Water and Food Insecurity and Associations with Disrupted Sexual and Reproductive Health Care Access in the COVID-19 Pandemic: Mixed Methods Findings with Urban Refugee Youth in Kampala, Uganda

Background: The COVID-19 pandemic has exacerbated resource insecurity among refugee youth in Uganda, Sub-Saharan Africa’s largest refugee hosting nation. This is particularly salient in Kampala, where refugees disproportionately experience poverty and restricted access to basic resources, which can potentially increase risks of stress and poor health outcomes. Limited research has focused on water and food insecurity with urban refugee youth, despite growing refugee urbanization. There are also knowledge gaps regarding resource insecurities, such as food and water insecurity, and sexual and reproductive health outcomes among urban refugee youth. To understand sexual and reproductive health needs during COVID-19, we conducted a multi-method study with urban refugee youth living in informal settlements in Kampala, Uganda.

Methods: This study involved in-depth individual interviews with refugee youth aged 16-24 (n=24), followed by cross-sectional surveys with a peer-recruited sample of urban refugee youth (N=340) in Kampala. We applied thematic analyses across qualitative data to explore linkages between ecosocial factors and sexual and reproductive health. Multivariable logistic and linear regression assessed quantitative associations between food insecurity and water insecurity and: pandemic-related disrupted sexual and reproductive health access; past 12-month transactional sex; pandemic-related unplanned pregnancy; condom efficacy; and sexual relationship power, adjusting for age, gender, and informal settlement.

Results: Key themes across qualitative narratives (n=24; n=12 women, n=12 men; mean age: 21 years) included: a) pandemic-related economic insecurity contributed to survival sex, migration, and subsequent unplanned pregnancy; b) reduced sexual and reproductive health service access (e.g., condoms, HIV testing, contraception) was amplified by pre-existing low sexual and reproductive health knowledge and pandemic-related lockdowns; and c) water insecurity and food insecurity magnified chronic stress. Survey participants (n=340; mean age: 21 years old, 51% women, 49% men) reported high food insecurity (65%) and water insecurity (47%). One-third (35.0%) reported reduced sexual/reproductive health service access, including no access to contraception (94.5%), condoms (86.4%), HIV testing (81.2%), and pregnancy testing (94.8%). In adjusted analyses, water insecurity (adjusted odds ratio [aOR]: 1.82, 95% confidence interval [CI]: 1.12-2.96) and food insecurity (aOR: 1.89 95%CI=1.10-3.27) were associated with increased odds of disrupted sexual and reproductive health access. Water insecurity was associated with increased likelihood of unplanned pregnancies (aOR: 2.49, 95%CI=1.11-5.62) and transactional sex (aOR: 2.67, 95%CI=1.03-6.93) and reduced sexual relationship power (β= -2.34, 95%CI= -4.58, -0.09). Women (vs. men) (adjusted β= -3.61, 95%CI= -5.07, -2.16) and water insecure participants (adjusted β= -3.96, 95%CI= -5.44, -2.47) reported reduced condom efficacy. Water insecurity was associated with double the odds of food insecurity (aOR: 2.27; CI: 1.40-3.68).

Conclusions: Multi-method findings suggest that co-occurring food and water insecurity were associated with poorer sexual and reproductive health and were also described by refugee youth as central stressors. This critical finding suggests the need to incorporate water insecurity in food insecurity and health programming to accelerate achievement of SDG 2 (zero hunger), SDG 3 (good health and well-being), and SDG 6 (clean water and sanitation). Understanding interactions between food and water insecurity within larger socio-structural risk environments can advance localized sexual and reproductive health promotion with refugee youth.