Female Sex and Cardiovascular Disease Risk in Rural Uganda: a Cross-Sectional, Population-Based Study

Background: Sex-based differences in cardiovascular disease (CVD) burden are widely acknowledged, with male sex considered a risk factor in high-income settings. However, these relationships have not been examined in sub- Saharan Africa (SSA). We aimed to apply the American Heart Association (AHA) ideal cardiovascular health (CVH) tool modified by the addition of C-reactive protein (CRP) to examine potential sex-based differences in the prevalence of CVD risk in rural Uganda. Methods: In a cross-sectional study nested within a population-wide census, 857 community-living adults completed physical and laboratory-based assessments to calculate individual ideal CVH metrics including an eight category for CRP levels. We summarized sex-specific ideal CVH indices, fitting ordinal logistic regression models to identify correlates of improving CVH. As secondary outcomes, we assessed subscales of ideal CVH behaviours and factors. Models included inverse probability of sampling weights to determine population-level estimates. Results: The weighted-population mean age was 39.2 (1.2) years with 52.0 (3.7) % females. Women had ideal scores in smoking (80.4% vs. 68.0%; p \u3c 0.001) and dietary intake (26.7% vs. 16.8%; p = 0.037) versus men, but the opposite in body mass index (47.3% vs. 84.4%; p \u3c 0.001), glycated hemoglobin (87.4% vs. 95.2%; p = 0.001), total cholesterol (80.2% vs. 85.0%; p = 0.039) and CRP (30.8% vs. 49.7%; p = 0.009). Overall, significantly more men than women were classified as having optimal cardiovascular health (6–8 metrics attaining ideal level) (39.7% vs. 29.0%; p = 0.025). In adjusted models, female sex was correlated with lower CVH health factors sub-scales but higher ideal CVH behaviors. Conclusions: Contrary to findings in much of the world, female sex in rural SSA is associated with worse ideal CVH profiles, despite women having better indices for ideal CVH behaviors.Future work should assess the potential role of socio-behavioural sex-specific risk factors for ideal CVH in SSA, and better define the downstream consequence

Water Insecurity and Gendered Risk for Depression in Rural Uganda: A Hotspot Analysis

Background: Water insecurity is linked to depression in low- and middle-income countries (LMICs), though it remains unclear how geospatial clustering of water insecurity in rural regions is associated with risk for depression. Methods: We conducted a population-based survey of a rural parish in southwestern Uganda (N = 1603) to evaluate the joint geospatial clustering of water insecurity and risk for depression among men and women living in rural Uganda. Results: Geospatial clustering of self-reported water insecurity and depressive symptoms was found to be present among both men and women. Depression hotspots were more often observed near water insecurity hotspots among women, relative to men. Multivariable regression revealed that residing in a water insecurity hotspot significantly increased risk for depressive symptoms among women, but not among men. Conclusions: Residing in a water insecurity hotspot is associated with greater risk for probable depression among women, but not among men, pointing to the need for focused depression screening among women residing in water insecure households. Keywords: Water insecurity, Depression, Geospatial, Gender, Sub-Saharan Afric

Household Water Insecurity, Missed Schooling, and the Mediating role of Caregiver Depression in Rural Uganda

Background: School attendance rates in sub-Saharan Africa are among the lowest worldwide, placing children at heightened risk for poor educational and economic outcomes. One understudied risk factor for missed schooling is household water insecurity, which is linked to depression among women and may increase children’s water-fetching burden at the expense of educational activities, particularly among children of depressed caregivers. In this study conducted in rural Uganda, we assessed the association between household water insecurity and child school participation and the mediating pathways behind these associations. Method: We conducted a population-based, cross-sectional study of female household heads (N = 257) and their children ages 5–17 (N = 551) in the rural regions surrounding the town of Mbarara, in southwestern Uganda. We used multivariable linear regressions to estimate the association between water insecurity and missed schooling. We then assessed the extent to which the association was mediated by caregiver depression. Results: Among children, water insecurity had a statistically significant association with the number of missed school days (a standard deviation increase in water insecurity resulted in 0.30 more missed school days in the last week). The estimated association was partially mediated by caregiver depression. When stratified by sex, this mediating pathway remained significant for boys, but not among girls. Conclusions: Water insecurity is a risk factor for missed schooling among children in rural Uganda. Caregiver depression partially mediated this relationship. Also addressing caregiver mental health in water insecure families may more fully address the needs of sub-Saharan African families and promote educational participation among youth

Reliability, Validity, and Factor Structure of the Hopkins Symptom Checklist-25: Population-Based Study of Persons Living with HIV in Rural Uganda

Depression and anxiety are highly comorbid among people living with HIV ( PLHIV ), but few instruments for screening or measurement have been validated for use in sub-Saharan Africa. The objective of this study was to determine the reliability, validity, and factor structure of the 25-item Hopkins Symptom Checklist ( HSCL ) in a population-based sample of PLHIV in rural Uganda. This study was nested within an ongoing population-based cohort of all residents living in Nyakabare Parish, Mbarara District, Uganda. All participants who identified as HIV-positive by self-report were included in this analysis. We performed parallel analysis on the scale items and estimated the internal consistency of the identified sub-scales using ordinal alpha. To assess construct validity we correlated the sub-scales with related constructs, including subjective well being (happiness), food insecurity, and health status. Of 1814 eligible adults in the population, 158 ( 8.7 % ) self-reported being HIV positive. The mean age was 41 years, and 68 % were women. Mean HSCL-25 scores were higher among women compared with men ( 1.71 vs. 1.44; t = 3.6, P \u3c 0.001 ). Parallel analysis revealed a three-factor structure that explained 83% of the variance: depression ( 7 items ), anxiety ( 5 items ) , and somatic symptoms ( 7 items ) . The ordinal alpha statistics for the sub-scales ranged from 0.83 to 0.91. Depending on the sub-scale, between 27 and 41 % of the sample met criteria for caseness. Strong evidence of construct validity was shown in the estimated correlations between sub-scale scores and happiness, food insecurity, and self-reported overall health. The HSCL-25 is a reliable and valid measure of mental health among PLHIV in rural Uganda. In cultural contexts where somatic complaints are commonly elicited when screening for symptoms of depression, it may be undesirable to exclude somatic items from depression symptom checklists administered to PLHIV

Measuring personal beliefs and perceived norms about intimate partner violence: Population-based survey experiment in rural Uganda

Background: Demographic and Health Surveys (DHS) conducted throughout sub-Saharan Africa indicate there is widespread acceptance of intimate partner violence, contributing to an adverse health risk environment for women. While qualitative studies suggest important limitations in the accuracy of the DHS methods used to elicit attitudes toward intimate partner violence, to date there has been little experimental evidence from sub-Saharan Africa that can be brought to bear on this issue. Methods and findings We embedded a randomized survey experiment in a population-based survey of 1,334 adult men and women living in Nyakabare Parish, Mbarara, Uganda. The primary outcomes were participants’ personal beliefs about the acceptability of intimate partner violence and perceived norms about intimate partner violence in the community. To elicit participants’ personal beliefs and perceived norms, we asked about the acceptability of intimate partner violence in five different vignettes. Study participants were randomly assigned to one of three survey instruments, each of which contained varying levels of detail about the extent to which the wife depicted in the vignette intentionally or unintentionally violated gendered standards of behavior. For the questions about personal beliefs, the mean (standard deviation) number of items where intimate partner violence was endorsed as acceptable was 1.26 (1.58) among participants assigned to the DHS-style survey variant (which contained little contextual detail about the wife’s intentions), 2.74 (1.81) among participants assigned to the survey variant depicting the wife as intentionally violating gendered standards of behavior, and 0.77 (1.19) among participants assigned to the survey variant depicting the wife as unintentionally violating these standards. In a partial proportional odds regression model adjusting for sex and village of residence, with participants assigned to the DHS-style survey variant as the referent group, participants assigned the survey variant that depicted the wife as intentionally violating gendered standards of behavior were more likely to condone intimate partner violence in a greater number of vignettes (adjusted odds ratios [AORs] ranged from 3.87 to 5.74, with all p < 0.001), while participants assigned the survey variant that depicted the wife as unintentionally violating these standards were less likely to condone intimate partner violence (AORs ranged from 0.29 to 0.70, with p-values ranging from <0.001 to 0.07). The analysis of perceived norms displayed similar patterns, but the effects were slightly smaller in magnitude: participants assigned to the “intentional” survey variant were more likely to perceive intimate partner violence as normative (AORs ranged from 2.05 to 3.51, with all p < 0.001), while participants assigned to the “unintentional” survey variant were less likely to perceive intimate partner violence as normative (AORs ranged from 0.49 to 0.65, with p-values ranging from <0.001 to 0.14). The primary limitations of this study are that our assessments of personal beliefs and perceived norms could have been measured with error and that our findings may not generalize beyond rural Uganda. Conclusions: Contextual information about the circumstances under which women in hypothetical vignettes were perceived to violate gendered standards of behavior had a significant influence on the extent to which study participants endorsed the acceptability of intimate partner violence. Researchers aiming to assess personal beliefs or perceived norms about intimate partner violence should attempt to eliminate, as much as possible, ambiguities in vignettes and questions administered to study participants. Trial registration ClinicalTrials.gov NCT02202824

Female sex and cardiovascular disease risk in rural Uganda: a cross-sectional, population-based study

Abstract Background Sex-based differences in cardiovascular disease (CVD) burden are widely acknowledged, with male sex considered a risk factor in high-income settings. However, these relationships have not been examined in sub-Saharan Africa (SSA). We aimed to apply the American Heart Association (AHA) ideal cardiovascular health (CVH) tool modified by the addition of C-reactive protein (CRP) to examine potential sex-based differences in the prevalence of CVD risk in rural Uganda. Methods In a cross-sectional study nested within a population-wide census, 857 community-living adults completed physical and laboratory-based assessments to calculate individual ideal CVH metrics including an eight category for CRP levels. We summarized sex-specific ideal CVH indices, fitting ordinal logistic regression models to identify correlates of improving CVH. As secondary outcomes, we assessed subscales of ideal CVH behaviours and factors. Models included inverse probability of sampling weights to determine population-level estimates. Results The weighted-population mean age was 39.2 (1.2) years with 52.0 (3.7) % females. Women had ideal scores in smoking (80.4% vs. 68.0%; p < 0.001) and dietary intake (26.7% vs. 16.8%; p = 0.037) versus men, but the opposite in body mass index (47.3% vs. 84.4%; p < 0.001), glycated hemoglobin (87.4% vs. 95.2%; p = 0.001), total cholesterol (80.2% vs. 85.0%; p = 0.039) and CRP (30.8% vs. 49.7%; p = 0.009). Overall, significantly more men than women were classified as having optimal cardiovascular health (6–8 metrics attaining ideal level) (39.7% vs. 29.0%; p = 0.025). In adjusted models, female sex was correlated with lower CVH health factors sub-scales but higher ideal CVH behaviors. Conclusions Contrary to findings in much of the world, female sex in rural SSA is associated with worse ideal CVH profiles, despite women having better indices for ideal CVH behaviors. Future work should assess the potential role of socio-behavioural sex-specific risk factors for ideal CVH in SSA, and better define the downstream consequences of these differences

Water insecurity and gendered risk for depression in rural Uganda: a hotspot analysis

Abstract Background Water insecurity is linked to depression in low- and middle-income countries (LMICs), though it remains unclear how geospatial clustering of water insecurity in rural regions is associated with risk for depression. Methods We conducted a population-based survey of a rural parish in southwestern Uganda (N = 1603) to evaluate the joint geospatial clustering of water insecurity and risk for depression among men and women living in rural Uganda. Results Geospatial clustering of self-reported water insecurity and depressive symptoms was found to be present among both men and women. Depression hotspots were more often observed near water insecurity hotspots among women, relative to men. Multivariable regression revealed that residing in a water insecurity hotspot significantly increased risk for depressive symptoms among women, but not among men. Conclusions Residing in a water insecurity hotspot is associated with greater risk for probable depression among women, but not among men, pointing to the need for focused depression screening among women residing in water insecure households

When You Have No Water, It Means You Have No Peace : A Mixed-methods, Whole-population Study of Water Insecurity and Depression in Rural Uganda

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\u27s lived experiences with water insecurity may lead to emotional distress

Perceived norms about the acceptability of intimate partner violence, unadjusted estimates by survey condition (<i>n =</i> 1,334).

<p>Perceived norms about the acceptability of intimate partner violence, unadjusted estimates by survey condition (<i>n =</i> 1,334).</p