Exploring associations between adolescent sexual and reproductive health stigma and HIV testing awareness and uptake among urban refugee and displaced youth in Kampala, Uganda

Figures & data

Table 1. Ugandan adolescent sexual and reproductive health stigma scale items by gender among urban refugee and displaced adolescents and young people in Kampala, Uganda (n = 445)

	Items	Women		Men
		No n (%)	Yes n (%)	No n (%)	Yes n (%)
Factor 1 loadings	Sexual activity & pregnancy stigma subscale
Item 1	People behave differently toward a young person whom they know has had sex (enacted*)	64 (19.2)	269 (80.9)	24 (21.4)	88 (78.6)
Item 5	Becoming pregnant and having a baby as a young person would cause people to behave differently around me (enacted*)	46 (13.8)	287 (86.2)	23 (20.5)	89 (79.5)
Item 6	Becoming pregnant and having a baby as a young person would cause others to tease, insult, swear, or gossip about me (enacted*)	49 (14.7)	284 (85.3)	21 (18.8)	91 (81.3)
Item 7	Having sex as a young person is a form of disobedience (internalized*)	110 (33.0)	223 (67.0)	35 (31.3)	77 (68.8)
Item 10	Young people who use modern family planning are viewed as bad girls (internalised*)	59 (17.7)	274 (82.3)	23 (20.5)	89 (79.5)
Item 11	Having sex as a young person brings disgrace and shame to a young woman and her family (internalised*)	52 (15.6)	281 (84.4)	28 (25.0)	84 (75.0)
Item 12	Becoming pregnant and having a baby as a young person would bring disgrace to my family (internalised*)	82 (24.6)	251 (75.4)	31 (27.7)	81 (72.3)
Factor 2 loadings	Modern family planning & abortion stigma subscale
Item 2	People behave differently toward a young person whom they know has had an abortion (enacted*)	22 (6.6)	311 (93.4)	15 (13.4)	97 (86.9)
Item 3	People behave differently toward a young person whom they know has used modern family-planning methods (enacted*)	75 (22.5)	258 (77.5)	30 (26.8)	82 (73.2)
Item 4	Having sex as a young person often leads to getting beaten or physically hurt by one’s parents (enacted*)	91 (27.3)	242 (72.7)	38 (33.9)	74 (66.1)
Item 8	Young women who have abortions are bad girls (internalised*)	64 (19.2)	269 (80.8)	22 (19.6)	90 (80.4)
Item 9	Young women who use modern family planning are promiscuous (internalised*)	122 (36.6)	211 (63.4)	44 (39.3)	68 (60.7)
Item 15	Modern family planning is not acceptable for unmarried women (stigmatising lay attitudes*)	132 (39.6)	201 (60.4)	39 (34.8)	73 (65.2)
Item 16	Modern family planning methods have bad effects on a woman’s health (stigmatising lay attitudes*)	25 (7.5)	308 (92.5)	8 (7.1)	104 (92.9)
No factor loading	Items not included in Ugandan adolescent SRH scale
Item 13	Becoming pregnant and having a baby as a young person would make me feel ashamed and bad about myself (internalised*)	86 (25.8)	247 (74.2)	45 (40.2)	67 (59.8)
Item 14	Young women who have abortions will encourage others to have abortions (stigmatising lay attitudes*)	178 (53.5)	155 (46.5)	68 (60.7)	44 (39.3)
Item 17	Having an abortion is committing murder (stigmatising lay attitudes*)	54 (16.2)	279 (83.8)	10 (8.9)	102 (91.1)
Item 18	The media, including the television, internet, or magazines, has a strong impact on young people’s sexual behaviour (stigmatising lay attitudes*)	156 (46.8)	177 (53.2)	54 (48.2)	58 (51.8)
Item 19	When teens have sex for the first time, it is usually because they were pressured by their friends or partners to do so (stigmatising lay attitudes*)	225 (67.6)	108 (32.4)	65 (58.0)	47 (42.0)

*Original adolescent SRH stigma subscale dimensions.

Items = SRH stigma items that loaded onto each subscale.

Figure 1. Confirmatory factor analysis results of the Ugandan Adolescent Sexual and Reproductive Health Stigma Scale among urban refugee and displaced adolescents and young people living in Kampala, Uganda

Note: Items = sexual and reproductive health stigma items that loaded onto each subscale; A-SAP = Adolescent sexual activity and pregnancy stigma; A-MFPAS = Adolescent modern family planning and abortion stigma.

Table 2. Characteristics of urban refugee and displaced adolescents and young people in Kampala, Uganda, by gender (n = 445)

Variables	Full sample (n = 445) n (%) or mean (SD, range)	Women (n = 333) n (%) or mean (SD, range)	Men (n = 112) n (%) or mean (SD, range)	p Value
Sociodemographic factors
Age, years	19.59 (2.59, 16–24)	19.31 (2.56, 16–24)	20.45 (2.51, 16–24)	.237
Education				.001
Less than secondary school	234 (52.6)	190 (57.1)	44 (39.3)
Secondary school education	211 (47.4)	143 (42.9)	68 (60.7)
Place of birth				.000
South Sudan	35 (7.9)	30 (9.0)	5 (4.5)
Burundi	115 (25.8)	111 (33.3)	4 (3.6)
Democratic Republic of the Congo	249 (56.0)	153 (45.9)	96 (85.7)
Rwanda	19 (4.3)	19 (5.7)	0 (0.0)
Others	27 (6.1)	20 (6.0)	7 (6.3)
Time in Uganda				.001
<1 year	35 (7.9)	23 (6.9)	12 (10.7)
1–5 years	265 (59.6)	186 (55.9)	79 (70.5)
>5 years	145 (32.6)	124 (37.2)	21 (18.8)
Immigration status (n = 442)				.000
Refugees	391 (88.5)	305 (92.4)	86 (76.8)
Seeking asylum/undocumented	51 (11.5)	25 (7.6)	26 (23.2)
Employment (n = 428)				.242
Unemployed	176 (41.1)	144 (46.2)	44 (25.0)
Student	190 (44.4)	131 (42.0)	35 (18.4)
Employed	48 (11.2)	37 (13.8)	12 (25.0)
Lifetime forced sex				.003
No	354 (79.6)	254 (76.3)	100 (89.3)
Yes	91 (20.4)	79 (23.7)	12 (10.7)
Relationship status				.205
No current partner	187 (44.3)	144 (46.2)	43 (39.1)
Dating one partner/married	185 (43.8)	131 (42.0)	54 (49.1)
Casual dating/multiple partners	50 (11.8)	37 (11.9)	13 (11.8)
HIV testing engagement and outcomes
Aware of HIV testing services in one’s community				.003
No	155 (34.8)	129 (38.7)	26 (23.2)
Yes	290 (65.2)	204 (61.3)	86 (76.8)
Lifetime HIV testing				.264
No	195 (43.8)	151 (45.3)	44 (39.3)
Yes	250 (56.2)	182 (54.7)	68 (60.7)
HIV testing results (n = 250)				.539
HIV-negative	237 (94.8)	171 (94.0)	66 (97.1)
HIV-positive	9 (3.6)	8 (4.4)	1 (1.5)
I don’t know (did not pick up my results)	4 (1.6)	3 (1.6)	1 (1.5)
Time of last HIV test (n = 250)				.004
<3 months	61 (24.4)	53 (29.1)	8 (11.8)
3–6 months	62 (24.8)	49 (26.9)	13 (19.1)
6–12 months	37 (14.8)	23 (12.6)	14 (20.6)
>1 year	90 (36.0)	57 (31.3)	33 (48.5)
Adolescent SRH Stigma
Sexual activity & pregnancy stigma	5.55 (1.944, 0–7)	5.61 (1.97, 0–7)	5.34 (1.85, 0–7)	.214
Modern family planning & abortion stigma	6.21 (1.83, 0–7)	6.04 (1.64, 0–7)	6.27 (1.64, 0–7)	.200
HIV-related stigma	31.48 (6.05, 10–40)	32.04 (6.31, 10–40)	29.79 (4.86, 13–40)	.001

Table 3. Characteristics of urban refugee and displaced adolescent girls and young women in Kampala, Uganda, by awareness of HIV testing services and lifetime HIV testing (n = 333)

Variables	Full sample n (%) or mean (SD, range)	Aware of HIV testing services n (%) or mean (SD, range)	Not aware of HIV testing services n (%) or mean (SD, range)	p Value	Lifetime HIV testing (ever) n (%) or mean (SD, range)	Lifetime HIV testing (never) n (%) or mean (SD, range)	p Value
Sociodemographic factors
Age, years	19.31 (2.56, 16–24)	19.94 (2.59, 16–24)	18.30 (2.16, 16–24)	.000	20.02 (2.49, 16–24)	18.45 (2.39, 16–24)	0.000
Education (n = 333)				.000			0.000
Less than secondary school	190 (57.1)	100 (49.0)	90 (69.8)		82 (45.1)	108 (71.5)
Secondary school education	143 (42.9)	104 (51.0)	39 (30.2)		100 (54.9)	43 (28.5)
Place of birth (n = 333)				.000			0.920
South Sudan	30 (9.0)	21 (10.3)	9 (7.0)		15 (8.2)	15 (9.9)
Burundi	111 (33.3)	82 (40.2)	29 (22.5)		64 (35.2)	47 (31.1)
Democratic Republic of the Congo	153 (45.9)	72 (35.2)	81 (62.8)		81 (44.5)	72 (47.7)
Rwanda	19 (5.7)	16 (7.8)	3 (2.3)		11 (6.0)	8 (5.3)
Others	20 (6.0)	13 (6.4)	7 (5.4)		11 (6.0)	9 (6.0)
Time in Uganda (n = 333)				.650			.291
>1 year	23 (6.9)	12 (5.9)	11 (8.5)		14 (7.7)	9 (6.0)
1–5 years	186 (55.9)	115 (56.4)	71 (55.0)		107 (58.8)	79 (52.3)
<5 years	124 (37.2)	77 (37.7)	47 (36.4)		61 (33.5)	63 (41.7)
Immigration status (n = 330)				.791			.009
Refugees	305 (92.4)	187 (92.1)	9 (7.1)		161 (89.0)	144 (96.6)
Seeking asylum/undocumented	25 (7.6)	16 (7.9)	118 (92.9)		20 (11.0)	5 (3.4)
Employment (n = 333)				.000			.000
Unemployed	132 (38.6)	89 (43.6)	43 (33.3)		99 (54.4)	33 (21.9)
Student	155 (46.5)	72 (35.3)	83 (64.3)		58 (31.9)	97 (64.2)
Employed	46 (13.8)	43 (21.1)	3 (2.3)		25 (13.7)	21 (13.9)
Lifetime forced sex (n = 333)				.023			.000
No	254 (76.3)	147 (72.1)	107 (82.9)		120 (65.9)	134 (88.7)
Yes	79 (23.7)	57 (27.9)	22 (17.1)		62 (34.1)	17 (11.3)
Relationship status (n = 312)				.001			.000
No current partner	144 (46.2)	71 (38.4)	73 (57.5)		58 (34.5)	86 (59.7)
Dating one partner/married	131 (42.0)	85 (45.9)	46 (36.2)		90 (53.6)	41 (28.5)
Casual dating/multiple partners	37 (11.9)	29 (15.7)	8 (6.3)		20 (11.9)	17 (11.8)
Stigma
Adolescent SRH Stigma
Sexual activity & pregnancy stigma	5.61 (1.97, 0–7)	5.09 (2.22, 0–7)	6.44 (1.05, 0–7)	.000	5.17 (2.24, 0–7)	6.14 (1.42, 0–7)	.000
Modern family planning & abortion stigma	6.04 (1.64, 0–7)	5.78 (2.02, 0–7)	7.03 (1.35, 0–7)	.000	5.75 (1.97, 0–7)	6.89 (1.59, 0–7)	.000
HIV-related stigma	32.05(6.31, 10–40)	31.58 (6.05, 10–40)	32.78 (6.65, 13–40)	.093	31.47 (6.54, 13–40)	32.74 (5.95, 13–40)	.064

Note: Higher scores indicated experiencing more stigma.

Table 4. Characteristics of urban refugee and displaced adolescent boys and young men in Kampala, Uganda, by awareness of HIV testing services and lifetime HIV testing (n = 112)

Variables	Full sample n (%) or mean (SD, range)	Aware of HIV testing services n (%) or mean (SD, range)	Not aware of HIV testing services n (%) or mean (SD, range)	p Value	Lifetime HIV testing (ever) n (%) or mean (SD, range)	Lifetime HIV testing (never) n (%) or mean (SD, range)	p Value
Sociodemographic factors
Age, years	20.45(2.51, 16–24)	20.70 (2.48, 16–24)	19.62 (2.45, 16–24)	.053	21.16 (2.43, 16–24)	19.34 (2.23, 16–24)	.000
Education (n = 112)				.202			.008
Less than secondary school	44 (39.3)	31 (36.0)	13 (50.0)		20 (29.4)	24 (54.5)
Secondary school education	68 (60.7)	55 (64.0)	13 (50.0)		48 (70.6)	20 (45.5)
Place of birth (n = 112)				.105			.130
South Sudan	5 (4.5)	5 (5.8)	0 (0.0)		3 (4.4)	2 (4.5)
Burundi	4 (33.3)	3 (3.5)	1 (3.8)		4 (5.9)	0 (0.0)
Democratic Republic of the Congo	96 (85.7)	75 (87.2)	21 (80.8)		59 (86.8)	37 (84.1)
Others	7 (6.3)	3 (42.9)	4 (15.4)		2 (2.9)	5 (11.4)
Time in Uganda (n = 112)				.001			.441
>1 year	12 (10.7)	4 (4.7)	8 (30.8)		6 (8.8)	6 (13.6)
1–5 years	79 (70.5)	64 (74.4)	15 (57.7)		47 (69.1)	32 (72.7)
<5 years	21 (18.8)	18 (20.9)	3 (11.5)		15 (22.1)	6 (13.6)
Immigration status (n = 112)				.008			.413
Refugees	86 (76.8)	71 (82.6)	15 (57.7)		54 (79.4)	32 (72.7)
Seeking asylum/undocumented	26 (23.2)	15 (17.4)	11 (42.3)		14 (20.6)	12 (27.3)
Employment (n = 95)				.091			.061
Unemployed	44 (46.3)	35 (48.6)	9 (39.1)		27 (46.6)	17 (45.9)
Student	35 (36.8)	22 (30.6)	13 (56.5)		17 (29.3)	18 (48.6)
Employed	16 (16.8)	11 (20.8)	1 (4.3)		14 (24.1)	2 (5.4)
Lifetime forced sex				.196			.421
No	100 (89.3)	75 (87.2)	25 (96.2)		62 (91.2)	38 (86.4)
Yes	12 (10.7)	11 (12.8)	1 (3.8)		6 (8.8)	6 (13.6)
Relationship status (n = 112)				.167			.826
No current partner	45 (40.2)	31 (36.0)	14 (53.8)		27 (39.7)	18 (40.9)
Dating one partner/married	54 (48.2)	43 (50.0)	11 (42.3)		34 (50.0)	20 (45.5)
Casual dating/multiple partners	13 (11.6)	12 (14.0)	1(3.6)		7 (10.3)	6 (13.6)
Stigma factors
Adolescent SRH Stigma
Sexual activity & pregnancy stigma	5.34 (1.85, 0–7)	5.36 (1.81, 0–7)	5.31 (2.02, 0–7)	.899	5.31 (1.89, 0–7)	5.41 (1.82, 0–7)	.781
Modern family planning & abortion stigma	6.27 (1.64, 0–8)	5.96 (1.54, 0–7)	6.31 (1.93, 0–7)	.905	5.81 (1.54, 0–7)	6.41 (1.73, 0–7)	.058
HIV-related stigma	29.79 (4.86, 18–40)	29.44 (4.69, 18–40)	30.92 (5.29, 18–40)	.174	29.43 (4.36, 18–40)	30.34 (5.54, 18–40)	.333

Table 5. Multivariable logistic regression results examining associations between stigma and HIV testing services awareness and lifetime HIV testing among urban refugee and displaced adolescent girls and young women in Kampala, Uganda (n = 333)

	Awareness of HIV testing services		Lifetime HIV testing
Indicators	Unadjusted odds ratio (95% confidence intervaI)	Adjusted odds ratio (95% confidence intervaI)	Unadjusted odds ratio (95% confidence intervaI)	Adjusted odds ratio (95% confidence intervaI)
Stigma factors
Sexual activity & pregnancy stigma	0.59 (0.47, 0.71)***	0.68 (0.54, 0.87) **	0.60 (0.49, 0.73) ***	0.92 (0.74, 1.13)
Modern family planning & abortion stigma	0.64 (0.55, 0.75) ***	0.79 (0.64, 0.99) *	0.74 (0.65, 0.85) ***	0.78 (0.63, 0.97)*
HIV-related stigma	0.96 (0.94, 1.01)	1.02 (0.98, 1.06)	0.96 (0.93, 1.00)	0.99 (0.95, 1.04)
Sociodemographic factors
Age	3.15 (1.94, 5.12) ***	1.21 (0.58, 2.54)	3.90 (2.42, 6.26) ***	1.18 (1.02, 1.38) *
Secondary school education (reference: less than secondary school)	2.40 (1.51, 3.82) ***	1.83 (0.92, 3.63)	3.06 (1.94, 4.84) ***	1.71 (0.86, 3.40)
Employment (reference: employed)
Unemployed	0.14 (0.04, 0.49) ***	0.12 (0.03, 0.48)**	2.52 (1.25, 5.08) **	3.75 (1.43, 9.83) **
Student	0.06 (0.02, 0.20) ***	0.09 (0.02, 0.35)***	0.50 (0.26, 0.98) **	1.54 (0.57, 4.19)
Lifetime forced sex (reference: no)	0.53 (0.31, 0.92)*	1.42 (0.69, 2.92)	0.25 (0.14, 0.44) ***	0.17 (0.07, 0.37) ***
Relationship status (reference: single)
Dating one partner/married	1.90 (1.17, 3.09)**	1.23 (0.68, 2.23)	3.26 (1.98, 5.35) ***	3.80 (1.94, 7.44) ***
Casual dating/multiple partners	3.73 (1.59, 8.70)**	0.77 (0.25, 2.36)	1.74 (0.84, 3.61)	1.17 (0.42, 3.26)
Model fit indices
n	333	333	333	333
Block χ² (sig)		38.29 (0.000) df = 3		15.49 (0.001) df = 3
Percentage correctly classified		67		74.4
Nagelkerke R^2		0.35		0.44

*p < .05; **p < .01; ***p < .001.

Table 6. Multivariable logistic regression results examining associations between stigma and HIV testing services awareness and lifetime HIV testing among urban refugee and displaced adolescent boys and young men in Kampala, Uganda (n = 112)

Indicators	Awareness of HIV testing services		Lifetime HIV testing
	Unadjusted odds ratio (95% confidence intervaI)	Adjusted odds ratio (95% confidence intervaI)	Unadjusted odds ratio (95% confidence intervaI)	Adjusted odds ratio (95% confidence intervaI)
Stigma factors
Sexual activity & pregnancy stigma	1.02 (0.80, 1.28)	1.21 (0.87, 1.68)	0.97 (0.78, 1.19)	1.08 (0.96, 1.69)
HIV-related stigma	0.94 (0.86, 1.03)	0.95 (0.86, 1.05)	0.96 (0.88, 1.04)	0.98 (0.89, 1.07)
Sociodemographic factors
Age	2.42 (0.99, 5.92)*	2.22 (0.73, 6.71)	3.48 (1.56, 7.68)**	2.82 (1.06, 7.63)*
Post-secondary school education (reference: less than secondary school)	1.77 (0.73, 4.30)	1.05 (0.33, 3.32)	2.88 (1.31, 6.35)**	1.75 (0.66, 5.16)
Relationship status (reference: single)
Dating one partner/married	1.76 (0.71, 4.41)	1.53 (9.57, 4.09)	1.13 (0.50, 2.56)	0.79 (0.37, 2.23)
Casual dating/multiple partners	5.42 (0.64, 45.85)	5.07 (0.57, 45.40)	0.78 (0.22, 2.69)	0.57 (0.16, 2.44)
Model fit indices
n	112	112	112	112
Specificity		79.7		77.3
Sensitivity		71.4		73.5
Nagelkerke R^2		0.30		0.14

*p < .05; **p < .01; ***p < .001.