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Background Although mental health challenges disproportionately affect people in humanitarian contexts, most refugee youth do not receive the mental health support needed. Uganda is the largest refugee-hosting nation in Africa, hosting over 1.58 million refugees in 2022, with more than 111,000 living in the city of Kampala. There is limited information about effective and feasible interventions to improve mental health outcomes and mental health literacy, and to reduce mental health stigma among urban refugee adolescents and youth in low- and middle-income countries (LMICs). Virtual reality (VR) is a promising approach to reduce stigma and improve mental health and coping, yet such interventions have not yet been tested in LMICs where most forcibly displaced people reside. Group Problem Management Plus (GPM+) is a scalable brief psychological transdiagnostic intervention for people experiencing a range of adversities, but has not been tested with adolescents and youth to date. Further, mobile health (mHealth) strategies have demonstrated promise in promoting mental health literacy. Objective The aim of this study is to evaluate the feasibility and effectiveness of two youth-tailored mental health interventions (VR alone and VR combined with GMP+) in comparison with the standard of care in improving mental health outcomes among refugee and displaced youth aged 16-24 years in Kampala, Uganda. Methods A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomized in a 1:1:1 design. Approximately 330 adolescents (110 per cluster) are enrolled and will be followed for approximately 16 weeks. Data will be collected at three time points: baseline enrollment, 8 weeks following enrollment, and 16 weeks after enrollment. Primary (depression) and secondary outcomes (mental health literacy, attitudes toward mental help–seeking, adaptive coping, mental health stigma, mental well-being, level of functioning) will be evaluated. Results The study will be conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (#40965; May 12, 2021), Mildmay Uganda Research Ethics Committee (MUREC-2021-41; June 24, 2021), and Uganda National Council for Science & Technology (SS1021ES; January 1, 2022). A qualitative formative phase was conducted using focus groups and in-depth, semistructured key informant interviews to understand contextual factors influencing mental well-being among urban refugee and displaced youth. Qualitative findings will inform the VR intervention, SMS text check-in messages, and the adaptation of GPM+. Intervention development was conducted in collaboration with refugee youth peer navigators. The trial launched in June 2022 and the final follow-up survey will be conducted in November 2022. Conclusions This study will contribute to the knowledge of youth-tailored mental health intervention strategies for urban refugee and displaced youth living in informal settlements in LMIC contexts. Findings will be shared in peer-reviewed publications, conference presentations, and with community dissemination. Trial Registration ClinicalTrials.gov NCT05187689; https://clinicaltrials.gov/ct2/show/NCT05187689 International Registered Report Identifier (IRRID) DERR1-10.2196/42342

Background Effective measurement of Gender Equality and Women’s Empowerment (GEWE) is challenging in low and middle-income countries (LMICs), and even more so in humanitarian settings. Conflict, natural disasters, and epidemics may increase gender inequities, but also present an opportunity to address them. This scoping review describes and identifies gaps in the measurement tools, methods, and indicators used to measure GEWE in humanitarian settings, and presents a dashboard that can be used by researchers, organizations and governments to identify GEWE measurement tools. Methods Scientific articles published between January 2004 and November 2019 were identified using Embase, Medline, PsycInfo, CINAHL, Scopus, and PAIS index. Relevant non peer-reviewed literature was downloaded from the websites of humanitarian organizations. Publications on women and/or girls impacted by a humanitarian crisis in a LMIC, within 5 years of data collection, were included. Publications were double-screened in the title/abstract and full-text stages. We used a machine learning software during the title/abstract screening to increase the efficiency of the process. Measurement tools, sampling and data collection methods, gap areas (geographical, topical and contextual), and indicators were catalogued for easy access in an interactive Tableau dashboard. Results Our search yielded 27,197 publications and 2396 non peer-reviewed literature reports. One hundred and seventy publications were included in the final review. Extracted indicators were categorized into seven domains: economic, health, human development, leadership, psychological, security and justice, and sociocultural. The vast majority of studies were observational, and over 70% utilized a cross-sectional study design. Thirty-eight toolkits and questionnaires were identified in this review, of which 19 (50%) were designed specifically for humanitarian settings. Sociocultural was the largest domain in number of studies and indicators in this review, with gender-based violence indicators reported in 66% of studies. Indicators of economic, human development and leadership were uncommon in the peer-reviewed literature. Discussion While there has been some effort to measure GEWE in conflict-affected and other humanitarian settings, measurement has largely focused on violence and security issues. A more comprehensive framework for measuring GEWE in these settings is needed; objective measurement of women’s empowerment and gender equality should be prioritized by organizations providing humanitarian aid.

Ambiguity around age ranges for adolescence and adulthood can make the application of age-based nutrition cutoffs confusing. We examined how estimates generated using the age-based anthropometric cutoffs for adolescent girls (10 to, Among late-adolescent and young women, the age-based anthropometric cutoffs yield estimates with a large magnitude of difference between and within groups for indicators of undernutrition, particularly thinness and stunting.

BackgroundEffective measurement of all health indicators and especially SRHR is difficult in humanitarian settings. Displacement and insecurity due to conflict, natural disasters, and epidemics place women and girls at higher risk of SRHR-related morbidity and mortality and reduce the coverage of essential SRHR services. This scoping review describes the measurement tools, methods, and indicators used to measure SRHR coverage and outcome indicators in humanitarian settings in the past 15 years and presents an accessible dashboard that can be used by governments, researchers and implementing organizations to identify available SRHR measurement tools.MethodsScientific articles published between January 2004 and May 2019 were identified using Embase, Medline, PsycInfo, CINAHL, Scopus, PAIS index as well as relevant non-peer-reviewed literature available through websites of humanitarian organizations. Publications including data from low- or middle-income countries (LMICs), focused on women and/or girls living in areas impacted by a humanitarian crisis, where data was collected within five years of the crisis were included. Indicators extracted from these publications were categorized according to validated SRHR indicators recommended by the World Health Organization (WHO). Measurement tools, sampling and data collection methods, gap areas (geographical, topical and contextual), and indicators were catalogued for easy access in an interactive Tableau dashboard.ResultsOur search yielded 42,081 peer-reviewed publications and 2,569 non-peer-reviewed reports. After initial title and abstract screening, 385 publications met the inclusion criteria. SRHR indicators were categorized into nine domains: abortion, antenatal care, family planning, gender-based violence, HIV and sexually transmitted infections, maternal health, maternal mortality, menstrual and gynecological health, and obstetric care (delivery). A total of 65 tools and questionnaires measuring SRHR were identified, of which 25 were designed specifically for humanitarian settings.DiscussionAlthough SRHR was measured in humanitarian settings, several gaps in measurement were identified. Abortion and gynaecological health were not consistently measured across included studies or validated WHO indicators. Toolkits and indicators identified in this review may be used to inform future SRHR data collection in humanitarian settings. However, identifying and/or developing innovative data collection methodologies should be a research priority, especially in light of the recent COVID-19 pandemic.

Background Although most births in Mali occur in health facilities, a substantial number of newborns still die during delivery and within the first 7 days of life, mainly because of existing training deficiencies and the challenges of maintaining intrapartum and postpartum care skills. Objective This trial aims to assess the effectiveness and cost-effectiveness of an intervention combining clinical audits and low-dose, high-frequency (LDHF) in-service training of health care providers and community health workers to reduce perinatal mortality. Methods The study is a three-arm cluster randomized controlled trial in the Koulikoro region in Mali. The units of randomization are each of 84 primary care facilities. Each trial arm will include 28 facilities. The facilities in the first intervention arm will receive support in implementing mortality and morbidity audits, followed by one-day LDHF training biweekly, for 6 months. The health workers in the second intervention arm (28 facilities) will receive a refresher course in maternal neonatal and child health (MNCH) for 10 days in a classroom setting, in addition to mortality and morbidity audits and LDHF hands-on training for 6 months. The control arm, also with 28 facilities, will consist solely of the standard MNCH refresher training delivered in a classroom setting. The main outcomes are perinatal deaths in the intervention arms compared with those in the control arm. A final sample of approximately 600 deliveries per cluster was expected for a total of 30,000 newborns over 14 months. Data sources included both routine health records and follow-up household surveys of all women who recently gave birth in the study facility 7 days postdelivery. Data collection tools will capture perinatal deaths, complications, and adverse events, as well as the status of the newborn during the perinatal period. A full economic evaluation will be conducted to determine the incremental cost-effectiveness of each of the case-based focused LDHF hands-on training strategies in comparison to MNCH refresher training in a classroom setting. Results The trial is complete. The recruitment began on July 15, 2019, and data collection began on July 23, 2019, and was completed in November 2020. Data cleaning or analyses began at the time of submission of the protocol. Conclusions The results will provide policy makers and practitioners with crucial information on the impact of different health care provider training modalities on maternal and newborn health outcomes and how to successfully implement these strategies in resource-limited settings. Trial Registration ClinicalTrials.gov NCT03656237; https://clinicaltrials.gov/ct2/show/NCT03656237 International Registered Report Identifier (IRRID) DERR1-10.2196/28644

BACKGROUND Although most births in Mali occur in health facilities, a substantial number of newborns still die during delivery and within the first 7 days of life, mainly because of existing training deficiencies and the challenges of maintaining intrapartum and postpartum care skills. OBJECTIVE This trial aims to assess the effectiveness and cost-effectiveness of an intervention combining clinical audits and low-dose, high-frequency (LDHF) in-service training of health care providers and community health workers to reduce perinatal mortality. METHODS The study is a three-arm cluster randomized controlled trial in the Koulikoro region in Mali. The units of randomization are each of 84 primary care facilities. Each trial arm will include 28 facilities. The facilities in the first intervention arm will receive support in implementing mortality and morbidity audits, followed by one-day LDHF training biweekly, for 6 months. The health workers in the second intervention arm (28 facilities) will receive a refresher course in maternal neonatal and child health (MNCH) for 10 days in a classroom setting, in addition to mortality and morbidity audits and LDHF hands-on training for 6 months. The control arm, also with 28 facilities, will consist solely of the standard MNCH refresher training delivered in a classroom setting. The main outcomes are perinatal deaths in the intervention arms compared with those in the control arm. A final sample of approximately 600 deliveries per cluster was expected for a total of 30,000 newborns over 14 months. Data sources included both routine health records and follow-up household surveys of all women who recently gave birth in the study facility 7 days postdelivery. Data collection tools will capture perinatal deaths, complications, and adverse events, as well as the status of the newborn during the perinatal period. A full economic evaluation will be conducted to determine the incremental cost-effectiveness of each of the case-based focused LDHF hands-on training strategies in comparison to MNCH refresher training in a classroom setting. RESULTS The trial is complete. The recruitment began on July 15, 2019, and data collection began on July 23, 2019, and was completed in November 2020. Data cleaning or analyses began at the time of submission of the protocol. CONCLUSIONS The results will provide policy makers and practitioners with crucial information on the impact of different health care provider training modalities on maternal and newborn health outcomes and how to successfully implement these strategies in resource-limited settings. CLINICALTRIAL ClinicalTrials.gov NCT03656237; https://clinicaltrials.gov/ct2/show/NCT03656237 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/28644

Shaoyuan Wang,1 Jean-Luc Kortenaar,1,2 Mark W Hull,3 Gordon Arbess,4 James RM Owen,4 Darrell HS Tan1,5,6 1Division of Infectious Diseases, St Michael’s Hospital, Toronto, ON, Canada; 2Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; 3Department of Medicine, University of British Columbia, Vancouver, BC, Canada; 4Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON, Canada; 5Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, ON, Canada; 6Division of Infectious Diseases, University of Toronto, Toronto, ON, Canada Background: Daily tenofovir disoproxil fumarate (TDF)/emtricitabine as HIV pre-exposure prophylaxis (PrEP) causes subclinical decreases in bone mineral density (BMD). We surveyed PrEP users to assess feasibility for a clinical trial of vitamin D supplementation to mitigate TDF-induced BMD loss. Methods: We recruited participants using or starting PrEP in Toronto and Vancouver. The primary objective was to assess the acceptability of daily or weekly vitamin D supplementation. We also assessed the acceptability of calcium supplementation, existing use of non-pharmacological bone health interventions, prevalence of osteoporosis risk factors, and bone health knowledge (Osteoporosis Knowledge Test, OKT). Results: Of 161 participants, 72.1% were current PrEP users, 18.0% were starting PrEP, and 9.9% did not indicate their PrEP status. All identified as males, 88.8% as gays, and 67.1% as Whites. Median (IQR) age was 32.0 (29.0, 40.0) years, and 62.1% reported family income ≥$60,000/year. Among those not already using the interventions, willingness to supplement with daily vitamin D, weekly vitamin D, or daily calcium was very high at 90.9%, 96.4%, and 93.0 %, respectively. Only 31.0% reported adequate dietary calcium intake, while 42.9% reported ≥1 osteoporosis risk factor (most commonly, alcohol and smoking). Overall bone health knowledge was low, as median (IQR) OKT score was 16/32. In post hoc comparisons, current PrEP users may have been more likely than new PrEP users to engage in bone loading exercise (Bone-specific Physical Activity Questionnaire score=12.5 vs 3.6,P=0.001) and have greater bone health knowledge (OKT=17 vs 14,P=0.08), but they had similar levels of current vitamin D supplementation (37.4% vs 21.4%,P=0.11), calcium supplementation (11.2% vs 13.8%, P=0.70), and adequate dietary calcium intake (32.7% vs 25.0%,P=0.43). Discussion: The high acceptability of vitamin D and calcium supplementation in this cohort suggests that enrollment into a clinical trial of such interventions to mitigate PrEP-induced BMD loss is feasible. Keywords: HIV, pre-exposure prophylaxis, vitamin D, calcium, bone and bones, bone density