = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001), married (ARRsurvey = 1.74, 95% CI, 1.29 to 2.35, p < 0.001; ARRhealth fair = 1.41, 95% CI, 1.13 to 1.76, p = 0.002), and members of more community groups (ARRsurvey = 1.26 per group, 95% CI, 1.10 to 1.44, p = 0.001; ARRhealth fair = 1.26 per group, 95% CI, 1.12 to 1.43, p < 0.001). Attendance was less likely among study participants who lived farther from meeting locations (ARRsurvey = 0.54 per kilometer, 95% CI, 0.30 to 0.97, p = 0.041; ARRhealth fair = 0.57 per kilometer, 95% CI, 0.38 to 0.86, p = 0.007). Leveraging the cohort’s sociocentric design, social network analyses suggested that information conveyed during community sensitization meetings could reach a broader group of potential study participants through attendees’ social network and household connections. Study limitations include lack of detailed data on reasons for attendance/nonattendance at community sensitization meetings; achieving a representative sample of community members was not an explicit aim of the study; and generalizability may not extend beyond this study setting. Conclusions In this longitudinal, sociocentric social network study conducted in rural Uganda, we observed that older age, female sex, being married, membership in more community groups, and geographical proximity to meeting locations were correlated with attendance at community sensitization meetings held in advance of bio-behavioral research activities. Information conveyed during meetings could have reached a broader portion of the population through attendees’ social network and household connections. To ensure broader input and potentially increase participation in health-related research studies, the dissemination of research-related information through community sensitization meetings may need to target members of underrepresented groups., In a social network cohort study, Emily Satinsky and colleagues estimate demographic, health, economic and social network factor associated with attendance at community sensitization meetings held in advance of participation in health-related research studies in rural Uganda., Author summary Why was this study done? Community engagement is central to the conduct of health-related research studies as a means of developing trust, increasing awareness of and engagement with research procedures, and safeguarding ethical good practice. Community sensitization meetings are often held in advance of global health research activities to build community awareness of key scientific and research concepts and to create opportunities for collaboration and feedback. Since successful research implementation requires buy-in from a range of stakeholders, fulfillment of community sensitization meeting aims requires widespread attendance and, potentially, subsequent dissemination of information to community members not in attendance. What did the researchers do and find? We conducted a longitudinal, sociocentric social network study with 1,630 adults in a rural region of southwestern Uganda to understand the demographic, health, economic, and social network correlates of attendance at community sensitization meetings held before 2 research study activities. Attendance at community sensitization meetings was more likely among study participants who were older age, women, married, members of more community groups, and living in closer geographical proximity to the meeting locations. Nonattendees living in the households of meeting attendees were more likely (compared with meeting attendees) to be younger age, men, unmarried, and members of fewer community groups. What do these findings mean? These findings suggest that information dissemination, relationships, and trust achieved through the use of community sensitization meetings held in advance of research studies may disproportionately extend to certain sociodemographic subgroups. However, information conveyed during community sensitization meetings may reach a broader sample of the population via informal transmission through attendees’ social network and household connections. Future community sensitization efforts should aim to better target members of underrepresented groups.

BACKGROUND: Studies from high-income contexts have found evidence that norms about substance use are misperceived. The accuracy of perceived norms about khat and cannabis use in Uganda have not previously been described. METHODS: We conducted a population-based study targeting all resident adults across eight villages in southwestern Uganda. Personal khat and/or cannabis use frequency was based on self-report. We measured perceived norms about substance use by eliciting individuals’ perceptions about how often most other adult men and most other adult women in their villages used these substances. We compared perceived norms to aggregated village rates of use to assess the extent to which norms were misperceived. We used multivariable Poisson regression to estimate correlates of misperceived norms. RESULTS: Among 1626 participants (91% response rate), only 29 men (4%) and 9 women (1%) reported any lifetime use of khat and/or cannabis. However, 695 participants (43%) did not think lifetime abstinence was the norm among men in their villages, and 256 participants (16%) did not think lifetime abstinence was the norm among women. Moreover, 219 participants (13%) incorrectly believed most men in their village regularly used khat and/or cannabis (≥4 times per week). Misperceived norms were present across subgroups and were correlated with larger social networks, symptoms of depression, loneliness, and younger age. CONCLUSION: In this study of all adults across 8 villages in rural Uganda, many participants misperceived norms about khat and/or cannabis use. Providing accurate information about prevailing norms in the local population may help prevent initiation of khat and/or cannabis use among adults in this context.

Background In resource-limited settings, the Filmer & Pritchett asset index is frequently used to measure household economic status. Little is known about how its validity is affected by differential reporting or recall within households. Methods As part of a whole-population survey in a rural region of southwestern Uganda, we elicited household asset information from married dyads (404 men and 404 matched women) residing within the same households. We assessed the extent to which the asset index yielded differing measures of relative household wealth, depending on whether the husband’s or wife’s survey data were used in its calculation. To estimate agreement, we used Cohen’s κ for binary and categorical variables, and Cronbach’s α for continuous variables. We also assessed the extent to which asset wealth quintiles assigned based on husbands’ vs wives’ reporting were concordant, and whether discordance was related to demographic characteristics. Results For most individual assets, agreement ranged from moderate to very good. Asset index scores based on husbands’ vs wives’ reporting were positively correlated (Pearson r = 0.85). Corresponding wealth quintiles were moderately concordant (weighted κ = 0.65); 171 households (43%) differed by one or more quintiles when the husbands’ vs wives’ reporting was used, and 43 (11%) differed by two or more quintiles. Concordance in asset wealth quintile could not be explained by joint educational attainment, age, or age difference. Conclusions There is significant intra-household variability in household asset reporting that can materially affect how households are classified on a widely used measure of relative household asset wealth.

OBJECTIVES: Atrial fibrillation (AF) is a major risk factor for stroke, which is the leading cause of cardiovascular mortality in sub-Saharan Africa. However, there is limited population-based epidemiological data on AF in sub-Saharan Africa. We sought to estimate the prevalence and correlates of AF in rural Uganda. METHODS: We conducted a cross-sectional study using community health fairs in 2015 targeting eight villages in rural Uganda. Study participants completed a medical history, a clinical exam, blood collection, and 12-lead electrocardiographic (ECG) screening. Of 1,814 participants enrolled in a parent cohort study that includes 98% of adults residing in the geographic area, 856 attended a health fair and were included in this study. Our primary outcome was AF or atrial flutter. We modelled population prevalence of the outcome with inverse probability of treatment weighting using data collected from the full population. RESULTS: 856 (47.2%) adults in the area attended a health fair and were included in the analysis. Health fair attendees were older (42 vs 34 years, p

This study aims to characterize associations between depression symptom severity and HIV infection, both prior to and in years after ART initiation, among older adults. The Ugandan Non-Communicable Diseases & Aging Cohort Study (UGANDAC) is a study of 154 PLWH on ART and 142 community-based, HIV-negative controls. The Hopkins Checklist (HSCL), a 15-item depression scale, was used to screen for depression. We estimate differences in depressive symptoms by HIV and ART status and use multivariable log binomial regression to quantify differences in probable depression between PLWH on ART. HIV-infected and HIV-uninfected participants had a similar age (mean 52.0 vs. 51.9, p = 0.854) and sex distribution (47.4 vs. 47.9% female, p = 0.934). PLWH on ART had lower depression symptom severity than HIV-uninfected controls (mean score: 1.50 vs. 1.60, p = 0.006) and a lower prevalence of probable depression (21.4 vs. 33.8%, p = 0.017). Among 102 PLWH with pre-ART depression screening scores available, their mean depression symptom severity was similar to HIV-uninfected participants (mean 1.56 vs. 1.60, p = 0.512). In adjusted models, PLWH on ART had a lower prevalence of probable depression than HIV-negative controls [adjusted prevalence ratio: 0.68 (95% CI 0.47-0.99)]. In an observational cohort of PLWH over 40 on long-term ART and matched, community-based HIV-uninfected controls in rural Uganda, we found a lower prevalence of self-reported depression among aging PLWH on ART.

ObjectiveTo assess the association between food insecurity and depression symptom severity stratified by sex, and test for evidence of effect modification by social network characteristics.DesignA population-based cross-sectional study. The nine-item Household Food Insecurity Access Scale captured food insecurity. Five name generator questions elicited network ties. A sixteen-item version of the Hopkins Symptom Checklist for Depression captured depression symptom severity. Linear regression was used to estimate the association between food insecurity and depression symptom severity while adjusting for potential confounders and to test for potential network moderators.SettingIn-home survey interviews in south-western Uganda.SubjectsAll adult residents across eight rural villages; 96 % response rate (n1669).ResultsSevere food insecurity was associated with greater depression symptom severity (b=0·4, 95 % CI 0·3, 0·5,Pb=0·3, 95 % CI 0·2, 0·4,PConclusionsIn this population-based study from rural Uganda, food insecurity was associated with mental health for both men and women. Future research is needed on networks and food insecurity-related shame in relation to depression symptoms among food-insecure men.

Background Mental illness stigma is a fundamental barrier to improving mental health worldwide, but little is known about how to durably reduce it. Understanding of mental illness as a treatable medical condition may influence stigmatizing beliefs, but available evidence to inform this hypothesis has been derived solely from high-income countries. We embedded a randomized survey experiment within a whole-population cohort study in rural southwestern Uganda to assess the extent to which portrayals of mental illness treatment effectiveness influence personal beliefs and perceived norms about mental illness and about persons with mental illness. Methods and findings Study participants were randomly assigned to receive a vignette describing a typical woman (control condition) or one of nine variants describing a different symptom presentation (suggestive of schizophrenia, bipolar, or major depression) and treatment course (no treatment, treatment with remission, or treatment with remission followed by subsequent relapse). Participants then answered questions about personal beliefs and perceived norms in three domains of stigma: willingness to have the woman marry into their family, belief that she is receiving divine punishment, and belief that she brings shame on her family. We used multivariable Poisson and ordered logit regression models to estimate the causal effect of vignette treatment assignment on each stigma-related outcome. Of the participants randomized, 1,355 were successfully interviewed (76%) from November 2016 to June 2018. Roughly half of respondents were women (56%), half had completed primary school (57%), and two-thirds were married or cohabiting (64%). The mean age was 42 years. Across all types of mental illness and treatment scenarios, relative to the control vignette (22%–30%), substantially more study participants believed the woman in the vignette was receiving divine punishment (31%–54%) or believed she brought shame on her family (51%–73%), and most were unwilling to have her marry into their families (80%–88%). In multivariable Poisson regression models, vignette portrayals of untreated mental illness, relative to the control condition, increased the risk that study participants endorsed stigmatizing personal beliefs about mental illness and about persons with mental illness, irrespective of mental illness type (adjusted risk ratios [ARRs] varied from 1.7–3.1, all p < 0.001). Portrayals of effectively treated mental illness or treatment followed by subsequent relapse also increased the risk of responses indicating stigmatizing personal beliefs relative to control (ARRs varied from 1.5–3.0, all p < 0.001). The magnitudes of the estimates suggested that portrayals of initially effective treatment (whether followed by relapse or not) had little moderating influence on stigmatizing responses relative to vignettes portraying untreated mental illness. Responses to questions about perceived norms followed similar patterns. The primary limitations of this study are that the vignettes may have omitted context that could have influenced stigma and that generalizability beyond rural Uganda may be limited. Conclusions In a population-based, randomized survey experiment conducted in rural southwestern Uganda, portrayals of effectively treated mental illness did not appear to reduce endorsement of stigmatizing beliefs about mental illness or about persons with mental illness. These findings run counter to evidence from the United States. Further research is necessary to understand the relationship between mental illness treatment and stigmatizing attitudes in Uganda and other countries worldwide. Trial registration The experimental procedures for this study were registered with ClinicalTrials.gov as "Measuring Beliefs and Norms About Persons With Mental Illness" (NCT03656770)., Justin Rasmussen and colleagues study reactions to representations of mental illness in Ugandan women., Author summary Why was this study done? Mental illness stigma is a fundamental barrier to improving mental health worldwide. While there has been some progress in understanding how to reduce mental illness stigma in high-income countries, it is unclear how this understanding might generalize to low- and middle-income countries. The extent to which people perceive that mental illness can be effectively treated may be an important component of changing negative beliefs about mental illness. What did the researchers do and find? We conducted a survey experiment to understand how information about successful treatment of mental illness might affect stigmatizing beliefs in rural southwestern Uganda. This experiment involved randomly assigning different people in eight villages to be read a vignette about: a woman who had signs suggestive of one of three different types of mental illness; a woman who had these signs and was treated successfully; or a woman who had these signs and was treated successfully but subsequently relapsed. We found that stigma toward mental illness in the community was common and was generally unaffected by descriptions of successful treatment. What do these findings mean? If unaddressed, stigma will continue to pose a major barrier to improving population mental health in Uganda. We need to do more research to understand the relationship between perceptions of mental illness treatment and stigmatizing attitudes in Uganda and other countries worldwide. Engaging local etiologies, making treatment more accessible, and understanding how mental illness shapes social relationships independent of actual symptoms might be important avenues of research and program implementation to explore.

Background Most of the global burden of pollution-related morbidity and mortality is believed to occur in resource-limited settings, where HIV serostatus and sex may influence the relationship between air pollution exposure and respiratory morbidity. The lack of air quality monitoring networks in these settings limits progress in measuring global disparities in pollution-related health. Personal carbon monoxide monitoring may identify sub-populations at heightened risk for air pollution-associated respiratory morbidity in regions of the world where the financial cost of air quality monitoring networks is prohibitive. Methods From September 2015 through May 2017, we measured 48-h ambulatory carbon monoxide (CO) exposure in a longitudinal cohort of HIV-infected and uninfected adults in rural southwestern Uganda. We fit generalized mixed effects models to identify correlates of CO exposure exceeding international air quality thresholds, quantify the relationship between CO exposure and respiratory symptoms, and explore potential effect modification by sex and HIV serostatus. Results Two hundred and sixty study participants completed 419 sampling periods. Personal CO exposure exceeded international thresholds for 50 (19%) participants. In covariate-adjusted models, living in a home where charcoal was the main cooking fuel was associated with CO exposure exceeding international thresholds (adjusted odds ratio [AOR] 11.3, 95% confidence interval [95%CI] 4.7–27.4). In sex-stratified models, higher CO exposure was associated with increased odds of respiratory symptoms among women (AOR 3.3, 95%CI 1.1–10.0) but not men (AOR 1.3, 95%CI 0.4–4.4). In HIV-stratified models, higher CO exposure was associated with increased odds of respiratory symptoms among HIV-infected (AOR 2.5, 95%CI 1.01–6.0) but not HIV-uninfected (AOR 1.4, 95%CI 0.1–14.4) participants. Conclusions In a cohort in rural Uganda, personal CO exposure frequently exceeded international thresholds, correlated with biomass exposure, and was associated with respiratory symptoms among women and people living with HIV. Our results provide support for the use of ambulatory CO monitoring as a low-cost, feasible method to identify subgroups with heightened vulnerability to pollution-related respiratory morbidity in resource-limited settings and identify subgroups that may have increased susceptibility to pollution-associated respiratory morbidity. Electronic supplementary material The online version of this article (10.1186/s12940-019-0517-z) contains supplementary material, which is available to authorized users.

Background The global burden of chronic obstructive pulmonary disease (COPD) disproportionately affects resource-limited settings such as sub-Saharan Africa (SSA), but population-based prevalence estimates in SSA are rare. We aimed to estimate the population prevalence of COPD and chronic respiratory symptoms in rural southwestern Uganda. Methods Adults at least 18 years of age who participated in a population-wide census in rural southwestern Uganda completed respiratory questionnaires and lung function testing with bronchodilator challenge at health screening events in June 2015. We defined COPD as post-bronchodilator forced expiratory volume in one second to forced vital capacity ratio less than the lower limit of normal. We fit multivariable linear and log binomial regression models to estimate correlates of abnormal lung function and respiratory symptoms, respectively. We included inverse probability of sampling weights in models to facilitate population-level estimates. Results Forty-six percent of census participants (843/1814) completed respiratory questionnaires and spirometry, of which 565 (67%) met acceptability standards. COPD and respiratory symptom population prevalence were 2% (95% confidence interval (CI) = 1%-3%) and 30% (95% CI = 25%-36%), respectively. Respiratory symptoms were more prevalent and lung function was lower among women and ever-smokers (P

Rationale HIV-related stigma profoundly affects the physical and social wellbeing of people living with HIV, as well as the community’s engagement with testing, treatment, and prevention. Based on theories of stigma elaborating how it arises from the relationships between the stigmatized and the stigmatizer as well as within the general community, we hypothesized that social networks can shape HIV-related stigma. Objective To estimate social network correlates of HIV-related stigma. Methods During 2011-2012, we collected complete social network data from a community of 1669 adults (“egos”) in Mbarara, Uganda using six culturally-adapted name generators to elicit different types of social ties (“alters”). We measured HIV-related stigma using the 9-item AIDS-Related Stigma Scale. HIV serostatus was based on self-report. We fitted linear regression models that account for network autocorrelation to estimate the association between egos’ HIV-related stigma, alters’ HIV-related stigma and alters’ self-reported HIV serostatus, while adjusting for egos’ HIV serostatus, network centrality, village size, perceived HIV prevalence, and sociodemographic characteristics. Results The average AIDS-Related Stigma Score was 0.79 (Standard Deviation = 0.50). In the population 116 (7%) egos reported being HIV-positive, and 757 (46%) reported an HIV-positive alter. In the multivariable model, we found that egos’ own HIV-related stigma was positively correlated with their alters’ average stigma score (b=0.53; 95% confidence interval [CI] 0.42-0.63) and negatively correlated with having one or more HIV-positive alters (b=-0.05; 95% CI -0.10 to -0.003). Conclusion Stigma-reduction interventions should be targeted not only at the level of the individual but also at the level of the network. Directed and meaningful contact with people living with HIV may also reduce HIV-related stigma.

Background Sex-based differences in cardiovascular disease (CVD) burden are widely acknowledged, with male sex considered a risk factor in high-income settings. However, these relationships have not been examined in sub-Saharan Africa (SSA). We aimed to apply the American Heart Association (AHA) ideal cardiovascular health (CVH) tool modified by the addition of C-reactive protein (CRP) to examine potential sex-based differences in the prevalence of CVD risk in rural Uganda. Methods In a cross-sectional study nested within a population-wide census, 857 community-living adults completed physical and laboratory-based assessments to calculate individual ideal CVH metrics including an eight category for CRP levels. We summarized sex-specific ideal CVH indices, fitting ordinal logistic regression models to identify correlates of improving CVH. As secondary outcomes, we assessed subscales of ideal CVH behaviours and factors. Models included inverse probability of sampling weights to determine population-level estimates. Results The weighted-population mean age was 39.2 (1.2) years with 52.0 (3.7) % females. Women had ideal scores in smoking (80.4% vs. 68.0%; p

Background Lack of access to clean water has well known implications for communicable disease risks, but the broader construct of water insecurity is little studied, and its mental health impacts are even less well understood. Methods and findings We conducted a mixed-methods, whole-population study in rural Uganda to estimate the association between water insecurity and depression symptom severity, and to identify the mechanisms underlying the observed association. The whole-population sample included 1776 adults (response rate, 91.5%). Depression symptom severity was measured using a modified 15-item Hopkins Symptom Checklist for Depression. Water insecurity was measured with a locally validated 8-item Household Water Insecurity Access Scale. We fitted multivariable linear and Poisson regression models to the data to estimate the association between water insecurity and depression symptom severity, adjusting for age, marital status, self-reported overall health, household asset wealth, and educational attainment. These models showed that water insecurity was associated with depression symptom severity (b = 0.009; 95% confidence interval [CI], 0.004–0.15) and that the estimated association was larger among men (b = 0.012; 95% CI, 0.008–0.015) than among women (b = 0.008; 95% CI, 0.004–0.012. We conducted qualitative interviews with a sub-group of 30 participants, focusing on women given their traditional role in household water procurement in the Ugandan context. Qualitative analysis, following an inductive approach, showed that water insecurity led to “choice-less-ness” and undesirable social outcomes, which in turn led to emotional distress. These pathways were amplified by gender-unequal norms. Conclusions Among men and women in rural Uganda, the association between water insecurity and depression symptom severity is statistically significant, substantive in magnitude, and robust to potential confounding. Data from the qualitative interviews provide key narratives that reveal the mechanisms through which women's lived experiences with water insecurity may lead to emotional distress.

People living with HIV (PLWH) are more likely to smoke compared to HIV-uninfected counterparts, but little is known about smoking behaviors in sub-Saharan Africa. To address this gap in knowledge, we characterized smoking cessation patterns among people living with HIV (PLWH) compared to HIV-uninfected individuals in rural Uganda. PLWH were at least 40 years of age and on antiretroviral therapy for at least three years, and HIV-uninfected individuals were recruited from the clinical catchment area. Our primary outcome of interest was smoking cessation, which was assessed using an adapted WHO STEPS smoking questionnaire. We fit Cox proportional hazards models to compare time to smoking cessation between PLWH pre-care, PLWH in care, and HIV-uninfected individuals. We found that, compared to HIV-uninfected individuals, PLWH in care were less likely to have ever smoked (40% vs. 49%, p = 0.04). The combined sample of 267 ever-smokers had a median age of 56 (IQR 49-68), 56% (n = 150) were male, and 26% (n = 70) were current smokers. In time-to-event analyses, HIV-uninfected individuals and PLWH prior to clinic enrollment ceased smoking at similar rates (HR 0.8, 95% CI 0.5-1.2). However, after enrolling in HIV care, PLWH had a hazard of smoking cessation over twice that of HIV-uninfected individuals and three times that of PLWH prior to enrollment (HR 2.4, 95% CI 1.3-4.6, p = 0.005 and HR 3.0, 95% CI 1.6-5.5, p = 0.001, respectively). In summary, we observed high rates of smoking cessation among PLWH after engagement in HIV care in rural Uganda. While we hypothesize that greater access to primary care services and health counseling might contribute, future studies should better investigate the mechanism of this association.

Background Water insecurity is linked to depression in low- and middle-income countries (LMICs), though it remains unclear how geospatial clustering of water insecurity in rural regions is associated with risk for depression. Methods We conducted a population-based survey of a rural parish in southwestern Uganda (N = 1603) to evaluate the joint geospatial clustering of water insecurity and risk for depression among men and women living in rural Uganda. Results Geospatial clustering of self-reported water insecurity and depressive symptoms was found to be present among both men and women. Depression hotspots were more often observed near water insecurity hotspots among women, relative to men. Multivariable regression revealed that residing in a water insecurity hotspot significantly increased risk for depressive symptoms among women, but not among men. Conclusions Residing in a water insecurity hotspot is associated with greater risk for probable depression among women, but not among men, pointing to the need for focused depression screening among women residing in water insecure households.

HIV testing is an essential part of treatment and prevention. Using population-based data from 1664 adults across eight villages in rural Uganda, we assessed individuals' perception of the norm for HIV testing uptake in their village and compared it to the actual uptake norm. In addition, we examined how perception of the norm was associated with personal testing while adjusting for other factors. Although the majority of people had been tested for HIV across all villages, slightly more than half of men and women erroneously thought that the majority in their village had never been tested. They underestimated the prevalence of HIV testing uptake by 42 percentage points (s.d. = 17 percentage points), on average. Among men, perceiving that HIV testing was not normative was associated with never testing for HIV (AOR = 2.6; 95% CI 1.7-4.0, p

Hundreds of millions of persons worldwide lack adequate access to water. Water insecurity, which is defined as having limited or uncertain availability of safe water or the ability to acquire safe water in socially acceptable ways, is typically overlooked by development organizations focusing on water availability. To address the urgent need in the literature for validated measures of water insecurity, we conducted a population-based study in rural Uganda with 327 reproductive-age women and 204 linked men from the same households. We used a novel method of photo identification so that we could accurately elicit study participants’ primary household water sources, thereby enabling us to identify water sources for objective water quality testing and distance/elevation measurement. Our psychometric analyses provided strong evidence of the internal structure, reliability, and validity of a new 8-item Household Water Insecurity Access Scale. Important intra-household gender differences in perceptions of water insecurity were observed, with men generally perceiving household water insecurity as being less severe compared to women. In summary, the Household Water Insecurity Access Scale represents a reliable and valid measure of water insecurity, particularly among women, and may be useful for informing and evaluating interventions to improve water access in resource limited settings.

HIV is associated with chronic obstructive pulmonary disease (COPD) in high resource settings. Similar relationships are less understood in low resource settings. We aimed to estimate the association between HIV infection, tuberculosis, and COPD in rural Uganda. The Uganda Non-communicable Diseases and Aging Cohort study observes people 40 years and older living with HIV (PLWH) on antiretroviral therapy, and population-based HIV-uninfected controls in rural Uganda. Participants completed respiratory questionnaires and post-bronchodilator spirometry. Among 269 participants with spirometry, median age was 52 (IQR 48–55), 48% (n = 130) were ever-smokers, and few (3%, n = 9) reported a history of COPD or asthma. All participants with prior tuberculosis (7%, n = 18) were PLWH. Among 143 (53%) PLWH, median CD4 count was 477 cells/mm3 and 131 (92%) were virologically suppressed. FEV1 was lower among older individuals (− 0.5%pred/year, 95% CI 0.2–0.8, p

INTRODUCTION: Depression and anxiety are highly comorbid among people living with HIV (PLHIV), but few instruments have been validated for use in sub-Saharan Africa. The objective of this study was to determine the reliability and validity of the 25-item Hopkins Symptom Checklist (HSCL) in a population-based sample of PLHIV in rural Uganda. METHODS: We conducted a scale validation sub-study of PLHIV nested within an ongoing population-based sample of all residents living in Nyakabare Parish, Mbarara District, Uganda. All participants identified as HIV-positive by self-report were administered the 25-item HSCL. We performed parallel analysis on the scale items and estimated internal consistency of the identified sub-scales using ordinal alpha. To assess construct validity we compared the sub-scales to related constructs, including subjective well being (happiness), food insecurity, and health status. RESULTS: Of 1,814 eligible adults in the population, 158 (8.7%) self-reported being HIV positive. The mean age was 41 years, and 68% were women. Mean HSCL-25 scores were higher among women compared with men (1.71 vs. 1.44; t=3.6, P