'This is what is going to help me': Developing a co-designed and theoretically informed harm reduction intervention for mobile youth in South Africa and Uganda

Examining the resilience of mobile youth in KwaZulu-Natal, South Africa: a qualitative inquiry through the lens of protection and risk

BACKGROUND

The last few decades have seen a demographic shift in the age of migrants with more young people involved, especially with regards to internal migration. Socio-economic deprivation, limited resources and adversities contribute to many young people leaving rural areas in low- and middle-income countries in search of a better life in urban settings. This move often requires an adaptation process and resilience to the adversities young people face while still in the challenging developmental life stage of adolescence, exposing them to health and physical risks.

METHODS

As part of Lending a Hand support intervention, we conducted repeat in-depth interviews with 20 young people that had recently relocated from other rural villages to a peri-urban setting in uMkhanyakude district, KwaZulu-Natal in South Africa. Data were analysed thematically using inductive and deductive approaches and managed in NVivo software.

RESULTS

The participants shared that there were alarming rates of teenage pregnancies in their local area and attributed this to younger girls dating older men for economic gain, which also exposed them to infectious diseases. Some vulnerabilities described by young people included coming from a single parent home, experiencing psychological distress, and living far away from the support of family. Other young people were able to use community-based resources as well as adaptive emotion regulation strategies that offered protective support such as church, school, and peer networks around them.

CONCLUSIONS

The accessibility and availability of protective resources offered support and provided strength to young people. This fostered resilience for these young people and in a way incorporated aspects of the collectivist communities they live in. Considering resources that are easily available in resource limited settings is important as young people may be more comfortable and confident to access and use. These protective factors may help curb some of the impact of the risks that they are exposed to.

Co-creation and community engagement in implementation research with vulnerable populations: a co-creation process in China

Background Top-down implementation strategies led by researchers often generate limited or tokenistic community engagement. Co-creation, a community engagement methodology, aims to create a shared leadership role of program beneficiaries in the development and implementation of programs, and encourages early and deep involvement of community members. We describe our experience using a four-stage co-creation approach to adapt and implement a sexually transmitted diseases (STD) testing intervention among men who have sex with men (MSM) in China. Methods We adapted a four-stage approach to co-creation. First, we conducted a needs assessment based on our prior work and discussions with community members. Second, we planned for co-creation by establishing co-creator roles and recruiting co-creators using both stratified convenience and opportunistic sampling. Third, we conducted co-creation via hybrid online/in-person focus groups (four multistakeholder groups and four MSM-only groups). Finally, we evaluated validity of the co-creation process through qualitative observations by research staff, analyzed using rapid qualitative analysis, and evaluated co-creator experience through post-discussion survey Likert scales and open-ended feedback. Results Needs assessment identified the needs to adapt our STD intervention to be independently run at community-based and public clinics, and to develop explanations and principles of co-creation for our potential co-creators. In total, there were 17 co-creation members: one co-creation lead (researcher), two co-chairs (one gay influencer and one research assistant), eight MSM community members, four health workers (two health professionals and two lay health workers) and two research implementers and observers. Co-created contents for the trial included strategies to decrease stigma and tailor interventions to MSM at public STD clinics, strategies to integrate STD testing services into existing community-led clinics, and intervention components to enhance acceptability and community engagement. Our evaluation of validity identified three main themes: challenges with representation, inclusivity versus power dynamics and importance of leadership. Surveys and free responses suggested that the majority of co-creators had a positive experience and desired more ownership. Conclusion We successfully adapted a structured co-creation approach to adapt and implement an STD testing intervention for a vulnerable population. This approach may be useful for implementation, and further research is needed in other contexts and populations.

"She held my hand and advised me": Young migrants' experiences of individual peer support to access health and social services in two small towns in southwestern Uganda

We describe how a pilot intervention called "Lending a Hand" was implemented to mitigate some of the risks associated with migration among young recent migrants (14-24 years) in two small towns in south-western Uganda. The design of the intervention was informed by the `protection-risk framework', with key protection components of the intervention (positive role models/ "good" social network, safer environment, health and social support) affording support to young migrants to counter risks in their new environment. As part of the intervention (November 2021-January 2023), peer supporters were recruited and trained to provide practical assistance, emotional support, and guidance to young recent migrants. We conducted qualitative in-depth interviews with 20 young migrants (11 males and 9 females). They were purposively selected to participate in two in-depth interviews each to explore their experiences with peer support. Young migrants were eligible to participate if they were aged between 14 and 24 years and in their first year as a migrant in the town. Data were analysed thematically, and three themes on the role of peer supporters were identified based on the protection-components drawn from the protection-risk framework: facilitating access to health services, offering responsive and person-centred support and fostering a social support system, friendship and mentorship. We found that peer supporters improved young migrants' access to health and social support. They facilitated access to healthcare services, provided information and counselling services and offered responsive and person-centred support. Peer supporters in the Lending a Hand intervention played a valuable role in addressing healthcare challenges faced by young migrants. This experience offers lessons for the integration of formal peer support into interventions targeting young migrants to access health and social support services.

Gendered risks: access to and utilization of sexual and reproductive health services among young migrants in Southwestern Uganda: the role of the 'lending a hand' intervention

Introduction

Young migrants may engage in risky behaviours due to social, economic, and psychological challenges as they try to "get by" in their new host communities. This can result in unintended pregnancies, sexually transmitted infections including HIV, and poor mental health outcomes.During a study to test the feasibility and acceptability of an early intervention to reduce the harm of patterns of risk associated with migration, we assessed access to and utilization of sexual and reproductive health services (SRH) among recent migrants (14-24 years) in south-western Uganda.

Methods

The intervention conducted in 2022/23 involved training peer supporters to provide referral advice and support to young people. Between March-November 2022, 20 young migrants (11 males and 9 females) were purposively selected to participate in two in-depth interviews each to explore their experiences during the intervention. Data were analysed thematically.

Results

Women engaged in transactional sex to supplement their low pay while men got involved in risky behaviour once they had earned some money. Many suffered from sexually transmitted infections-related symptoms, were at risk for HIV infection and some women had fears of unwanted pregnancy. While some tried to seek for SRH services from public facilities, poor health service delivery such as long queues and shortages of drugs, discouraged them from going there. Young people tried to access treatment from private facilities but could not afford the costs. The intervention increased knowledge about SRH and supported young people to access services from the public health facilities at no cost thus increasing utilization.

Conclusion

Sexual health risks were experienced differently by women and men. The women were likely to experience symptoms related to sexually transmitted infections (including HIV) much earlier than men and this could increase their likelihood to engage with SRH services. The intervention served to increase men's readiness to access SRH services by providing them at a time and place that is convenient. Recognizing the different risk profiles of young people is important in tailoring appropriate interventions to promote equitable access and utilization of SRH services for both genders in this vulnerable population.

Exploring ecosocial contexts of alcohol use and misuse during the COVID-19 pandemic among urban refugee youth in Kampala, Uganda: Multi-method findings

Urban refugees may be disproportionately affected by socio-environmental stressors that shape alcohol use, and this may have been exacerbated by additional stressors in the COVID-19 pandemic. This multi-method study aimed to understand experiences of, and contextual factors associated with, alcohol use during the pandemic among urban refugee youth in Kampala, Uganda. We conducted a cross-sectional survey (n = 335), in-depth individual interviews (IDI) (n = 24), and focus groups (n = 4) with urban refugee youth in Kampala. We also conducted key informant interviews (n = 15) with a range of stakeholders in Kampala. We conducted multivariable logistic regression analyses with survey data to examine socio-demographic and ecosocial (structural, community, interpersonal) factors associated with ever using alcohol and alcohol misuse. We applied thematic analyses across qualitative data to explore lived experiences, and perceived impacts, of alcohol use. Among survey participants (n = 335, mean age= 20.8, standard deviation: 3.01), half of men and one-fifth of women reported ever using alcohol. Among those reporting any alcohol use, half (n = 66, 51.2 %) can be classified as alcohol misuse. In multivariable analyses, older age, gender (men vs. women), higher education, and perceived increased pandemic community violence against women and children were associated with significantly higher likelihood of ever using alcohol. In multivariable analyses, very low food security, relationship status, transactional sex, and lower social support were associated with increased likelihood of alcohol misuse. Qualitative findings revealed: (1) alcohol use as a coping mechanism for stressors (e.g., financial insecurity, refugee-related stigma); and (2) perceived impacts of alcohol use on refugee youth health (e.g., physical, mental). Together findings provide insight into multi-level contexts that shape vulnerability to alcohol mis/use among urban refugee youth in Kampala and signal the need for gender-tailored strategies to reduce socio-environmental stressors.

Community engagement tools in HIV/STI prevention research

PURPOSE OF REVIEW

Community engagement is key to the success of sustainable public health interventions. This review highlights recent published studies that describe the use of community-engaged methods in sexually transmitted infection (STI) prevention research.

RECENT FINDINGS

We organized the findings using a socio-ecological model. At the individual level, communities were engaged through participation in formative research, short-term consultations and community advisory board participation, as well as co-creation activities. At the interpersonal level, studies reviewed described peer-led interventions that leverage the influence and guidance of peers, patient-led interventions in the form of patient navigation and notification, as well as those that mobilize social networks and the power of social relationships to promote health. At the organizational and community level, multisectoral, multifacility collaborations between community, government, and academic stakeholders were highlighted. At the policy and population level, communities were engaged through community dialogues to disseminate research findings, as well as in developing strategic frameworks and clinical guidelines. Digital tools have also been leveraged for effective community engagement.

SUMMARY

Communities have an effective role to play in STI prevention and can be engaged at multiple levels. Future efforts may consider the use of community engagement tools highlighted in this review, including digital technologies that have the potential to reach more diverse end-users.

Making sense of uncertainty: The precarious lives of young migrants from rural Kwazulu-Natal, South Africa

This study aims to examine the experiences of young migrants and the role of uncertainty in their precarious lives. Drawing on data from individual interviews and a workshop with young migrants aged 16-24 years old in KwaZulu-Natal, South Africa, we use uncertainty as a theoretical lens, to illustrate the ways in which young migrants' experiences provide meaning for them and give them an opportunity to assess, and plan for better opportunities despite the stark outlook. Thematic analysis was used to examine the multidimensionality of socio-spatial identities in young migrants. The findings illustrate how young migrants hustle for opportunities to lead valuable lives in the face of uncertainty. The implications highlight how attending to the complex intersectional nuances of uncertainty can serve as an enabler of aspirations, alongside essential structural factors influencing migration among young people brought up in rural communities. However, in proposing this alternative view of positive uncertainty, the structural violence experienced by these young people should not be overlooked and should be addressed as per their context.

Youth migration and access to health services in a trading centre in southern Uganda: A qualitative exploration

Impeded access to health services is a major factor influencing migrant health. In Uganda, previous research has shown lower utilisation of health services for young rural-urban migrants compared to their non-migrant counterparts. However, access to health services does not start at utilisation, but can be hampered by being able to identify a need for care. Using qualitative methods, we aimed to explore young rural-urban migrants' perceptions of health and patterns of engagement with health services. We analysed, using thematic analysis, a purposive sample of 18 in-depth interviews with 10 young people who had recently migrated within Uganda. Our results are presented through a framework conceptualising access at the intersection between abilities of people and characteristics of services. Participants perceived a need for care mostly through serious crises. Their ability to obtain care was hindered by a lack of resources, as well as the relative social isolation brought by migration. Our study highlights other barriers to accessing care such as the role of social norms and HIV-related stigma in health issues prioritisation, and healthcare workers' attitudes. This knowledge can inform approaches to ensure that community-based services are able to support healthcare access and improved health outcomes for this vulnerable group.

Enhancing a peer supporter intervention for young mothers living with HIV in Malawi, Tanzania, Uganda, and Zambia: Adaptation and co-development of a psychosocial component

ABSTRACTYoung mothers living with HIV (YMHIV) experience heightened risks to their mental health, as their transition to adulthood is marked by social stigma, health and socioeconomic challenges. Targeted psychosocial interventions may improve the mental health of YMHIV; however, no evidence-based interventions have been developed for this group. Peer support models, more common for youth living with HIV, show promise as a design to reach YMHIV in a non-stigmatising way. This manuscript describes the process of adapting and co-developing an evidence-based psychosocial component (Boost) of a larger intervention called Ask-Boost-Connect-Discuss. Peer supporters in Malawi, Tanzania, Uganda, and Zambia used ABCD to guide group sessions with YMHIV. The research team partnered with an implementing partner, Paediatric-Adolescent Treatment Africa, to undertake this work in three phases: 1) formative research, 2) content adaptation and development, and 3) consultation, refinement, and modification. YMHIV (n = 4), peer supporters (n = 21), and technical advisors (n = 4) were engaged as co-developers, shaping the resulting Boost intervention component at each phase. Peer support models may effectively reach young mothers, and consultation, co-creation, and integration with existing programming can offer rich insights to inform these models. We discuss the implications and promise of this approach.

"Other risks don't stop": adapting a youth sexual and reproductive health intervention in Zimbabwe during COVID-19

COVID-19 threatens hard-won gains in sexual and reproductive health (SRH) through compromising the ability of services to meet needs. Youth are particularly threatened due to existing barriers to their access to services. CHIEDZA is a community-based integrated SRH intervention for youth being trialled in Zimbabwe. CHIEDZA closed in March 2020, in response to national lockdown, and reopened in May 2020, categorised as an essential service. We aimed to understand the impact of CHIEDZA's closure and its reopening, with adaptations to reduce COVID-19 transmission, on provider and youth experiences. Qualitative methods included interviews with service providers (n = 22) and youth (n = 26), and observations of CHIEDZA sites (n = 10) and intervention team meetings (n = 7). Analysis was iterative and inductive. The sudden closure of CHIEDZA impeded youth access to SRH services. The reopening of CHIEDZA was welcomed, but the necessary adaptations impacted the intervention and engagement with it. Adaptations restricted time with healthcare providers, heightening the tension between numbers of youths accessing the service and quality of service provision. The removal of social activities, which had particularly appealed to young men, impacted youth engagement and access to services, particularly for males. This paper demonstrates how a community-based youth-centred SRH intervention has been affected by and adapted to COVID-19. We demonstrate how critical ongoing service provision is, but how adaptations negatively impact service provision and youth engagement. The impact of adaptations additionally emphasises how time with non-judgemental providers, social activities, and integrated services are core components of youth-friendly services, not added extras.