Social ecological resources for youths living with HIV in western Uganda.

Introduction: The adversities faced by youths living with HIV (YLWH) are manifold, resulting not only from the health impact but also from society's response to HIV and the people living with it. This study sought to explore these youths' perceptions and representations of what promotes resilience. Methods: Photovoice methodology was chosen to elicit first-person accounts that are grounded in lived experience and experiential knowledge. Eleven young people, boys and girls aged 14-21 living in western Uganda, participated in seven group sessions aimed at imagining, producing and discussing visual stories about what fosters resilience in the face of HIV-related adversity. The visual stories were subjected to inductive content analysis by the participants, and then thematically analyzed and interpreted by the researchers using the theoretical framework of social-ecological resilience. Results: We found that participants experience well-being amidst HIV-related adversity through managing tensions in material resources, sense of identity, power and control in their lives, cultural adherence, relationships, sense of cohesion and social justice. Discussion: The findings add to the body of knowledge on youth resilience in Sub-Saharan Africa by documenting multisystemic resources for YLWH in Ugandan communities. The findings further show that resources are highly incidental and situational, neither widely available nor structurally embedded in society. The study therefore informs the global HIV/AIDS agenda to spur ecologies of resilience around YLWH.

Photovoicing Empowerment and Social Change for Youth Living With HIV/AIDS in Uganda.

In this article, we present new insights to the application of photovoice as a tool for empowerment of the marginalized and an antecedent for social change. Special attention is directed to the use of photovoice in raising critical consciousness of the stigmatized and marginalized youth living with HIV/AIDS as a catalyst for empowerment through both the process and content of the research. The article also expounds on the practical execution of photovoice that is not adequately elaborated in projects within resource limited settings.

HIV-Related Stigma Among Youth Living With HIV in Western Uganda.

We present an explanatory theory for HIV-related stigma from the perspectives of youth living with HIV/AIDS (YLWHA) in Western Uganda, on which the fight against this relentless stigma in this age group and locality can be founded. A constant comparative method was used to analyze textual data from in-depth interviews with 35 YLWHA, selected from three health facilities. A stigma process model for YLWHA was developed with the stigmatizing feelings and behaviors as the core category. Concepts delineating causes, consequences, and moderators of HIV-related stigma emerged from the data to complete the stigma process. The specific focus on YLWHA and contextual characteristics adds new dimensions to the understanding of HIV-related stigma that are scant in existing HIV-related stigma models. In light of our findings, research is necessary to identify context-specific strategies to overcome the deep-rooted causes of stigmatizing views and behaviors in all social spheres of YLWHA within Western Uganda.

Care and support for youth living with HIV/AIDS in secondary schools: perspectives of school stakeholders in western Uganda.

BACKGROUND: Although schools have been identified as significant settings in the response to the HIV/AIDS pandemic, limited research is available on how they can accommodate Youth Living with HIV/AIDS (YLWHA), especially in resource limited countries. In this study, we explored strategies by school stakeholders (school staff, parents/caretakers, and students) in western Uganda to care for and support YLWHA in their schools. METHODS: The article utilizes data collected between May and October, 2019 from a qualitative inquiry based on focus group discussions and interviews with 88 school stakeholders purposively selected from 3 secondary schools in western Uganda. Textual data was analyzed thematically involving both inductive and deductive coding. RESULTS: We identified 7 overarching interrelated themes in which participants reported strategies to care for and support YLWHA: counselling and guidance; social support networks and linkages; knowledge and skills; anti-stigma and anti-discrimination measures; disclosure of HIV status; treatment and management of HIV/AIDS; and affirmative actions for YLWHA. Stakeholders' strategies often differed regarding what was considered appropriate, the approach and who to take lead in supporting YLWHA. CONCLUSIONS: Despite the limited care and support strategies specific for YLWHA currently available in schools, our study points to optimism and high potential given stakeholders' identified avenues for improvement. We posit that promoting HIV/AIDS-care and support in schools is a gradual process requiring each school to develop a strong knowledge base about HIV/AIDS and support needs of YLWHA, develop a coherent and school-wide approach, and collaborate extensively with external stakeholders who are significant in supporting YLWHA.

Experiences and effects of HIV-related stigma among youth living with HIV/AIDS in Western Uganda: A photovoice study.

HIV-related stigma has been identified as a significant stressor affecting Quality of Life of Youth Living With HIV/AIDS (YLWHA). Gaining a contextualized understanding of how this stigma is experienced by YLWHA in Western Uganda is crucial in addressing it in this group and setting. In this study, we explored the lived experiences of YLWHA with HIV-related stigma. Photovoice was used to gain insight into the lived experiences of HIV-related stigma in 11 YLWHA (15-19 years), purposively selected from a hospital-based peer support group. Group interview transcripts, notes and photographs were subjected to phenomenological hermeneutic analysis. Encounters with enacted, anticipated and internalized stigmas and their myriad sequels were prevalent in the photos and narratives of participants. Our findings were categorized and presented in 5 main themes that were identified through the analysis: being devalued, experiencing fear, experiencing injustices, feeling lonely, and lacking future perspectives. HIV-related stigmas were experienced in various socio-ecological domains but predominantly in homes and schools that ought to be supportive surroundings for youths. A multilevel approach, targeting the entire society where the root causes of stigma can be found and specific contexts like schools and homes where youth are confronted with stigma on a daily basis is proposed for a wholistic intervention.

Experiences and perceptions of youth living with HIV in Western Uganda on school attendance: barriers and facilitators.

BACKGROUND: The globally recognized socio-economic benefits of education have stirred many countries in Sub-Saharan Africa like Uganda to promote universal access to schooling by removing fiscal barricades for those in primary and secondary schools. However, the proportion of Youth Living With HIV/AIDS (YLWHA) missing school, studying with difficulties and dropping out of school in Uganda has been observed to be higher than that of other youth. This study aimed at understanding the barriers and facilitators for YLWHA in Uganda to attend school. METHODS: We conducted a qualitative inquiry with 35 purposively selected YLWHA aged 12 to 19 years, including 16 females at three accredited Antiretroviral Therapy (ART) treatment centres in Kabarole district in Western Uganda. Individual semi-structured interviews were tape-recorded, transcribed verbatim and subjected to thematic inductive analysis. RESULTS: We identified five main themes in which barriers to attend school were reported and four main themes in which facilitators were reported by participants. The main themes for barriers were: 1) management of ART and illnesses, 2) fear, negative thoughts and self-devaluation, 3) lack of meaningful and supportive relationships, 4) reactionary attitudes and behaviours from others at school, 5) financial challenges. The main themes for facilitators were: 1) practical support at school, home and community, 2) counselling, encouragement and spirituality, 3) individual coping strategies, 4) hopes, dreams and opportunities for the future. CONCLUSION: Most of the barriers reported arose from HIV-related stigma and financial challenges whose genesis transcends school boundaries. While YLWHA reported measures to cope, and support from other people, these were non-sustainable and on a limited scale due to disclosure apprehension at school and the indiscretion of those who learnt about their status. To promote supportive school environments for YLWHA, integrated curricular and extracurricular interventions are necessary to increase HIV knowledge, dispel misconceptions about HIV and consequently transform the school community from a stigmatizing one to a supportive one.

Youth living with HIV/AIDS in secondary schools: perspectives of peer educators and patron teachers in Western Uganda on stressors and supports.

As Youth Living With HIV/AIDS (YLWHA) continue to survive and live with HIV chronically due to effective Antiretroviral Therapy (ART), it is paramount to work toward maximising their psychosocial wellbeing. The school where these YLWHA are expected to spend most of their time is an excellent environment to investigate this. In this study, we explore perspectives of Peer Educators (PEs) in secondary schools of one district in Western Uganda on how YLWHA are perceived in school, on their daily stressors and their way of coping with their HIV-positive serostatus given the support of the schools. We conducted eight focus groups with a total of 59 students who were members of Peer Educators Clubs (PECs) as well as 8 in-depth interviews with patron teachers of PECs in eight secondary schools of Kabarole district, selected through a stratified random sampling method. Focus groups and interviews were tape-recorded, transcribed and analysed thematically both inductively and deductively. Stressors and support in schools, as identified by the PEs were categorised into three interrelated thematic domains; psychological wellbeing of YLWHA, disclosure of HIV status by YLWHA, and health and treatment adherence. Stigma was found to be a key stressor and an intermediary in all the three thematic domains Stressors affecting psychological wellbeing were fear of death and uncertainty of the future compounded by financial and academic challenges. Stressors affecting disclosure centred around lack of privacy, confidentiality and fear of loss of friends. Stressors affecting treatment adherence included lack of privacy while taking drugs, unintended disclosure while obtaining drugs or seeking permission to attend clinic appointments and fear of drug adverse effects due to poor nutrition. A supportive school environment involved the availability of a school nurse, counselling services and PECs. We conclude that the school environment brings more stressors than supports for YLWHA. The daily stressors related to HIV stigma, uncertainty, disclosure, privacy and confidentiality render schooling a hassle for YLWHA. Interventions that promote resilient school communities are necessary to foster disclosure in a non-discriminatory and stigma-free environment. This calls for concerted efforts from all school stakeholders.

Challenges and support for quality of life of youths living with HIV/AIDS in schools and larger community in East Africa: a systematic review.

BACKGROUND: Youths living with HIV/AIDS (YLWHA) experience innumerable challenges within schools and the larger community. Nonetheless, these environments are potential sources of support for such youths. This review provides a synthesis of evidence about these challenges and support available for YLWHA to inform the design and implementation of interventions that support the wellbeing of youths living with HIV/AIDS in an East African context. METHODS: We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane central registry of systematic reviews and randomized control trials for studies conducted in East Africa and published in English in the last 10 years (March 2007 to March 2017). We also searched Google Scholar and reference lists of all included studies. We purposed to include both qualitative and quantitative data but no quantitative data merited inclusion. We analyzed qualitative data using a framework thematic analysis. RESULTS: We included 16 primary studies conducted in clinic and community settings that used qualitative or mixed methods. Three overarching themes-psychosocial wellbeing, treatment and health, and disclosure of HIV status together with a sub-theme of stigma that was important across the three overarching themes-were the basis for analysis. In each overarching theme, a duality of challenges versus support was reported. Psychosocial wellbeing included subthemes of challenges in schools and larger community, financial challenges, domestic violence, sexual and reproductive health challenges, and psychosocial support. CONCLUSION: YLWHA experience numerous challenges and support needs, some of which occur in schools and affect their QoL. The effects of these challenges are poor health and educational outcomes as well as school dropout. The schools in which youths spend most of their formative years have not provided adequate support for YLWHA. This review identified that although most of the challenges that studies identified arose from within schools and that a few supportive approaches were available, none of the studies explored how these supportive approaches would work in schools. It was additionally identified that stigma complicates challenges of living with HIV/AIDS necessitating interventions for the wellbeing of YLWHA to understand and address HIV-stigma and its ramifications. Such interventions ought to be sustainable in schools, culturally appropriate, and multidisciplinary in order to promote the general health of all students.

Toward a culturally sensitive conceptualization of resilience: Participatory research with war-affected communities in northern Uganda.

Resilience research with war-affected populations has long conceptualized resilience as the absence of psychopathology and operationalized it by use of standardized measures. However, literature on resilience increasingly highlights the importance of also including indicators of positively valued functioning as well as contextually sensitive indicators of resilience. This study used a participatory approach to examine the contextual conceptualization of youth resilience in the aftermath of war in northern Uganda, as defined by groups of stakeholders (youths, parents, elders, leaders, teachers) in four communities. The results identify 40 indicators covering a multiplicity of domains of functioning. The rationales behind these indicators were clustered into the broad themes: progress, self-reliance, social connectedness, morality, health, and comfort. The findings suggest that positively and negatively valued aspects of functioning are both key to conceptualizing resilience, and indicate the importance of including contextually distinguished indicators. The findings further point to the role of individual and collective processes in the construction of resilience, and to the need to take into account the contexts wherein resilience is conceptualized and observed. This study generated contextually sensitive indicators of young people's resilience, which can be used, complementary to existing measures of functioning, to provide a more comprehensive and culturally sensitive view of youths' resilience in the wake of war adversity.

Unpacking Constructs: A Network Approach for Studying War Exposure, Daily Stressors and Post-Traumatic Stress Disorder.

Conflict-affected populations are exposed to stressful events during and after war, and it is well established that both take a substantial toll on individuals' mental health. Exactly how exposure to events during and after war affect mental health is a topic of considerable debate. Various hypotheses have been put forward on the relation between stressful war exposure (SWE), daily stressors (DS) and the development of post-traumatic stress disorder (PTSD). This paper seeks to contribute to this debate by critically reflecting upon conventional modeling approaches and by advancing an alternative model to studying interrelationships between SWE, DS, and PTSD variables. The network model is proposed as an innovative and comprehensive modeling approach in the field of mental health in the context of war. It involves a conceptualization and representation of variables and relationships that better approach reality, hence improving methodological rigor. It also promises utility in programming and delivering mental health support for war-affected populations.

Dealing with the consequences of war: resources of formerly recruited and non-recruited youth in northern Uganda.

PURPOSE: This article explores resources that help formerly recruited young people in dealing with war-related adversity and subsequent challenges, hence fostering their resilience. METHODS: Self-reports on pertinent resources were collected from 1,008 northern Ugandan youth, of whom 330 had formerly been recruited by the Lord's Resistance Army. Based on the conceptual framework developed by the Psychosocial Working Group, the reported resources were thematically clustered and quantitatively analyzed. RESULTS: This study identified a range of human, social, and cultural resources, with little difference between groups. Religious beliefs, social support, and mental health resources were most frequently reported by former child soldiers. CONCLUSIONS: These results reveal a multitude of resources and suggest that it is important to build on these resources in interventions that aim to support former child soldiers in the aftermath of armed conflict.

War-related experiences of former child soldiers in northern Uganda: comparison with non-recruited youths.

BACKGROUND: Armed conflict imposes huge hardship on young people living in war zones. This study assessed former child soldiers' experience and perception of stress in common war events during the armed conflict in northern Uganda and compares it with their non-recruited counterparts. AIM: To investigate whether child soldiers experienced more severe exposure to war events, and explore how war might affect youths differently, depending on the co-occurrence of these events. METHODS: The study was undertaken in four northern Ugandan districts in 22 secondary schools with a sample size of 981 youths, about half of whom had been child soldiers. The participants completed a questionnaire on socio-demographic characteristics and stressful war events which was analyzed using descriptive statistics, a probabilistic index and correlation network analysis. RESULTS: Former child soldiers had significantly greater experience of war events than their non-recruited counterparts. The violence of war is more central in their experience and perception of stress, whereas the scarcity of resources and poor living conditions are most central for non-recruited participants. The extent to which a war event, such as separation from the family, is perceived as stressful depends on the experience and perception of other stressful war events, such as confrontation with war violence for former child soldiers and life in an Internally Displaced Persons' camp for non-recruited participants. CONCLUSION: The network approach permitted demonstration of the many ways in which war-affected youths encounter and appraise stressful war events. War events might function as moderators or mediators of the effect that other war events exert on the lives and well-being of young people living in war zones. This demands comprehensive and individualized assessment.

Beyond child soldiering: the interference of daily living conditions in former child soldiers' longer term psychosocial well-being in northern Uganda.

Given the various developments in former child soldiers' psychosocial well-being over time, the question arises as to which factors are associated with the prevalence of psychological distress. An ongoing debate points to the plausible importance of child soldiering-related and post-child soldiering factors. This study is an exploratory analysis of both types of association with former child soldiers' psychosocial well-being in the longer term. Follow-up data on a convenience sample of 424 northern Ugandan former child soldiers are analysed. Psychological symptoms are assessed by a review of the intake and assessment forms of the Rachele Rehabilitation Centre, which were not validated and did not include a standardised translation into the local language. These psychological symptoms and possible associated factors are analysed using binary logistic regression analysis. Thereby, both child soldiering-related and post-child soldiering variables are accounted for. The outcomes reveal almost no significant main effects of child soldiering-related variables, while a range of post-child soldiering variables (number of meals a day, school attendance, insults and professional support) are clearly associated with the prevalence of the measured psychological symptoms in the longer term. These exploratory conclusions should be further investigated in representative samples of former child soldiers using validated assessment tools.

"It helps me transform in my life from the past to the new": the meaning of resources for former child soldiers.

Although former child soldiers face considerable challenges after their return from the warring faction to the war-affected society, the presence of resources enables many to maintain well-being in the wake of child soldiering. Academic research has recently engaged with identifying these salient resources, but has left the question why they are helpful to former child soldiers largely unaddressed. This study therefore focuses on the meaning underlying certain phenomena that causes them to become resources. Semistructured in-depth interviews and a free-listing task on resources were conducted with 48 northern Ugandan former child soldiers. The phenomenological hermeneutical method is applied to analyze their lived experiences and the meaning they assign to resources. Four essential themes emerge from this study, representing the fourfold meaning of resources for former child soldiers in helping them (a) to break with their former existence as child soldiers, (b) to be able to overcome the challenges in their current life, (c) to belong to others and the environment to which they have returned, and (d) to become the person they aspire to be. Considering these research themes in the context of former child soldiers' return process, parallels with theories on transition are recognized and further explored so as to contextualize this emerging meaning. As such, this research delivers empirical evidence illustrating how resources help to pilot former child soldiers through transition in the wake of child soldiering.

Challenges faced by former child soldiers in the aftermath of war in Uganda.

PURPOSE: Warfare takes a profound toll of all layers of society, creating multiple and multilevel challenges that impinge on the psychosocial well-being of affected individuals. This study aims to assess the scope and salience of challenges confronting former child soldiers and at identifying additional challenges they face compared to non-recruited young people in war-affected northern Uganda. METHODS: The study was carried out with a stratified random sample of northern Ugandan adolescents (n = 1,008), of whom a third had formerly been recruited (n = 330). The mixed-method comparison design consisted of a constrained free listing task to determine the challenges; a free sorting task to categorize them into clusters; and statistical analysis of their prevalence among formerly recruited youth and of how they compare with those of nonrecruited youth. RESULTS: Altogether, 237 challenges were identified and clustered into 15 categories, showing that formerly recruited participants mainly identified "emotional" and "training and skills"-related challenges. Compared with nonrecruited counterparts, they reported significantly more "emotional" and fewer "social and relational" challenges, with the exception of stigmatization. Overall, there was similarity between the challenges reported by both groups. CONCLUSIONS: The challenges confronting formerly recruited youths reach well beyond the effects of direct war exposure and emerge mainly from multiple influence spheres surrounding them. These challenges are largely shared in common with nonrecruited youths. This multidimensional and collective character of challenges calls for comprehensive psychosocial interventions through which healing the psychological wounds of war is complemented by mending the war-affected surroundings at all levels and in all life areas.

Informal and formal supports for former child soldiers in Northern Uganda.

This study aimed to evaluate the potential contribution of informal community initiatives and formal interventions in support of former child soldiers' resilience in the wake of armed conflict. Using a cross-sectional survey design, a stratified random sample of 330 formerly recruited and 677 nonrecruited young people was consulted about their perspective on desirable support for former child soldiers provided by close support figures, communities, humanitarian organizations, and governments. Data analysis occurred by conducting qualitative thematic analysis and statistical chi-square analysis to explore clusters, similarities, and variations in reported support across the different "agents," hereby comparing the perspectives of formerly recruited and non-recruited participants. The results indicated that formerly recruited and non-recruited participants had comparable perspectives that call for the contribution of various informal and formal support systems to former child soldiers' human capacities and the communal sociocultural fabric of war-affected societies. This highlights the importance of community-based, collective, and comprehensive support of formerly recruited young people and their surroundings in the aftermath of armed conflict.

Forced conscription of children during armed conflict: experiences of former child soldiers in northern Uganda.

OBJECTIVE: Child soldiering can be considered as one of the worst practices of institutionalized child abuse. However, little is known about the scope and nature of this abuse and the consequent experiences of children enrolled in an armed faction. This research aims at enriching the knowledge on the experiences of child soldiers in the Lord's Resistance Army (LRA) in northern Uganda. METHODS: The databases of 4 former Interim Care Centres for returned child soldiers in northern Uganda, comprising socio-demographic information of 8,790 returnees, and additional data from the Rachele Rehabilitation Centre on war-related experiences of 1,995 former child soldiers, are analyzed using descriptive statistics, analysis of covariance and regression analysis. RESULTS: During on average 1.5 years in captivity, nearly all participants had various war-related experiences, whereby 88% witnessed and 76% forcibly participated in atrocities. Variations in exposure to warfare appear to be mainly associated with age of abduction, duration of captivity, location of captivity, being military trained, and being a rebel's wife. CONCLUSIONS: These findings testify to the vastness of abuse lived through by the child soldiers in this study. They fulfilled a multifaceted position in the LRA, which delivers a range of potential direct and indirect consequences. The variables decisive in differential experiences unveil trends in the strategic abduction by the LRA and in differential exposure to warfare among child soldiers. IMPLICATIONS: The variation in exposure to warfare urges for an individualized approach and monitoring of returning child soldiers. In order to address the potential indirect impact of child soldiering, support also needs to be oriented towards the child's network, based on a socio-ecological approach.