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      Factors associated with prior engagement in high-risk sexual behaviours among adolescents (10–19 years) in a pastoralist post-conflict community, Karamoja sub-region, North eastern Uganda

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          Abstract

          Background

          Adolescent sexual risky behaviours continue to be significant drivers of the HIV epidemic globally. The objective of this study was to determine factors associated with prior engagement in high-risk sexual behaviours among adolescents (10–19 years) in Karamoja sub-region, a pastoralist and post-conflict community in North-eastern Uganda.

          Methods

          Between August and September 2016, we conducted a cross-sectional study among 1439 adolescents receiving primary healthcare services at nine public health facilities located in five of the seven districts that make up Karamoja sub-region. High-risk sexual behaviour was defined as engaging in sex with two or more (2+) sexual partners in the 6 months preceding the survey or exchanging sex for money or gifts with no or inconsistent use of condoms over the same period of time. Factors associated with prior engagement in high-risk sexual behaviours were analysed using a modified Poison regression model with log-link and Poisson-family via a generalized linear model.

          Results

          Eighty-two percent (81.8%, n = 1177) of the respondents had ever tested for HIV while 62 % (61.5%, n = 885) had ever had sex. Of those that had ever had sex, 11.4% ( n = 101) reported prior engagement in high-risk sexual behaviours. Prior engagement in high-risk sexual behaviours was lower among men than women (adjusted prevalence ratio (adj. PR) = 0.46; 95% Confidence Interval (95% CI): 0.33, 0.62) and those whose sex debut was above 14 years (adj.PR = 0.63; 95% CI: 0.57, 0.69). However, prior engagement in high-risk sexual behaviours was significantly higher in adolescents who were not aware of their recent sexual partner’s HIV status (adj.PR = 2.43; 95% CI: 1.68, 3.52) and those who used illicit drugs (adj.PR = 2.76; 95% CI: 1.88, 4.05).

          Conclusion

          Prior engagement in high-risk sexual behaviours was significantly associated with having sex with partners of unknown HIV sero-status and use of illicit drugs. These findings suggest a need for targeted interventions to improve mutual HIV status disclosure between sexual partners while minimizing their use of illicit drugs/substances.

          Electronic supplementary material

          The online version of this article (10.1186/s12889-019-7352-6) contains supplementary material, which is available to authorized users.

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          Most cited references36

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          The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies

          Introduction Many questions in medical research are investigated in observational studies [1]. Much of the research into the cause of diseases relies on cohort, case-control, or cross-sectional studies. Observational studies also have a role in research into the benefits and harms of medical interventions [2]. Randomised trials cannot answer all important questions about a given intervention. For example, observational studies are more suitable to detect rare or late adverse effects of treatments, and are more likely to provide an indication of what is achieved in daily medical practice [3]. Research should be reported transparently so that readers can follow what was planned, what was done, what was found, and what conclusions were drawn. The credibility of research depends on a critical assessment by others of the strengths and weaknesses in study design, conduct, and analysis. Transparent reporting is also needed to judge whether and how results can be included in systematic reviews [4,5]. However, in published observational research important information is often missing or unclear. An analysis of epidemiological studies published in general medical and specialist journals found that the rationale behind the choice of potential confounding variables was often not reported [6]. Only few reports of case-control studies in psychiatry explained the methods used to identify cases and controls [7]. In a survey of longitudinal studies in stroke research, 17 of 49 articles (35%) did not specify the eligibility criteria [8]. Others have argued that without sufficient clarity of reporting, the benefits of research might be achieved more slowly [9], and that there is a need for guidance in reporting observational studies [10,11]. Recommendations on the reporting of research can improve reporting quality. The Consolidated Standards of Reporting Trials (CONSORT) Statement was developed in 1996 and revised 5 years later [12]. Many medical journals supported this initiative [13], which has helped to improve the quality of reports of randomised trials [14,15]. Similar initiatives have followed for other research areas—e.g., for the reporting of meta-analyses of randomised trials [16] or diagnostic studies [17]. We established a network of methodologists, researchers, and journal editors to develop recommendations for the reporting of observational research: the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. Aims and Use of the STROBE Statement The STROBE Statement is a checklist of items that should be addressed in articles reporting on the 3 main study designs of analytical epidemiology: cohort, case-control, and cross-sectional studies. The intention is solely to provide guidance on how to report observational research well: these recommendations are not prescriptions for designing or conducting studies. Also, while clarity of reporting is a prerequisite to evaluation, the checklist is not an instrument to evaluate the quality of observational research. Here we present the STROBE Statement and explain how it was developed. In a detailed companion paper, the Explanation and Elaboration article [18–20], we justify the inclusion of the different checklist items and give methodological background and published examples of what we consider transparent reporting. We strongly recommend using the STROBE checklist in conjunction with the explanatory article, which is available freely on the Web sites of PLoS Medicine (http://www.plosmedicine.org/), Annals of Internal Medicine (http://www.annals.org/), and Epidemiology (http://www.epidem.com/). Development of the STROBE Statement We established the STROBE Initiative in 2004, obtained funding for a workshop and set up a Web site (http://www.strobe-statement.org/). We searched textbooks, bibliographic databases, reference lists, and personal files for relevant material, including previous recommendations, empirical studies of reporting and articles describing relevant methodological research. Because observational research makes use of many different study designs, we felt that the scope of STROBE had to be clearly defined early on. We decided to focus on the 3 study designs that are used most widely in analytical observational research: cohort, case-control, and cross-sectional studies. We organised a 2-day workshop in Bristol, UK, in September 2004. 23 individuals attended this meeting, including editorial staff from Annals of Internal Medicine, BMJ, Bulletin of the World Health Organization, International Journal of Epidemiology, JAMA, Preventive Medicine, and The Lancet, as well as epidemiologists, methodologists, statisticians, and practitioners from Europe and North America. Written contributions were sought from 10 other individuals who declared an interest in contributing to STROBE, but could not attend. Three working groups identified items deemed to be important to include in checklists for each type of study. A provisional list of items prepared in advance (available from our Web site) was used to facilitate discussions. The 3 draft checklists were then discussed by all participants and, where possible, items were revised to make them applicable to all three study designs. In a final plenary session, the group decided on the strategy for finalizing and disseminating the STROBE Statement. After the workshop we drafted a combined checklist including all three designs and made it available on our Web site. We invited participants and additional scientists and editors to comment on this draft checklist. We subsequently published 3 revisions on the Web site, and 2 summaries of comments received and changes made. During this process the coordinating group (i.e., the authors of the present paper) met on eight occasions for 1 or 2 days and held several telephone conferences to revise the checklist and to prepare the present paper and the Explanation and Elaboration paper [18–20]. The coordinating group invited 3 additional co-authors with methodological and editorial expertise to help write the Explanation and Elaboration paper, and sought feedback from more than 30 people, who are listed at the end of this paper. We allowed several weeks for comments on subsequent drafts of the paper and reminded collaborators about deadlines by e-mail. STROBE Components The STROBE Statement is a checklist of 22 items that we consider essential for good reporting of observational studies (Table 1). These items relate to the article's title and abstract (item 1), the introduction (items 2 and 3), methods (items 4–12), results (items 13–17) and discussion sections (items 18–21), and other information (item 22 on funding). 18 items are common to all three designs, while four (items 6, 12, 14, and 15) are design-specific, with different versions for all or part of the item. For some items (indicated by asterisks), information should be given separately for cases and controls in case-control studies, or exposed and unexposed groups in cohort and cross-sectional studies. Although presented here as a single checklist, separate checklists are available for each of the 3 study designs on the STROBE Web site. Table 1 The STROBE Statement—Checklist of Items That Should Be Addressed in Reports of Observational Studies Implications and Limitations The STROBE Statement was developed to assist authors when writing up analytical observational studies, to support editors and reviewers when considering such articles for publication, and to help readers when critically appraising published articles. We developed the checklist through an open process, taking into account the experience gained with previous initiatives, in particular CONSORT. We reviewed the relevant empirical evidence as well as methodological work, and subjected consecutive drafts to an extensive iterative process of consultation. The checklist presented here is thus based on input from a large number of individuals with diverse backgrounds and perspectives. The comprehensive explanatory article [18–20], which is intended for use alongside the checklist, also benefited greatly from this consultation process. Observational studies serve a wide range of purposes, on a continuum from the discovery of new findings to the confirmation or refutation of previous findings [18–20]. Some studies are essentially exploratory and raise interesting hypotheses. Others pursue clearly defined hypotheses in available data. In yet another type of studies, the collection of new data is planned carefully on the basis of an existing hypothesis. We believe the present checklist can be useful for all these studies, since the readers always need to know what was planned (and what was not), what was done, what was found, and what the results mean. We acknowledge that STROBE is currently limited to three main observational study designs. We would welcome extensions that adapt the checklist to other designs—e.g., case-crossover studies or ecological studies—and also to specific topic areas. Four extensions are now available for the CONSORT statement [21–24]. A first extension to STROBE is underway for gene-disease association studies: the STROBE Extension to Genetic Association studies (STREGA) initiative [25]. We ask those who aim to develop extensions of the STROBE Statement to contact the coordinating group first to avoid duplication of effort. The STROBE Statement should not be interpreted as an attempt to prescribe the reporting of observational research in a rigid format. The checklist items should be addressed in sufficient detail and with clarity somewhere in an article, but the order and format for presenting information depends on author preferences, journal style, and the traditions of the research field. For instance, we discuss the reporting of results under a number of separate items, while recognizing that authors might address several items within a single section of text or in a table. Also, item 22, on the source of funding and the role of funders, could be addressed in an appendix or in the methods section of the article. We do not aim at standardising reporting. Authors of randomised clinical trials were asked by an editor of a specialist medical journal to “CONSORT” their manuscripts on submission [26]. We believe that manuscripts should not be “STROBEd”, in the sense of regulating style or terminology. We encourage authors to use narrative elements, including the description of illustrative cases, to complement the essential information about their study, and to make their articles an interesting read [27]. We emphasise that the STROBE Statement was not developed as a tool for assessing the quality of published observational research. Such instruments have been developed by other groups and were the subject of a recent systematic review [28]. In the Explanation and Elaboration paper, we used several examples of good reporting from studies whose results were not confirmed in further research – the important feature was the good reporting, not whether the research was of good quality. However, if STROBE is adopted by authors and journals, issues such as confounding, bias, and generalisability could become more transparent, which might help temper the over-enthusiastic reporting of new findings in the scientific community and popular media [29], and improve the methodology of studies in the long term. Better reporting may also help to have more informed decisions about when new studies are needed, and what they should address. We did not undertake a comprehensive systematic review for each of the checklist items and sub-items, or do our own research to fill gaps in the evidence base. Further, although no one was excluded from the process, the composition of the group of contributors was influenced by existing networks and was not representative in terms of geography (it was dominated by contributors from Europe and North America) and probably was not representative in terms of research interests and disciplines. We stress that STROBE and other recommendations on the reporting of research should be seen as evolving documents that require continual assessment, refinement, and, if necessary, change. We welcome suggestions for the further dissemination of STROBE—e.g., by re-publication of the present article in specialist journals and in journals published in other languages. Groups or individuals who intend to translate the checklist to other languages should consult the coordinating group beforehand. We will revise the checklist in the future, taking into account comments, criticism, new evidence, and experience from its use. We invite readers to submit their comments via the STROBE Web site (http://www.strobe-statement.org/).
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            A simplified general method for cluster-sample surveys of health in developing countries.

            General guidelines are presented for the use of cluster-sample surveys for health surveys in developing countries. The emphasis is on methods which can be used by practitioners with little statistical expertise and no background in sampling. A simple self-weighting design is used, based on that used by the World Health Organization's Expanded Programme on Immunization (EPI). Topics covered include sample design, methods of random selection of areas and households, sample-size calculation and the estimation of proportions, ratios and means with standard errors appropriate to the design. Extensions are discussed, including stratification and multiple stages of selection. Particular attention is paid to allowing for the structure of the survey in estimating sample size, using the design effect and the rate of homogeneity. Guidance is given on possible values for these parameters. A spreadsheet is included for the calculation of standard errors.
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              Global patterns of mortality in young people: a systematic analysis of population health data.

              Pronounced changes in patterns of health take place in adolescence and young adulthood, but the effects on mortality patterns worldwide have not been reported. We analysed worldwide rates and patterns of mortality between early adolescence and young adulthood. We obtained data from the 2004 Global Burden of Disease Study, and used all-cause mortality estimates developed for the 2006 World Health Report, with adjustments for revisions in death from HIV/AIDS and from war and natural disasters. Data for cause of death were derived from national vital registration when available; for other countries we used sample registration data, verbal autopsy, and disease surveillance data to model causes of death. Worldwide rates and patterns of mortality were investigated by WHO region, income status, and cause in age-groups of 10-14 years, 15-19 years, and 20-24 years. 2.6 million deaths occurred in people aged 10-24 years in 2004. 2.56 million (97%) of these deaths were in low-income and middle-income countries, and almost two thirds (1.67 million) were in sub-Saharan Africa and southeast Asia. Pronounced rises in mortality rates were recorded from early adolescence (10-14 years) to young adulthood (20-24 years), but reasons varied by region and sex. Maternal conditions were a leading cause of female deaths at 15%. HIV/AIDS and tuberculosis contributed to 11% of deaths. Traffic accidents were the largest cause and accounted for 14% of male and 5% of female deaths. Other prominent causes included violence (12% of male deaths) and suicide (6% of all deaths). Present global priorities for adolescent health policy, which focus on HIV/AIDS and maternal mortality, are an important but insufficient response to prevent mortality in an age-group in which more than two in five deaths are due to intentional and unintentional injuries. WHO and National Health and Medical Research Council.
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                Author and article information

                Contributors
                +256 782701442 , rssebunya@baylor-uganda.org , ssebunyarogers@gmail.com
                jmatovu@musph.ac.ug
                fmakumbi@musph.ac.ug
                gkisitu@baylor-uganda.org
                amaganda@baylor-uganda.org
                akekitiinwa@baylor-uganda.org
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                1471-2458
                31 July 2019
                31 July 2019
                2019
                : 19
                : 1027
                Affiliations
                [1 ]ISNI 0000 0004 0397 2008, GRID grid.423308.e, Directorate of Research, Monitoring and Evaluation, Baylor College of Medicine Children’s Foundation, ; P.O. Box 72052, Kampala, Uganda
                [2 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, Department of Disease Control and Environmental Health, School of Public Health, , Makerere University College of Health Sciences, ; Kampala, Uganda
                [3 ]GRID grid.448602.c, Department of Community and Public Health, , Busitema University Faculty of Health Sciences, ; Mbale, Uganda
                [4 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, Department of Epidemiology and Biostatistics, School of Public Health, , Makerere University College of Health Sciences, ; Kampala, Uganda
                Author information
                http://orcid.org/0000-0003-1625-1579
                Article
                7352
                10.1186/s12889-019-7352-6
                6670181
                31366339
                3c0c6c1c-7b17-4d99-b4ff-cb87a9b619cf
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 28 May 2019
                : 22 July 2019
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Public health
                risk sexual behaviours,adolescents,conflict setting
                Public health
                risk sexual behaviours, adolescents, conflict setting

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