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Abstract Background Previous initiatives concerning adolescent sexual and reproductive health (SRH) education in Low-or-Middle Income Countries (LMICs) have been limited by cultural norms and misinformation perpetuated within families. Responding to the paucity of research on the implementation of SRH interventions in LMICs and limited knowledge regarding their mechanisms, this study undertakes a process evaluation of a parent-focused intervention to promote parent-adolescent communication about SRH in Uganda. Methods This paper explores the implementation, contextual factors and mechanisms of impact of the intervention, using the Medical Research Council (MRC) guidelines for process evaluations. Implementation was evaluated through indicators of dose, fidelity and adaptations, acceptability and feasibility. The contextual factors and mechanisms of impact were evaluated to refine the intervention’s causal assumptions. Data was collected during April - October 2021 in South-Western Uganda using a mixed-methods approach, including document analysis, intervention observations, interviews, focus group discussions and most significant change stories. Results The acceptability of the intervention was related to its community engagement, the strong rapport with delivery agents, and individual characteristics of participants. Five contextual factors influencing implementation were highlighted; (i) cultural norms, (ii) perceptions about youth SRH, (iii) poverty, (iv) Covid-19 pandemic, and (v) prior research projects in the community. When considering the intervention’s mechanisms of impact, four causal pathways were identified; (i) Awareness of SRH needs helped parents overcome stigma, (ii) Parenting skills training improved SRH communication, (iii) Group learning stimulated shared parenting, and (iv) Group learning improved co-parenting. Conclusion The paper presented three key learnings and corresponding recommendations for future research. Firstly, implementation success was credited to meaningful community engagement which improved acceptability and uptake. Secondly, the complex influences of contextual factors highlighted the need for contextual analysis in research studies to inform intervention design. Finally, this evaluation recognised the interplay between mechanisms of impact and suggested further research consider such combined impacts when designing intervention content.

Plain English summary Communication between parents and children about sexual and reproductive health (SRH) during the early adolescence stage (10–14 years) plays a significant role in creating positive reproductive health outcomes in later adolescence and adulthood. We conducted surveys in rural areas of Mbarara district among 218 pairs of caregivers and their children aged 10–14 years between January and February 2020. The purpose of the study was to understand whether there is communication between the two, and how comfortable they felt having discussions about SRH. We also asked caregivers and their children about their knowledge of SRH, and how they generally felt about SRH for young people. This study, however, reports only results from caregivers. We found that, on average, caregivers discussed 4 of the 10 SRH topics explored in this survey with their child, and that the majority of the caregivers reported being very comfortable discussing SRH—especially general health and bodily hygiene—with their children. On the whole, we found that caregivers’ SRH communication was largely influenced by their comfort with discussing SRH with their adolescent child. The level of comfort was influenced by the number of young adolescents living in a household. However, there is no clear justification for this finding from existing literature. In conclusion, there is a need for interventions that facilitate improvement of communication on SRH between parents/caregivers and young adolescents. These should focus on improving comfort levels by promoting communication skills for caregivers and emphasizing value clarification.

BackgroundThis paper presents findings from a qualitative effectiveness evaluation of an intervention aimed at improving caregiver-young adolescent sexual and reproductive health (SRH) communication including training modules for caregivers on parent-child SRH communication.MethodsData was collected (October 2021-November 2021) using a narrative interviewing technique with thirty caregivers (8 males and 22 females), who received the parent-child communication intervention in Mbarara district, south-western Uganda. We explored caregivers' experiences with the intervention based on four domains of change: caregiver-young adolescent communication on SRH issues, knowledge and attitudes towards adolescent SRH, parenting skills, and personal life and family. Thematic analysis was used to code and analyse the data, with attention to gender differences.ResultsFindings highlight positive parenting as a key attribute of SRH communication, along with a transformation of knowledge and attitudes towards the SRH of young adolescents leading to an overall improvement in SRH communication. However, communication is still limited to comfortable topics.ConclusionOur findings indicate improved caregiver-adolescent SRH communication practices following a community intervention. Programming for adolescent health on broader sexuality topics, comfortability and attitude change among caregivers could promote behaviour change on a long term. Future studies may focus on the long term impacts of interventions of this nature and test interventions aimed at addressing comfortability with discussingSRH issues.

Abstract Background Limited research has been conducted on the effectiveness of sexuality education for very young adolescents (VYAs) ages 10–14 years in Sub-Saharan Africa. Furthermore, evaluations of sexuality education programs often report outcomes of risky sexual practices, yet positive aspects of sexuality are hardly studied and rarely reported. This study evaluates the effectiveness of a Comprehensive Sexuality Education (CSE) intervention for VYAs in Uganda, analyzing both positive and negative outcome indicators. Methods We conducted a mixed methods study, incorporating a cluster randomized trial (NCT03669913) among pupils in 33 randomly selected primary schools in Mbarara district. This was followed by a qualitative evaluation of the intervention in 4 schools that included 14 in-depth interviews and 3 focus group discussions distributed among pupils, teachers and parents. Quantitative data were analyzed using ordered logistic regression to compare differences in the change from baseline to endline between the intervention and control arms. We conducted bivariate analysis and multiple regression analysis controlling for key covariates, including age, gender, school location (rural vs urban), truancy, and orphanhood. Qualitative data were analyzed by thematic approach using ATLAS TI. Results Between July 2016 and August 2017, 1096 pupils were recruited. Outcomes were studied among 380 pupils in the intervention arm and 484 pupils in the control arm. The proportion of pupils who ever had sex increased from 9 to 12.1% in intervention compared to 5.2 to 7.4% in the control group between baseline and endline, however the differences between groups were not statistically significant. We found greater improvements in sexual and reproductive health (SRH) knowledge among intervention schools (AOR: 2.18, 95% CI: 1.66–2.86) and no significant differences in self-esteem, body image or gender equitable norms. Qualitative evidence echoes perceived SRH knowledge acquisition, increased their perception of SRH related risks, and intentions to delay sexual intercourse to prevent unwanted pregnancy, HIV and other STIs. Conclusion This study demonstrates that CSE can improve SRH knowledge and behavioral intentions among VYAs in Uganda. These results further emphasize the importance of initiating sexuality education before most adolescents have started engaging in sexual activity, enabling them to make informed decisions in the future. Trial registration NCT03669913, registered retrospectively on September 13th, 2018.

Abstract Background Humanitarian crises and migration make girls and women more vulnerable to poor sexual and reproductive health (SRH) outcomes. Nevertheless, there is still a dearth of information on SRH outcomes and access to SRH services among refugee girls and young women in Africa. We conducted a mixed-methods study to assess SRH experiences, knowledge and access to services of refugee girls in the Nakivale settlement, Uganda. Methods A cross-sectional survey among 260 adolescent girls 13–19 years old was conducted between March and May 2018. Concurrently, in-depth interviews were conducted among a subset of 28 adolescents. For both methods, information was collected regarding SRH knowledge, experiences and access to services and commodities. The questionnaire was entered directly on the tablets using the Magpi® app. Descriptive statistical analysis and multinomial logistic regression were performed. Qualitative data was transcribed and analysed using thematic content analysis. Results A total of 260 participants were interviewed, with a median age of 15.9 years. The majority of girls were born in DR Congo and Burundi. Of the 93% of girls who had experienced menstruation, 43% had ever missed school due to menstruation. Regarding SRH knowledge, a total of 11.7% were not aware of how HIV is prevented, 15.7% did not know any STI and 13.8% were not familiar with any method to prevent pregnancy. A total of 30 girls from 260 were sexually active, of which 11 had experienced forced sexual intercourse. The latter occurred during conflict, in transit or within the camp. A total of 27 of 260 participants had undergone female genital mutilation (FGM). The most preferred sources for SRH information was parents or guardians, although participants expressed that they were afraid or shy to discuss other sexuality topics apart from menstruation with parents. A total of 30% of the female adolescents had ever visited a SRH service centre, mostly to test for HIV and to seek medical aid for menstrual problems. Conclusions Adolescent refugee girls lack adequate SRH information, experience poor SRH outcomes including school absence due to menstruation, sexual violence and FGM. Comprehensive SRH services including sexuality education, barrier-free access to SRH services and parental involvement are recommended.

Abstract Background In most Sub-Saharan African countries, little is known about young adolescents’ sexual and reproductive health (SRH). Though some efforts have been made to understand and improve SRH of older adolescents, very young adolescents (VYAs) are often overlooked, and little is known about their sexual knowledge and behaviors. The goal of this study was to describe SRH knowledge, information-seeking, and sexual behavior of VYAs in Uganda. Methods A cross-sectional survey was administered in 33 primary schools in June and July of 2016. Trained interviewers administered surveys to adolescents ages 10–14 regarding SRH knowledge, information-seeking, sexual behavior, and relevant covariates. Continuous variables were summarized as means (SD) or medians (IQR) whereas categorical variables were summarized as proportions (percentages). Results A total of 1096 adolescents were included in this analysis, 81.8% of which were from rural areas, with a median age of 12. Regarding sexually transmitted infections (STIs) knowledge; 95% knew HIV while 37% knew other STIs apart from HIV. Although 47% knew at least one way in which HIV is acquired only 8% knew at least four ways. Regarding contraceptive knowledge, 56% mentioned at least one modern method of preventing pregnancy (condoms, pills, intrauterine devices, implants, or injections). The majority (85%) of VYAs reported accessing SRH information in the media with 35% reporting accessing media with sexual content while 10% vs 22% consulted their father or mother respectively and 31% a school source. At least 7.6% of VYAs had ever had sexual intercourse, 90% of which were not using any protection. Conclusion Comprehensive SRH knowledge was low among VYAs in this study. Media remains an important source of information for SRH for this age group though it may be misused as some adolescents reported accessing sexual content that may be inappropriate. A large proportion of sexually active VYAs reported sexual risky behaviors. This study highlights the need for an accurate and more comprehensive SRH education approach for VYAs in Uganda at an opportune age before the majority engage in sexual behavior.

Abstract Background Psychotherapy is successful for the majority of patients, but not for every patient. Hence, further knowledge is needed on how treatments should be adapted for those who do not profit or deteriorate. In the last years prediction tools as well as feedback interventions were part of a trend to more personalized approaches in psychotherapy. Research on psychometric prediction and feedback into ongoing treatment has the potential to enhance treatment outcomes, especially for patients with an increased risk of treatment failure or drop-out. Methods/design The research project investigates in a randomized controlled trial the effectiveness as well as moderating and mediating factors of psychometric feedback to therapists. In the intended study a total of 423 patients, who applied for a cognitive-behavioral therapy at the psychotherapy clinic of the University Trier and suffer from a depressive and/or an anxiety disorder (SCID interviews), will be included. The patients will be randomly assigned either to one therapist as well as to one of two intervention groups (CG, IG2). An additional intervention group (IG1) will be generated from an existing archival data set via propensity score matching. Patients of the control group (CG; n = 85) will be monitored concerning psychological impairment but therapists will not be provided with any feedback about the patients assessments. In both intervention groups (IG1: n = 169; IG2: n = 169) the therapists are provided with feedback about the patients self-evaluation in a computerized feedback portal. Therapists of the IG2 will additionally be provided with clinical support tools, which will be developed in this project, on the basis of existing systems. Therapists will also be provided with a personalized treatment recommendation based on similar patients (Nearest Neighbors) at the beginning of treatment. Besides the general effectiveness of feedback and the clinical support tools for negatively developing patients, further mediating and moderating variables on this feedback effect should be examined: treatment length, frequency of feedback use, therapist effects, therapist’s experience, attitude towards feedback as well as congruence of therapist’s and patient’s evaluation concerning the progress. Additional procedures will be implemented to assess treatment adherence as well as the reliability of diagnosis and to include it into the analyses. Discussion The current trial tests a comprehensive feedback system which combines precision mental health predictions with routine outcome monitoring and feedback tools in routine outpatient psychotherapy. It also adds to previous feedback research a stricter design by investigating another repeated measurement CG as well as a stricter control of treatment integrity. It also includes a structured clinical interview (SCID) and controls for comorbidity (within depression and anxiety). This study also investigates moderators (attitudes towards, use of the feedback system, diagnoses) and mediators (therapists’ awareness of negative change and treatment length) in one study. Trial registration Current Controlled Trials NCT03107845 . Registered 30 March 2017.

The successful implementation of sexuality education policy for young people has been shown to depend on a sound legislative and institutional framework. This article shows that both institutional factors and contextual obstacles have impeded the implementation of sexuality education policy in Uganda. Qualitative research techniques were employed in the form of systematic document reviews and extensive field-work with 64 participants, of which 32 were in-depth interviews with policymakers and key stakeholders in Kampala and Mbarara districts. In addition, four focus group discussions (n = 32) were conducted with teachers. The analysis was carried out thematically and manually, using open and axial coding. It was found that policy success was primarily limited by two broad factors: firstly, by institutional weaknesses such as a lack of capacity, inadequate financial commitment, poor coordination between relevant ministries and ineffective monitoring, and regulatory frameworks; secondly, by social, cultural and religious norms that give informal power to religious and cultural leaders. Two strategies are suggested as potential ways forward: (i) a commitment to both the human and financial resources needed to monitor adolescent sexual, and reproductive health programmes, but more importantly (ii) the initiation of negotiations with cultural and religious leaders to yield more positive outcomes.

Background: Previous initiatives concerning adolescent sexual and reproductive health (SRH) education in Low-or-Middle Income Countries (LMICs) have been limited by cultural norms and misinformation perpetuated within families. Responding to the paucity of research on the implementation of SRH interventions in LMICs and limited knowledge regarding their mechanisms, this study undertakes a process evaluation of a parent-focused intervention to promote parent-adolescent communication about SRH in Uganda. Methods: This paper explores the implementation, contextual factors and mechanisms of impact of the intervention, using the Medical Research Council (MRC) guidelines for process evaluations. Implementation was evaluated through indicators of dose, fidelity and adaptations, acceptability and feasibility. The contextual factors and mechanisms of impact were evaluated to refine the intervention's causal assumptions. Data was collected during April - October 2021 in South-Western Uganda using a mixed-methods approach, including document analysis, intervention observations, interviews, focus group discussions and most significant change stories. Results: The acceptability of the intervention was related to its community engagement, the strong rapport with delivery agents, and individual characteristics of participants. Five contextual factors influencing implementation were highlighted; (i) cultural norms, (ii) perceptions about youth SRH, (iii) poverty, (iv) Covid-19 pandemic, and (v) prior research projects in the community. When considering the intervention's mechanisms of impact, four causal pathways were identified; (i) Awareness of SRH needs helped parents overcome stigma, (ii) Parenting skills training improved SRH communication, (iii) Group learning stimulated shared parenting, and (iv) Group learning improved co-parenting. Conclusion: The paper presented three key learnings and corresponding recommendations for future research. Firstly, implementation success was credited to meaningful community engagement which improved acceptability and uptake. Secondly, the complex influences of contextual factors highlighted the need for contextual analysis in research studies to inform intervention design. Finally, this evaluation recognised the interplay between mechanisms of impact and suggested further research consider such combined impacts when designing intervention content. [ABSTRACT FROM AUTHOR]

Abstract Schistosomiasis is a water-related disease strongly linked with high-risk water and sanitation practices perpetuating disease transmission. In Uganda, despite health education and sensitisation efforts through communication campaigns by the Ministry of Health to reduce schistosomiasis prevalence, common risky practices still pose a challenge, especially among endemic communities. Here, we steered away from the conventional top-down approach to communication campaigns and explored alternative methods. We employed citizen science (CS) and other participatory action research (PAR) techniques as a bottom-up approach to co-design and implement a communication campaign among communities of western Uganda, to achieve a more tangible outcome of behaviour change for preventing schistosomiasis. We collected qualitative data using data party, world café, prioritisation and ranking, focus group discussion, and key informant interviews from 378 purposively selected individuals and analysed it using a thematic analysis model. Community volunteers, community radios and local leaders were the most preferred channels for passing schistosomiasis information identified by participants. Lack of access to safe water and healthcare services, open defecation, and inadequate knowledge of schistosomiasis are some of the most pressing problems prioritised. Door-to-door visits by citizen scientists (CSs), community meetings, drama, and tournaments were the channels proposed by CSs and community groups during the co-design workshops. Over 1000 households and about 9000 community members were directly reached using the channels. Endemic communities prefer receiving schistosomiasis information using local channels instead of conventional ones. Combining citizen science with other PAR approaches empowers communities to interpret research findings in their contexts and take charge of the interventions. As such, clear and simple message coverage and a high audience turn-up can be achieved. A follow-up study is needed to evaluate the process and impact of the communication intervention on the citizen scientists and the community’s knowledge, attitudes, and practices regarding preventive measures.