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Background Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC. Methods Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs. Findings The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles ( n  = 38) discussed sexual health domains including: GBV ( n  = 23); HIV/STI ( n  = 19); and CSE ( n  = 12). Over one-third ( n  = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care ( n  = 13); contraception ( n  = 13); fertility ( n  = 1); and safe abortion ( n  = 1). Eight included both reproductive and sexual health. Most grey literature ( n  = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels. Conclusions This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC. Plain English summary Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs.

Background There remain key knowledge gaps regarding HIV testing needs and priorities among refugee youth in low and middle-income country (LMIC) humanitarian settings. The HIV prevention cascade framework focuses on three domains (motivation, access, effective use) central to prevention uptake, yet is understudied in relationship to HIV testing, particularly among refugee youth. Uganda is an exemplar context to explore refugee youth HIV testing needs and priorities as it hosts 1.5 million refugees and is Africa’s largest refugee hosting nation. In this study, we explored perceptions and experiences regarding HIV testing among refugee youth living in Bidi Bidi refugee settlement, Uganda. Methods We conducted a community-based research study in Bidi Bidi Refugee Settlement, one of the world’s largest refugee settlements with over 195,000 residents. This qualitative study involved four focus groups (2 with young women, 2 with young men) with refugee youth aged 16–24 living in Bidi Bidi refugee settlement. We applied thematic analysis informed by the HIV prevention cascade to understand domains of motivation, access, and effective use that emerged as salient for HIV testing engagement. Results Participants ( n  = 40; mean age: 20 years, standard deviation: 2.2) included refugee young women ( n  = 20) and young men ( n  = 20), of whom 88% had a lifetime HIV test and 58% had ever heard of HIV self-testing. Participant discussions described HIV testing motivation was influenced by dimensions of: HIV treatment and testing knowledge; risk perception; positive and negative consequences of use; and social norms regarding gender and age. Access to HIV testing was shaped by: limited availability; distance and language barriers; confidentiality concerns; and affordability. Effective use of and engagement with HIV testing was related to HIV serostatus knowledge self-efficacy and in/equitable partner dynamics. Conclusions Complex, multi-level factors shape motivation for, access to, and effective use of HIV testing among refugee youth in Bidi Bidi. Findings align with the HIV prevention cascade framework that helps to identify gaps to inform intervention development with youth in humanitarian settings. HIV testing approaches tailored for refugee youth in contexts such as Bidi Bidi can foster HIV prevention and treatment literacy, gender equity, gender-based violence prevention, and intersectional stigma reduction.

Characteristics of enabling healthcare environments to support brief sexuality-related communication (BSC) are understudied in humanitarian settings. We implemented a qualitative study with refugee youth aged 16–24 living in Bidi Bidi Refugee Settlement to understand the feasibility of implementing BSC in a humanitarian context. We examined feelings toward doctor’s visits in general, including types of conversations youth engage in with healthcare providers, as well as comfort, safety, and willingness to talk with healthcare providers about sexual health. We implemented four focus groups with refugee youth in Bidi Bidi, two with young women and two with young men, and applied thematic analysis informed by a social contextual theoretical framework that explores enabling environments for sexual health promotion. Participants (n = 40; mean age: 20 years, standard deviation: 2.2; women: n = 20; men: n = 20) reported relational, symbolic, and material dimensions of context considered important when discussing sexual health. Relational contexts included a) trusting relationship with local healthcare practitioners, including practices that foster comfort and confidentiality, and b) family, friends, and mentors as additional sources of health information. Symbolic contexts refer to values, norms, and beliefs that reflect what is perceived as valuable and worthy, and in turn, what is devalued and stigmatized. Specific to sexual health, participants discussed stigma toward STIs and HIV, devaluation of women in healthcare settings, and generalized fear of doctors and disease as barriers to engaging in dialogue about sexual health with healthcare providers. Material contexts include agency linked with resource access and experiences. Youth narratives revealed that positive experiences accessing medication to manage pain and infections increased their willingness to engage in healthcare discussions, whereby clinic layouts and dynamics that compromised confidentiality and privacy reduced the likelihood of sexual health dialogue. Language barriers and healthcare provider time constraints were additional factors that reduced healthcare engagement. Taken together, findings can inform BSC implementation strategies that consider the inner and outer settings that shape sexual health dialogue and sexual health and wellbeing among refugee youth living in humanitarian settings.

Sexual and gender-based violence (SGBV) is a persistent concern in humanitarian contexts, yet there is a dearth of SGBV prevention and post-rape clinical care interventions tailored for refugee youth. Graphic medicine, the use of images and text such as in comic books, has been employed to depict lived experiences to promote health, wellbeing, and education. Comic books provide a low-cost, youth-friendly approach to health promotion that is accessible to varying literacy levels. Limited research, however, has described the process of developing graphic medicine approaches for SGBV prevention and sexual violence stigma reduction with and for refugee youth in humanitarian settings. To address this knowledge gap, this paper shares a Qualitative Comic Book Mapping approach, whereby qualitative data alongside theoretical and empirical SGBV literature informed the development of comic book scenarios with refugee youth aged 16-24 in Bidi Bidi refugee settlement, Uganda. Steps included conducting focus groups and in-depth individual interviews with 78 community members (youth, elders, service providers) in Bidi Bidi to explore SGBV lived experiences among refugee youth in Bidi Bidi and ideas for solutions to reduce SGBV and related stigma, in addition to improving post-rape care experiences and engagement. The Qualitative Comic Book Mapping approach involved: a) thematic analysis of qualitative data and identification of overarching themes; b) aligning qualitative themes with theories of change for SGBV prevention and stigma reduction; and c) co-developing comic book scenarios with refugee youth peer navigators and community experts to integrate SGBV prevention and stigma reduction theory with refugee youth lived experiences. The final comic book involved five youth-focused scenarios and was integrated in an intervention with refugee youth, including providing youth with a blank version of the comic book to complete themselves. We share how theoretically-informed comic books can be developed from qualitative data with refugee youth in a humanitarian setting.

IntroductionResearch with urban refugee youth in Uganda has documented co-occurring social (e.g., poverty) and health (e.g., depression) disparities associated with HIV vulnerabilities. Benefits of HIV self-testing (HIVST) in increasing HIV testing uptake among youth are well established, yet limited interventions have examined if combining HIVST with mental health promotion, or with mental health promotion alongside poverty reduction, is associated with greater improvements in HIV prevention and testing outcomes.Methods and analysisThe aim is to evaluate the effectiveness of: (1) HIVST alone (standard of care); (2) mobile health (mHealth) and graphic medicine (comic) programme for mental health alongside HIVST; and (3) the combination of HIVST, a livelihoods programme, and mHealth mental health programme, in advancing the primary outcome of HIV testing uptake and secondary outcomes (HIV status knowledge, linkage to confirmatory testing and HIV care, HIV knowledge, consistent condom use, condom use self-efficacy, sexual risk) with urban refugee youth in Kampala, Uganda. A three-arm randomised controlled trial will be implemented from 8 April 2024 to 31 October 2024 with youth across five informal settlements in Kampala, grouped into three sites based on proximity, and randomised in a 1:1:1 design. Approximately 330 participants (110 per arm) are enrolled and data collection will occur at three time points (baseline enrolment, 3-month follow-up and 6-month follow-up).Ethics and disseminationThe study received ethical approval from the University of Toronto (#37496), Mildmay Uganda Research Ethics Committee (#MUREC-2021-41) and Uganda National Council for Science & Technology (#SS1021ES). The trial is registered at ClinicalTrials.gov (NCT06270160). Study findings will produce new knowledge of the impacts of a mental health programme, and a combined mental health and livelihoods programme, on improving HIV prevention outcomes among urban refugee youth in Kampala. Findings will be shared in peer-reviewed publications, conference presentations and in community dissemination.Trial registration number NCT06270160 (date of registration: 13 February 2024).Trial sponsorDr. Carmen Logie, carmen.logie@utoronto.ca.

Refugee settlements globally experience increased exposure to extreme weather events (EWE) compared with host national settings; however, refugee youth climate-related health experiences in humanitarian settings are understudied. We explored the lived experiences of climate change and EWE related to physical health among refugee youth aged 16-24 in a Ugandan refugee settlement. We conducted a community-based, multi-method study. We purposively sampled refugee youth living in a Northern Ugandan refugee settlement reporting recent (past 14-day) EWE and/or resource insecurity. We conducted 32 refugee youth walk-along interviews to elicit a rich understanding of lived experiences in a target environment. During each interview, the youth brought the research assistant to places where they obtained resources (i.e. food, water, sanitation), took photos of their chosen places on a tablet, and described the photo and the place. We also conducted 12 in-depth interviews with key informants, comprising adults with experience working in this refugee settlement on refugee well-being, food security, water and sanitation hygiene (WASH), and/or climate change. We analysed the findings using template thematic analysis informed by the resource scarcity framework, which examines ecologic, social, and socioeconomic factors associated with resource insecurities. Participants (  = 44) included refugee youth (  = 32; mean age: 20.0, standard deviation [SD]: 2.4; 50% men, 50% women) and key informants (  = 12; mean age: 37.0, SD: 5.8; 75% men, 25% women). Participant narratives identified how flooding, heavy rain, and drought contributed to youth experiencing resource insecurities (food, water, sanitation), in turn increasing malnutrition risks, water-borne diseases, and risks of bodily harm. Flooding and heavy rains also contributed to vector-borne diseases, and drought to dehydration and hygiene-related infections. The findings highlight the need for better WASH infrastructure and increased food aid in Ugandan humanitarian settings, along with refugee youth-led initiatives to address the impacts of climate change on refugee well-being.

Song-making is a powerful tool with the potential to harness cultural knowledge to reduce stigma and support community-led advocacy. HIV prevalence (8.1%) among sex professionals in Congo is double the national average, yet stigma and discrimination deter sex professionals from accessing needed healthcare. Limited research has focused on developing music videos for reducing sex work-related stigma. In the Congolese context, music and song-making are deeply embedded cultural practices for storytelling and solidarity, making them especially resonant vehicles for community-led stigma reduction efforts. This manuscript describes the process of creating Esengo (“Joy”), a song and music video, to reduce stigma and promote the health and rights of sex professionals in Pointe-Noire, Congo. Esengo applies a strengths-based approach to address stigma by incorporating song lyrics, rhythms and melodies created and performed by sex professionals, first identifying ‘problems’ in sites of stigma followed by descriptions of ‘solutions’ that reflect improved community and healthcare scenarios, including animation of sex professional’s visual drawings. Lyrics, melodies, and drawings originate from a participatory mapping intervention that we developed and piloted with sex professionals in Pointe-Noire. We piloted Esengo with sex professionals and healthcare workers, who provided qualitative feedback on their emotional responses and perceptions of stigma, indicating its potential as a health promotion resource and stigma reduction tool. The process underscored how joy can be mobilized for social change, community slogans through songs can strengthen social movements, and community-based co-creation can itself facilitate knowledge translation. This community-based approach to song making may be adapted for other contexts, populations, and health issues to support sex professional-related and other stigma reduction, health promotion, training, and community empowerment.

BackgroundWater insecurity disproportionally affects socially marginalized populations and may harm mental health. Lesbian, gay, bisexual, transgender and queer (LGBTQ) persons are at the nexus of social marginalization and mental health disparities; however, they are understudied in water insecurity research. Yet LGBTQ persons likely have distinct water needs. We explored associations between water insecurity and mental health outcomes among LGBTQ adults in Mumbai, India and Bangkok, Thailand.MethodsThis cross-sectional survey with a sample of LGBTQ adults in Mumbai and Bangkok assessed associations between water insecurity and mental health outcomes, including anxiety symptoms, depression symptoms, loneliness, alcohol misuse, COVID-19 stress and resilience. We conducted multivariable logistic and linear regression analyses to examine associations between water insecurity and mental health outcomes.ResultsWater insecurity prevalence was 28.9% in Mumbai and 18.6% in Bangkok samples. In adjusted analyses, in both sites, water insecurity was associated with higher likelihood of depression symptoms, anxiety symptoms, COVID-19 stress, alcohol misuse and loneliness. In Mumbai, water insecurity was also associated with reduced resilience.ConclusionWater insecurity was common among LGBTQ participants in Bangkok and Mumbai and associated with poorer well-being. Findings signal the importance of assessing water security as a stressor harmful to LGBTQ mental health.

Introduction Humanitarian settings are underserved by HIV self-testing (HIV-ST). Methods We conducted a randomized controlled trial to evaluate the effectiveness of HIV-ST (Arm 1), HIV-ST alongside edutainment comics (Arm 2), and edutainment comics (Arm 3), compared with the standard of care (SOC), in increasing HIV testing with refugee youth aged 16–24 in the Bidi Bidi Refugee Settlement, Uganda. Intervention effects on HIV testing at 3-month follow-up (T2) were assessed using generalized estimating equation models alongside open-ended questions. Results Retention was 98% (n = 117/120) at T2. In adjusted analyses compared with the SOC, HIV testing changes from baseline to T2 were highest in Arm 2 (adjusted odds ratio [aOR]: 8.46; 95% confidence interval [CI]: 2.87–24.97), followed by Arm 3 (aOR: 4.14; 95% CI: 1.58–10.87), with no significant differences in Arm 1. Conclusion HIV self-testing is feasible for refugee youth in Uganda and can be supplemented with edutainment comics to advance HIV prevention efforts. Plain Language Summary: Findings from an HIV self-testing and comic intervention with refugee youth in a humanitarian setting in Uganda.

BackgroundThere is a high prevalence of depression among refugee youth in low- and middle-income countries, yet depression trajectories are understudied. This study examined depression trajectories, and factors associated with trajectories, among urban refugee youth in Kampala, Uganda.MethodsWe conducted a longitudinal cohort study with refugee youth aged 16–24 in Kampala, Uganda. We assessed depression using the Patient Health Questionnaire-9 and conducted latent class growth analysis (LCGA) to identify depression trajectories. Sociodemographic and socioecological factors were examined as predictors of trajectory clusters using multivariable logistic regression.ResultsData were collected from n = 164 participants (n = 89 cisgender women, n = 73 cisgender men, n = 2 transgender persons; mean age: 19.9, standard deviation: 2.5 at seven timepoints; n = 1,116 observations). Two distinct trajectory clusters were identified: “sustained low depression level” (n = 803, 71.9%) and “sustained high depression level” (n = 313, 28.1%). Sociodemographic (older age, gender [cisgender women vs. cisgender men], longer time in Uganda), and socioecological (structural: unemployment, food insecurity; interpersonal: parenthood, recent intimate partner violence) factors were significantly associated with the sustained high trajectory of depression.ConclusionsThe chronicity of depression highlights the critical need for early depression screening with urban refugee youth in Kampala. Addressing multilevel depression drivers prompts age and gender-tailored strategies and considering social determinants of health.