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Purpose Physically harsh discipline is associated with poor developmental outcomes among children. These practices are more prevalent in areas experiencing poverty and resource scarcity, including in low- and middle-income countries. Designed to limit social desirability bias, this cross-sectional study in rural Uganda estimated caregiver preferences for physically harsh discipline; differences by caregiver sex, child sex, and setting; and associations with indicators of household economic stress and insecurity. Method Three-hundred-fifty adult caregivers were shown six hypothetical pictographic scenarios depicting children whining, spilling a drink, and kicking a caregiver. Girls and boys were depicted engaging in each of the three behaviors. Approximately half of the participants were shown scenes from a market setting and half were shown scenes from a household setting. For each scenario, caregivers reported the discipline strategy they would use (time out, beating, discussing, yelling, ignoring, slapping). Results Two thirds of the participants selected a physically harsh discipline strategy (beating, slapping) at least once. Women selected more physically harsh discipline strategies than men (b = 0.40; 95% confidence interval [CI], 0.26 to 0.54). Participants shown scenes from the market selected fewer physically harsh discipline strategies than participants shown scenes from the household (b = -0.51; 95% CI, -0.69 to -0.33). Finally, caregivers selected more physically harsh discipline strategies in response to boys than girls. Indicators of economic insecurity were inconsistently associated with preferences for physically harsh discipline. Conclusions The high prevalence of physically harsh discipline preferences warrant interventions aimed at reframing caregivers’ approaches to discipline.

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.

COVID-19 led to widespread disruption of services that promote family well-being. Families impacted most were those already experiencing disparities due to structural and systemic barriers. Existing support systems faded into the background as families became more isolated. New approaches were needed to deliver evidence-based, low-cost interventions to reach families within communities. We adapted a family strengthening intervention developed in Kenya ("Tuko Pamoja") for the United States. We tested a three-phase participatory adaptation process. In phase 1, we conducted community focus groups including 11 organizations to identify needs and a community partner. In phase 2, the academic-community partner team collaboratively adapted the intervention. We held a development workshop and trained community health workers to deliver the program using an accelerated process combining training, feedback, and iterative revisions. In phase 3, we piloted Coping Together with 18 families, collecting feedback through session-specific surveys and participant focus groups. Community focus groups confirmed that concepts from Tuko Pamoja were relevant, and adaptation resulted in a contextualized intervention-"Coping Together"-an 8-session virtual program for multiple families. As in Tuko Pamoja, communication skills are central and applied for developing family values, visions, and goals. Problem-solving and coping skills then equip families to reach goals, while positive emotion-focused activities promote openness to change. Sessions are interactive, emphasizing skills practice. Participants reported high acceptability and appropriateness, and focus groups suggested that most content was understood and applied in ways consistent with the theory of change. The accelerated reciprocal adaptation process and intervention could apply across resource-constrained settings.

Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.Aunque las normas mal percibidas impulsan los comportamientos personales de salud, no sabemos acerca de este fenómeno en el contexto de la terapia antirretroviral (TAR). Este estudio transversal incluyó a todas las personas que viven con el VIH (PVVS) y con TAR en ocho pueblos de una parroquia en una región rural del suroeste de Uganda. Utilizamos encuestas para medir los informes de adherencia personal al TAR (no faltar ninguna dosis de TAR en los últimos 7 días se consideró como acción óptima; mientras que faltar las dosis se consideraron como acción subóptima) y las normas percibidas sobre la norma local de adherencia al TAR (si cada individuo pensó o no que 'la mayoría de las otras PVVS en esta parroquia omitieron alguna dosis en los últimos 7 días). Usamos modelos multivariables de regresión de Poisson para estimar la asociación entre las normas percibidas y la adherencia personal. De las 159 PVVS con TAR (tasa de respuesta del 95%), 142 (89%) reportaron que no faltaron ningua dosis. Sin embargo, 119 (75%) pensaron que la mayoría de los individuos en esta población de PVVS con TAR eran suboptimalmente adherentes. Esta percepción incorrecta sobre la norma local de adherencia al TAR fue prevalente en todos los subgrupos de PVVS. La percepción incorrecta de que la norma local de adherencia al TAR era subóptima se asoció con una menor probabilidad de adherencia óptima entre las PVVS casadas (riesgo relativo ajustado [aRR] = 0,83; intervalo de confianza [IC] del 95% 0,71-0,97). La asociación fue similar pero imprecisamente se estima para todas las PVVS (aRR = 0,91; IC 95% 0,82-1,01). Las intervenciones para corregir las normas mal percibidas de TAR, como una intervención independiente o como un complemento de otros programas de promoción de la adherencia, pueden influir en el comportamiento de la adherencia al TAR y tal vez reducir el estigma relacionado con el VIH.

BackgroundLittle is known about perceived norms about cigarette smoking in Uganda or the extent to which perceptions drive personal cigarette smoking behaviour.MethodsWe conducted a cross-sectional study in 2016–2018 that targeted all adults who resided within eight villages in Rwampara District, southwestern Uganda. Personal cigarette smoking frequency was elicited by self-report. We also asked participants what they believed to be the cigarette smoking frequency of most other adult men and women in their villages (i.e., perceived norms). Frequent cigarette smoking was defined as 4+ times/week. We compared perceived norms to cigarette smoking frequency reports aggregated at the village level. We used multivariable Poisson regression to estimate the association between perceived norms and personal cigarette smoking behaviour.ResultsAmong 1626 participants (91% response rate), 92 of 719 men (13%) and 6 of 907 women (0.7%) reported frequent smoking. However, 1030 (63%) incorrectly believed most men in their villages smoked cigarettes frequently. Additionally, 116 (7%) incorrectly believed that most women in their villages smoked cigarettes frequently. These misperceptions were pervasive across social strata. Men who misperceived frequent cigarette smoking as the norm among other men in their villages were more likely to smoke frequently themselves (adjusted relative risk=1.49; 95% CI, 1.13 to 1.97).ConclusionsMost adults overestimated cigarette smoking frequency among village peers. Men who incorrectly believed that frequent smoking was the norm were more likely to engage in frequent smoking themselves. Applying a ‘social norms approach’ intervention by promoting existing healthy norms may prevent smoking initiation or motivate reductions in smoking among men in rural Uganda.

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 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.

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 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.

Depression is a leading cause of disability worldwide, and has been found to be a consistent correlate of socioeconomic status (SES). The relative deprivation hypothesis proposes that one mechanism linking SES to health involves social comparisons, suggesting that relative SES rather than absolute SES is of primary importance in determining health status. Using data from a whole-population sample of 1,620 participants residing in rural southwestern Uganda, we estimated the independent associations between objective and subjective relative wealth and probable depression, as measured by the depression subscale of the Hopkins Symptom Checklist (HSCLD). Objective relative wealth was measured by an asset index based on information about housing characteristics and household possessions, which was used to rank study participants into quintiles (within each village) of relative household asset wealth. Subjective relative wealth was measured by a single question asking participants to rate their wealth, on a 5-point Likert scale, relative to others in their village. Within the population, 460 study participants (28.4%) screened positive for probable depression. Using Poisson regression with cluster-robust error variance, we found that subjective relative wealth was associated with probable depression, adjusting for objective relative wealth and other covariates (adjusted relative risk [aRR] comparing lowest vs. highest level of subjective relative wealth = 1.90, 95% confidence interval [CI]: 1.18, 3.06). Objective relative wealth was not associated with probable depression (aRR comparing lowest vs. highest quintile of objective relative wealth = 1.09, 95% CI: 0.77, 1.55). These results suggest that, in this context, subjective relative wealth is a stronger correlate of mental health status compared with objective relative wealth. Our findings are potentially consistent with the relative deprivation hypothesis, but more research is needed to explain how relative differences in wealth are (accurately or inaccurately) perceived and to elucidate the implications of these perceptions for health outcomes., Highlights • We analyzed data from a whole-population survey in rural Uganda. • Relative wealth was measured using both objective and subjective measures. • Subjective, but not objective, relative wealth was associated with depression. • The results are consistent with the relative deprivation hypothesis.

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.