Correlates of traditional medicine utilization among school-going adolescents and young people with mental health disorders in central and eastern Uganda: a cross-sectional survey

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Despite the growing burden, access to conventional mental healthcare remains limited. We investigated the correlates of traditional medicine (TM) utilization among students with self-reported mental health disorders in Uganda. Methods: In this cross-sectional study, we analyzed secondary data from a subsample of 302 students with self-reported history of a mental health disorder out of a sample of 1970 who completed the survey. In the primary study, stratified random sampling was used to select schools, and participants were selected proportionally. We used modified Poisson regression to examine the factors independently associated with TM use including demographic characteristics and the presence of emotional or behavioral disorders. Statistical significance was set at a p-value of less than 0.05. Results: Most participants were female (53.31%) and aged between 15 and18 years (71.57%). The majority of were in ordinary level of secondary education (92.54%), came from the Central region (74.50%) and attended schools in urban areas (53.97%). The median monthly family income was $83.3, with over half earning ≤$100 monthly (58.82%). Nearly half of the participants reported a family history of mental illness (49.82%), and a notable percentage had at least one behavioral disorder (25.83%) or emotional disorder (21.19%). The adjusted model suggested that rural school attendees had a 1.3 times higher prevalence of TM utilization [aPR:1.30(1.01-1.68), p=0.04] compared to urban ones, and those with parents or guardians who completed college/university had a 38% lower prevalence [aPR:0.62(0.41-0.94), p=0.025] of TM utilization compared to those with parents or guardians without formal education. Conclusion: A large proportion of the students utilized TM, largely influenced by rural residence, and parents’ education status. The high prevalence of TM use emphasizes the need for promoting biomedical healthcare to ensure timely and effective treatment for mental health conditions with a focus on socio-economic disparities. Prevalence traditional medicine mental health adolescents behavioral health Background Mental health disorders among adolescents and young people are increasingly recognized as a public health concern, with issues such as depression, anxiety, and behavioral disorders affecting millions( 1 ). Despite the limitations in estimating the burden of the problem globally, recent estimates indicate that one in seven adolescents experiences a mental disorder, with depression, anxiety, and behavioral disorders being leading causes of illness and disability( 2 ). Mental health disorders greatly contribute to premature deaths and low quality of life. In 2020, an estimated 49.4 million and 44.5 million DALYs were attributed to major depressive and anxiety disorders, respectively( 3 ). The COVID-19 pandemic period is believed to have aggravated the mental health burden across the globe with an additional 53.2M and 76.2M cases of major depressive and anxiety disorders, respectively( 3 ). Younger people, especially children, and adolescents were the most affected by the pandemic( 4 ) with an over 1% increase in both major depressive and anxiety disorders( 3 ). In Uganda, the estimated prevalence of depression was 48.1% during the COVID-19 pandemic compared to 29.3% in the pre-pandemic period( 5 ). Among school going children, the effect of the pandemic on rates of depression is known to have been larger given that schools and other social avenues were shut down during most of the pandemic( 4 ). Limited academic progress in the same period further complicates the mental health profile of school going children. Adolescence is a critical transitional stage in development marked by significant physical, emotional, and psychological changes between child and adulthood periods, often accompanied by mental health challenges( 2 ). Thus, adolescence requires substantial attention to prevent mental health challenges. Despite the growing burden of mental health challenges, access to conventional mental health care in low- and middle-income countries (LMICs) remains limited due to factors such as inadequate healthcare infrastructure( 6 – 8 ), stigma( 6 , 9 , 10 ), ignorance about mental health/services( 6 , 10 ), and the shortage of trained mental health professionals( 8 , 11 ). In resource-limited contexts, especially sub-Saharan Africa (SSA), 48.1% of individuals with mental disorders seek care from traditional or religious healers( 12 ). These alternative practices have deep cultural roots and are often more accessible due to geographic locations, cost and acceptability within local communities( 9 , 10 ). Available evidence indicated that up to 33.33% of people prefer traditional/alternative and complementary treatments for adolescent and children related mental health care to formal care( 10 ). Relying on alternative care may lead to delayed or no formal care which limits early identification and access to evidence based mental health interventions. Given the limited evidence on the efficacy of TM( 13 ) and its associated physical and human rights abuses( 14 , 15 ), its utilization may lead to poor health outcomes among people with mental disorders( 12 ). The World Health Organization’s traditional medicines strategy calls for promotion of safe and effective use of TM through country specific regulation of products, practices, and practitioners( 16 ). In Uganda, regulations to control TM use exist including the Witchcraft Act of 1957, and the Traditional and Complementary Medicine Act, 2019( 17 ). However, their operationalization is limited, and this makes the safety of TM a challenge. The utilization of alternative healthcare by adolescents with mental health challenges in SSA remains underexplored in academic literature. In Uganda, school-going adolescents represent a substantial proportion of vulnerable groups with limited mental health support and whose care seeking behavior for mental health services remains understudied( 18 ). Understanding the extent and nature of this issue is crucial for shaping effective mental health interventions and policies. We examined alternative healthcare utilization and its correlates among adolescents with mental health challenges in Uganda. This provides insights into how alternative health services function within the broader healthcare landscape and how it can be leveraged to improve timely health care seeking behavior. Methods Study design, setting, and population We analyzed secondary data on 302 students with self-reported mental health issues from a cross-sectional survey among 1,972 adolescents and young people aged 12-18 in eight secondary schools in Iganga and Mukono districts located in Eastern and Central Uganda respectively. Iganga district is predominantly rural, while Mukono is predominantly urban. The original survey assessed the mental health needs of secondary school adolescents including determining the prevalence of emotional and behavioral disorders; describing the associated demographic factors and mental health intervention practices and whether the current school intervention matched mental health needs. Inclusion criteria To be included in the original survey, the students had to be attending schools in the selected districts; were between 12 and 24 years old; whose parents/care takers consented; and the students gave assent and were willing to participate in the study. For this analysis, only those that had reported ever having mental illness were considered. Sampling procedures For the original sample, the central and eastern regions were purposively selected for the original survey because they are the most populated regions in Uganda. For schools, one school district was selected from each region based on its population and past academic performance. A list of all registered secondary schools in the respective districts was obtained from the District Education Officers (DEOs). We then created a list of schools and stratified them by their rural or urban status and government or private status. Stratified random sampling was then used to select four secondary schools from each district. These included two government-funded and two private schools in each district. Sample size For this analysis, we analyzed data on only those that reported history of mental illness. This was 302 (15.71%) of the 1,960 primary sample. For regression analysis, data on 286 were analyzed after excluding those who did not answer the question about service utilization. However, this sample size was considered to have sufficient power since a sample size of 204 would still predict a prevalence of 15.71%, with a precision of 95% and 95% CI. Data collection and tools The demographic characteristics and the Child & Adolescent Symptom Inventory-5 (CASI-5) were used for data collection. Face-to-face interviews were conducted by Psychiatric Clinical Officers (PCOs). PCOs are trained and able to conduct mental health diagnoses. The CASI-5 has over 100 questions to capture the frequency of various symptoms for 24 emotional and behavioral disorders. In each section of the CASI-5, respondents were asked about how often the symptoms impair social or behavioral functions. The data collection process took place between June and November 2017. Study measures and variable measurement Dependent variables: The dependent variable was utilization of traditional medicine for mental illness. This was assessed at two levels by self-reporting. First, the respondents were asked if they had ever had mental illness with Yes and No response options. For those who answered yes, they were asked what kind of treatment they sought with options of i) traditional medicine or ii) Western medicine. Covariates: These included demographic variables and presence of symptoms of various behavioral and emotional disorders. Demographic variables were sex (female/male), age (categorized in two groups i.e. 12-15 and 16-18 years), residence (rural/urban), family history of mental illness (yes/no), and level of education [Advanced (A’) or Ordinary (O’) level]. In addition to these variables, the nature of housing (permanent/ semi-permanent/hut), presence of domestic violence in the home (yes/no), and orphanhood (at least one parental death/both parents living) were used to measure hardship experiences. School characteristics were also assessed including sex status (mixed boys and girls or single sex school) and school ownership (private/government). Other covariates considered were having at least one behavioral and emotional disorder as measured using CASI-5. A Likert scale with values 0 = Never, 1 = Sometimes, 2 = Often, 3 = Very Often was used to quantify the participants’ responses to the CASI-5 survey. In this study, we considered those with responses of at least 2 (Often or Very Often) to have the symptoms. We also used the DSM-5 guidelines to classify the presence of symptoms of emotional or behavioral disorders(19) as described in a prior study conducted among school-going adolescents(20). Generally, for this analysis, the emotional disorders included major depressive disorder, generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder. The behavioral disorders included attention deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder. A person was considered to have emotional or behavioral disorder symptoms if they were found to meet the criteria for at least one of the disorders under each of these categories. Statistical Analysis First frequencies and percentages of the respondents were computed for each variable. Next, carried out bivariate analysis using modified Poisson regression to assess the associations between covariates (hardship experiences, demographic characteristics, school features and emotional or behavioral disorders) and utilization of traditional medicine. Modified Poisson regression which yields prevalence ratios (PR) instead of odds ratios was used because it is considered more conservative when the outcome is common(21, 22) and the prevalence of traditional medicine utilization (48.6%) was high. Backwards elimination was applied to build our final analytic model and only variables that had a p-value ≤ 0.2 at bivariate analysis were considered at the multivariable regression stage. Collinearity between independent variables was assessed using pairwise correlation analysis. Statistical significance was considered at p<0.05 and 95% confidence intervals are reported. Data were analyzed using StataNow/SEv14 (StataCorp LLC College Station Texas 77845). Results Participants socio-demographic characteristics As shown in Table 1, there were slightly more females (53.31%) than males (46.69%) with average age of 15.45 years (SD ± 1.88), and the majority were aged 15-18 years (71.57%). Overall, 17.61% of students were orphans; among those most had lost only their father (48.08%) or mother (40.38%) with only 6 students (11.5%) having lost both the mother and father. Most participants (92.54%) had attained the ordinary level of secondary education, while 42.6% of the parents had attained advanced/high school education. The majority (74.50%) were from the Central region, and 53.97% lived in urban areas. Most participants (78.23%) lived in permanent houses and 33.57% reported presence of domestic violence in the home. The mean monthly family income was 171.82 USD (SD±343.4), with 58.82% earning ≤100 USD monthly and majority of parents or guardians (57.29%) were small business owners. Nearly half (49.82%) reported a family history of mental illness and 25.83% of participants had at least one behavioral disorder or at least one emotional disorder (21.19%). Table 1: Participants socio-demographic characteristics (N=302) Characteristic n (%) Sex Male 141 (46.69) Female 161 (53.31) Age category, years (M=15.45, SD=1.88) 19-22 15 (5.02) 15-18 214 (71.57) 10-14 70 (23.41) Level of education Advanced level 22 (7.46) Ordinary level 273 (92.54) Region Eastern 77 (25.50) Central 225 (74.50) Urbanity Rural 139 (46.03) Urban 163 (53.97) Nature of housing Permanent 230 (78.23) Semi-permanent 64 (21.77) Domestic violence in the home Yes 96 (33.57) No 190 (66.43) Orphan Yes 53 (17.61) No 248 (82.39) Orphan type Lost both mother and father 6 (11.54) Only mother 21 (40.38) Only father 25 (48.08) Parent's education level None 37 (13.36) Elementary 29 (10.47) High school 118 (42.60) College/ university 93 (33.57) Family history of mental illness Yes 138 (49.82) No 139(59.09) Family's total monthly income (USD) Mean (±SD) 171.82 (±343.4) Median (IQR) 83.3 (2.8 - 2,639) Family's total monthly income (USD)* ≤ 100 39 (58.82) >100 27 (40.91) Parent or guardian’s employment Professional 33 (11.46) Casual laborer 22 (7.64) Teacher 23 (7.99) Small business owner 165 (57.29) Other 45 (15.63) Having ≥1 behavioral disorder No 224 (74.17) Yes 78 (25.83) Having ≥1 emotional disorder No 238 (78.81) Yes 64 (21.19) * Uganda shillings (UGX) to United States Dollar (USD) rate of 1USD=3,600UGX was used. M=Mean. SD=Standard Deviation, Mdn=Median As shown in Table 2, almost half (48.6%) of the participants had utilized traditional medicine. After statistical adjustment, only the location of the school in terms of being urban or rural and parent or guardian’s education level were independently associated with traditional medicine utilization. The prevalence of traditional medicine utilization among those who went to rural schools was 1.3 times that among those who went to urban schools [aPR:1.30(95%CI 1.01-1.68), p=0.04]. The prevalence of traditional medicine utilization among those whose parents or guardians completed college/ university was 38% lower compared to those whose parents or guardians had no formal education [aPR:0.62(95% CI 0.41-0.94), p=0.025]. Table 2: Bivariate and multivariable analysis of correlates of traditional medicine utilization (N=286) Characteristic Traditional medicine utilization cPR (95% CI) aPR (95% CI) Yes n(%) No n(%) Age category, years (M=15.45, SD=1.88) 10-14 40(28.78) 26(18.06) 1 15-18 94(67.63) 110(76.39) 1.20(0.59-2.42) 19-22 5(3.60) 8(5.56) 1.60(0.77-3.22) Region Central 105(75.54) 105(71.43) 1 Eastern 34(24.46) 42(28.57) 0.89(0.67-1.19) Nature of housing Permanent 104(76.47) 116(81.12) 1 Semi-permanent 32(23.53) 27(18.88) 1.15(0.87-1.51) Domestic violence in the home Yes 47(36.15) 43(30.50) 1 No 83(63.85) 98(69.50) 0.88(0.68-1.13) Orphan No 118(84.89) 117(80.14) Yes 21(15.11) 29(19.86) 0.84(0.59-1.19) Orphan type Both parents 3(14.29) 3(10.34) 1 Only mother 9(42.86) 12 (41.38) 0.86(0.33-2.21) Only father 9(42.86) 14(48.28) 0.78(0.30- 2.04) Family history of mental illness Yes 66(51.97) 67(48.91) 1 No 61(48.03) 70(51.09) 0.94(0.73-1.20) Family's total monthly income ≤ 100USD 15(60.00) 23(58.97) 1 >100USD 10(40.00) 16(41.03) 0.97(0.52-1.83) Having ≥1 behavioral disorder No 106(76.26) 106(72.11) 1 Yes 33(23.74) 41(27.89) 0.89(0.67-1.19) Having ≥1 emotional disorder No 113(81.29) 113(76.87) 1 Yes 26(18.71) 34(23.13) 0.87(0.63- 1.19) Sex Male 59(42.45) 74(50.34) 1 1 Female 80(57.55) 73(49.66) 1.18(0.92-1.50) 1.17(0.91-1.52) Level of education Advanced level 6(4.44) 14 (9.72) 1 1 Ordinary level 129(95.56) 130(90.28) 1.66(0.84-3.30) 1.40(0.70-2.80) Urbanity Urban 65(46.76) 90(61.22) 1 1 Rural 74(53.24) 57(38.78) 1.34(1.06-1.71)** 1.30(1.01-1.68)** Parent or guardian’s education level None 22(17.19) 13(9.63) 1 1 Elementary 11(8.59) 18(13.33) 0.60(0.35-1.03) 0.69(0.41-1.17) High school 57(44.53) 52(38.52) 0.83(0.60-1.14) 0.89(0.64-1.23) College/ University 38(29.69) 52(38.52) 0.67(0.47-0.95)* 0.62(0.41-0.94)** Parent or guardian’s employment Professional 14(10.53) 16(11.35) 1 1 Casual laborer 6(4.51) 16(11.35) 0.58(0.27-1.28) 0.57(0.26-1.24) Teacher 11(8.27) 11(7.80) 1.07(0.61-1.89) 1.11(0.63-1.97) Small business owner 78(58.65) 79(56.03) 1.06(0.70-1.61) 0.88(0.58-1.33) Other 24(18.05) 19(13.48) 1.19(0.75-1.91) 0.95(0.60-1.52) cPR : crude prevalence ratio; aPR : adjusted prevalence ratio *p≤0.04; **p≤0.025 Discussion This study revealed that nearly half (48.6%) of school-going adolescents and young people with self-reported mental health conditions utilized traditional medicine. Though we did not assess decision making in this study, it is most likely that for adolescents who are considered minors, their parents and guardians influence their healthcare utilization choices. Therefore, this discussion is based on that assumption. This high prevalence is not a surprise since studies in other African countries indicate that traditional medicine is often seen as more culturally appropriate and accessible than biomedical care( 23 – 26 ). Therefore, our findings are particularly of concern given that adolescence is a growth phase where untreated mental health conditions can have long-term consequences on academic achievement, social functioning, and overall development( 27 ). Though we did not explore dual utilization of TM and biomedical care, findings from systematic reviews also indicate that traditional medicine is often used alongside biomedical treatments( 28 , 29 ). Despite this, the high prevalence of TM utilization underscores the need to promote use of biomedical medicine since there are many effective mental health treatments and therapies especially when healthcare is timely sought. Dependance on TM may lead to delayed healthcare seeking, and thus exacerbate mental health related challenges among adolescents and young people. Most traditional practices applied in traditional mental health care lack scientific evidence( 13 ). In addition, some of the TM practices have been linked to human rights and physical abuses including chaining patients and starving of patients( 14 , 15 ) through food restriction and forced fasting( 28 , 30 ). Alternatively, the known TM preference could be leveraged to engage providers to offer basic psychosocial support to patients and as a channel to formal health care referral. This may help prevent late healthcare seeking behavior among adolescents and young people with mental conditions. Improved health care utilization has been reported where such engagements have been leverage, for example referral of expectant mothers by traditional birth attendants is reported to improve skilled birth attendance( 31 ). The prevalence of TM utilization among those who went to rural schools was 1.3 times that among those who went to urban schools. This is in line with findings from Ethiopia and Nigeria which also reported higher TM utilization in rural areas compared to urban areas( 32 – 34 ). One reason for this could be the possible traditional beliefs among people in rural areas, and limited access to biomedical care. Other researchers have also reported that traditional healers are a very much used source of mental healthcare, especially in areas with limited and unaffordable biomedical mental health services like in sub-Saharan Africa (SSA)( 28 ). It has also been reported that rural areas in Africa possess strong beliefs in TM with even a perception that most traditional medicines are better and more effective for some conditions ( 35 ). Such beliefs may facilitate more trust in TM than biomedical care just as other scholars have reported( 24 – 26 , 36 ). Health facilities may need to consider integrating mental health services into outreaches to serve rural areas. Targeted health education with emphasis on the dangers of TM since some traditional medicines have been found to have harmful side effects( 29 ) resulting from herbal constituents, contamination, or adulteration( 37 ) may also be important for the population. The prevalence of TM utilization among those whose parents or guardians completed college/university was 38% lower compared to those whose parents or guardians had no formal education. Though there have been mixed findings about the relationship between parent’s education level and TM utilization( 29 ), most studies align with our findings( 34 , 38 – 40 ) while others are contrary( 41 , 42 ). Higher TM use among those with low or no formal education could be attributed to possible higher health literacy among more educated parents which may counter possible beliefs in TM. Initiatives focused on promoting biomedical healthcare for mental health conditions should target such populations with lower formal levels of education. Contextualized approaches including use of translated education media that is culturally responsive as well as alternative health promotion approaches would be important. Strengths and limitations This study may have been affected by social desirability bias. Some studies have indicated that non-disclosure of TM use is very common( 29 ), and this could have affected our results. This analysis was based on secondary data analysis, and we did not assess decision making in this study which may have helped us to interpret our findings more authoritatively. We also did not explore dual utilization of TM and biomedical care, and social-cultural factors yet these could have been important to our discussion and conclusion. In addition, the age category of 19–22 years was underrepresented meaning that these results may only be interpreted in the context of adolescents. Nevertheless, this is one of the few studies focused on TM utilization for mental health among school going adolescents in Uganda. Conclusion A large proportion of adolescents in secondary schools with a self-reported mental condition utilized traditional medicine, influenced by rural residence, and parents’ education status. The high prevalence of traditional medicine use emphasizes the need for promoting biomedical healthcare to ensure timely and effective treatment for mental health conditions. Addressing traditional medicine use, particularly among rural populations and those with lower education levels may require increased access to quality mental healthcare, and education about biomedical treatments. Education focused on mindset change may also facilitate transition from utilization of TM to biomedical healthcare. More research among adolescents should focus on assessment of the effect of social-cultural factors on traditional medicine utilization. Declarations Ethics approval and consent to participate This study was approved by the Makerere University School of Medicine Research Ethics Committee (SOMREC). Permission to conduct the study was also obtained from the Uganda National Council for Science and Technology (UNCST). All respondents provided informed consent to participate in the study. Confidentiality and privacy were maintained throughout the research process. Acknowledgments We acknowledge the District Education Officers (DEOs), schools’ management, and research assistants. Funding This study was funded in part by the Swedish International Development Cooperation Agency (Sida) and Makerere University under Sida contribution No: 51180060. Data Availability The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. Authors’ contributions Conceptualization: CA, AK, RA; Methodology: CA, AK, RA; Writing – original draft: AK; Writing – review & editing: AK, CA, RA, MB, JD-G, LDC, RK. Authors’ information 1 Institute for Health and Humanity, Medical College of Wisconsin, Milwaukee, WI 53226, USA. 2 Makerere University College of Health Sciences, Uganda. 3 Uganda Martyrs University, Uganda. 4 Ministry of Health, Uganda. Competing interests The authors declare no competing interests. Consent for publication All authors consented to publish this article. 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Knowledge, attitude, practice, and management of traditional medicine among people of Burka Jato Kebele, West Ethiopia. Journal of Pharmacy and Bioallied Sciences. 2015;7(2):136-44. Sarki Z, Danjuma M. Socio-Demographic factors and utilization of traditional medicine in Kazaure town, Jigawa state, Nigeria. Int Journal of Emerging Knowledge. 2015;3:9-20. Yaa Ntiamoa-Baidu. Wildlife and food security in Africa. Rome, Italy: Food And Agriculture Organization of The United Nations; 1997 [cited 2024 11/19/2024]. Available from: https://www.fao.org/4/w7540e/w7540e0c.htm#:~:text=a)%20confidence%20in%20the%20system,believe%20that%20such%20medicines%20are. Kendi NN. Impact of Traditional Medicine Integration with Modern Healthcare in Africa. 2024. Ernst E. Serious psychiatric and neurological adverse effects of herbal medicines -- a systematic review. Acta psychiatrica Scandinavica. 2003;108(2):83-91. Nxumalo N, Alaba O, Harris B, Chersich M, Goudge J. Utilization of traditional healers in South Africa and costs to patients: Findings from a national household survey. Journal of Public Health Policy. 2011;32(1):S124-S36. Chintamunnee V, Mahomoodally MF. Herbal medicine commonly used against non-communicable diseases in the tropical island of Mauritius. Journal of Herbal Medicine. 2012;2(4):113-25. Ladele A, Bisi-Amosun O. Level of utilization of traditional and orthodox medicines by rural dwellers in Ile-Ogbo Community of Osun State, Nigeria. Journal of Agricultural Extension. 2014;18(1):155-68. ME B. Alternative medicine use among workers in an urban setting in North-Central Nigeria. Prevalence.31:0.319. Usifoh S, Udezi A. Social and economic factors influencing the patronage and use of complementary and alternative medicine in Enugu. Journal of Pharmacy & Bioresources. 2013;10(1):17-24. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6559755","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466735336,"identity":"d99ac26c-bba8-4a08-a856-8b3265581abb","order_by":0,"name":"Arthur Kiconco","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Arthur","middleName":"","lastName":"Kiconco","suffix":""},{"id":466735337,"identity":"954e8223-ed84-44ec-93f4-f2f64aecdffe","order_by":1,"name":"Catherine Abbo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYHACNiCWkGNjbwDSBhbE6GAGabEw5uc5ANIiQbSWisSZMxJAPCK08LefP/aYp0bC2ODm86sbfhRIAEW6E/BqkTiTzG7Mc0xCzuB2TtnNHqDDJM6c3YBXiwFDMps0DxvQlts5aTd4gFoMJHIJaOF/DNTyTyJxw80zaTf/EKVFAmgLb5sE0Pvsx24TZYvEjcdmknP7JICBnMN2W8ZAgoegX/j7E59JvPlWB4zK489uvvljI8ff3otfCwgw8YApHgMwSVA5CDD+AFPsD4hSPQpGwSgYBSMPAACQ/0JFipDX/QAAAABJRU5ErkJggg==","orcid":"","institution":"Makerere University","correspondingAuthor":true,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Abbo","suffix":""},{"id":466735338,"identity":"b352d9f7-4fac-4275-ae42-47f5d9028de6","order_by":2,"name":"Julia Dickson-Gomez","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"","lastName":"Dickson-Gomez","suffix":""},{"id":466735339,"identity":"4198eede-b834-4f68-903c-b0876bdd5e4e","order_by":3,"name":"Richard Kabanda","email":"","orcid":"","institution":"Uganda Martyrs University","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Kabanda","suffix":""},{"id":466735340,"identity":"1631382e-b8f2-436d-a454-c75ea6d05cfa","order_by":4,"name":"Max Bobholz","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Max","middleName":"","lastName":"Bobholz","suffix":""},{"id":466735341,"identity":"47f1c007-68f2-4aa1-ae63-41174583d423","order_by":5,"name":"Laura D. Cassidy","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"D.","lastName":"Cassidy","suffix":""},{"id":466735342,"identity":"eff27ae1-f213-49bc-bab3-791e9a048405","order_by":6,"name":"Ronald Anguzu","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Ronald","middleName":"","lastName":"Anguzu","suffix":""}],"badges":[],"createdAt":"2025-04-29 23:23:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6559755/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6559755/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84220498,"identity":"ef5a28c3-c1c0-4b35-afb9-def789fc849a","added_by":"auto","created_at":"2025-06-09 11:34:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":876259,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6559755/v1/cbf75bed-039f-4eeb-9f7a-02a2abff87f1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correlates of traditional medicine utilization among school-going adolescents and young people with mental health disorders in central and eastern Uganda: a cross-sectional survey","fulltext":[{"header":"Background","content":"\u003cp\u003eMental health disorders among adolescents and young people are increasingly recognized as a public health concern, with issues such as depression, anxiety, and behavioral disorders affecting millions(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite the limitations in estimating the burden of the problem globally, recent estimates indicate that one in seven adolescents experiences a mental disorder, with depression, anxiety, and behavioral disorders being leading causes of illness and disability(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMental health disorders greatly contribute to premature deaths and low quality of life. In 2020, an estimated 49.4\u0026nbsp;million and 44.5\u0026nbsp;million DALYs were attributed to major depressive and anxiety disorders, respectively(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The COVID-19 pandemic period is believed to have aggravated the mental health burden across the globe with an additional 53.2M and 76.2M cases of major depressive and anxiety disorders, respectively(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Younger people, especially children, and adolescents were the most affected by the pandemic(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) with an over 1% increase in both major depressive and anxiety disorders(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In Uganda, the estimated prevalence of depression was 48.1% during the COVID-19 pandemic compared to 29.3% in the pre-pandemic period(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Among school going children, the effect of the pandemic on rates of depression is known to have been larger given that schools and other social avenues were shut down during most of the pandemic(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Limited academic progress in the same period further complicates the mental health profile of school going children.\u003c/p\u003e \u003cp\u003eAdolescence is a critical transitional stage in development marked by significant physical, emotional, and psychological changes between child and adulthood periods, often accompanied by mental health challenges(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Thus, adolescence requires substantial attention to prevent mental health challenges. Despite the growing burden of mental health challenges, access to conventional mental health care in low- and middle-income countries (LMICs) remains limited due to factors such as inadequate healthcare infrastructure(\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), stigma(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), ignorance about mental health/services(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and the shortage of trained mental health professionals(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn resource-limited contexts, especially sub-Saharan Africa (SSA), 48.1% of individuals with mental disorders seek care from traditional or religious healers(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These alternative practices have deep cultural roots and are often more accessible due to geographic locations, cost and acceptability within local communities(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Available evidence indicated that up to 33.33% of people prefer traditional/alternative and complementary treatments for adolescent and children related mental health care to formal care(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Relying on alternative care may lead to delayed or no formal care which limits early identification and access to evidence based mental health interventions. Given the limited evidence on the efficacy of TM(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and its associated physical and human rights abuses(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), its utilization may lead to poor health outcomes among people with mental disorders(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe World Health Organization\u0026rsquo;s traditional medicines strategy calls for promotion of safe and effective use of TM through country specific regulation of products, practices, and practitioners(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In Uganda, regulations to control TM use exist including the Witchcraft Act of 1957, and the Traditional and Complementary Medicine Act, 2019(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, their operationalization is limited, and this makes the safety of TM a challenge.\u003c/p\u003e \u003cp\u003eThe utilization of alternative healthcare by adolescents with mental health challenges in SSA remains underexplored in academic literature. In Uganda, school-going adolescents represent a substantial proportion of vulnerable groups with limited mental health support and whose care seeking behavior for mental health services remains understudied(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Understanding the extent and nature of this issue is crucial for shaping effective mental health interventions and policies. We examined alternative healthcare utilization and its correlates among adolescents with mental health challenges in Uganda. This provides insights into how alternative health services function within the broader healthcare landscape and how it can be leveraged to improve timely health care seeking behavior.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design, setting, and population\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe analyzed secondary data on 302 students with self-reported mental health issues from a cross-sectional survey among 1,972 adolescents and young people aged 12-18 in eight secondary schools in Iganga and Mukono districts located in Eastern and Central Uganda respectively. Iganga district is predominantly rural, while Mukono is predominantly urban. The original survey assessed the mental health needs of secondary school adolescents including determining the prevalence of emotional and behavioral disorders; describing the associated demographic factors and mental health intervention practices and whether the current school intervention matched mental health needs.\u003c/p\u003e\n\u003ch2\u003eInclusion criteria\u003c/h2\u003e\n\u003cp\u003eTo be included in the original survey, the students had to be attending schools in the selected districts; were between 12 and 24 years old; whose parents/care takers consented; and the students gave assent and were willing to participate in the study. For this analysis, only those that had reported ever having mental illness were considered.\u003c/p\u003e\n\u003ch2\u003eSampling procedures\u003c/h2\u003e\n\u003cp\u003eFor the original sample, the central and eastern regions were purposively selected for the original survey because they are the most populated regions in Uganda. For schools, one school district was selected from each region based on its population and past academic performance. A list of all registered secondary schools in the respective districts was obtained from the District Education Officers (DEOs). We then created a list of schools and stratified them by their rural or urban status and government or private status.\u0026nbsp;Stratified random sampling was then used to select four secondary schools from each district. These included two government-funded and two private schools in each district.\u003c/p\u003e\n\u003ch2\u003eSample size\u003c/h2\u003e\n\u003cp\u003eFor this analysis, we analyzed data on only those that reported history of mental illness. This was 302 (15.71%) of the 1,960 primary sample. For regression analysis, data on 286 were analyzed after excluding those who did not answer the question about service utilization. However, this sample size was considered to have sufficient power since a sample size of 204 would still predict a prevalence of 15.71%, with a precision of 95% and 95% CI.\u003c/p\u003e\n\u003ch2\u003eData collection and tools\u003c/h2\u003e\n\u003cp\u003eThe demographic characteristics and the Child \u0026amp; Adolescent Symptom Inventory-5 (CASI-5) were used for data collection. Face-to-face interviews were conducted by Psychiatric Clinical Officers (PCOs). PCOs are trained and able to conduct mental health diagnoses. The CASI-5 has over 100 questions to capture the frequency of various symptoms for 24 emotional and behavioral disorders. In each section of the CASI-5, respondents were asked about how often the symptoms impair social or behavioral functions. The data collection process took place between June and November 2017.\u003c/p\u003e\n\u003ch2\u003eStudy measures and variable measurement\u003c/h2\u003e\n\u003cp\u003eDependent variables: The dependent variable was utilization of traditional medicine for mental illness. This was assessed at two levels by self-reporting. First, the respondents were asked if they had ever had mental illness with \u003cem\u003eYes\u003c/em\u003e and \u003cem\u003eNo\u0026nbsp;\u003c/em\u003eresponse options. For those who answered yes, they were asked what kind of treatment they sought with options of i) traditional medicine or ii) Western medicine.\u003c/p\u003e\n\u003cp\u003eCovariates:\u003cem\u003e\u0026nbsp;\u003c/em\u003eThese included demographic variables and\u003cem\u003e\u0026nbsp;\u003c/em\u003epresence of symptoms of various behavioral and emotional disorders. Demographic variables were sex (female/male), age (categorized in two groups i.e. 12-15 and 16-18 years), residence (rural/urban), family history of mental illness (yes/no), and level of education [Advanced (A\u0026rsquo;) or Ordinary (O\u0026rsquo;) level]. In addition to these variables, the nature of housing (permanent/ semi-permanent/hut), presence of domestic violence in the home (yes/no), and orphanhood (at least one parental death/both parents living) were used to measure hardship experiences. School characteristics were also assessed including sex status (mixed boys and girls or single sex school) and school ownership (private/government).\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOther covariates considered were having at least one behavioral and emotional disorder as measured using CASI-5.\u003cem\u003e\u0026nbsp;\u003c/em\u003eA Likert scale with values 0 = Never, 1 = Sometimes, 2 = Often, 3 = Very Often was used to quantify the participants\u0026rsquo; responses to the CASI-5 survey. In this study, we considered those with responses of at least 2 (Often or Very Often) to have the symptoms. We also used the DSM-5 guidelines to classify the presence of symptoms of emotional or behavioral disorders(19) as described in a prior study conducted among school-going adolescents(20). Generally, for this analysis, the emotional disorders included major depressive disorder, generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder. The behavioral disorders included attention deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder. A person was considered to have emotional or behavioral disorder symptoms if they were found to meet the criteria for at least one of the disorders under each of these categories.\u003c/p\u003e\n\u003ch2\u003eStatistical Analysis \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eFirst frequencies and percentages of the respondents were computed for each variable. Next, carried out bivariate analysis using modified Poisson regression to assess the associations between covariates (hardship experiences, demographic characteristics, school features and emotional or behavioral disorders) and utilization of traditional medicine. Modified Poisson regression which yields prevalence ratios (PR) instead of odds ratios was used because it is considered more conservative when the outcome is common(21, 22) and the prevalence of traditional medicine utilization (48.6%) was high. Backwards elimination was applied to build our final analytic model and only variables that had a p-value \u0026le; 0.2 at bivariate analysis were considered at the multivariable regression stage. Collinearity between independent variables was assessed using pairwise correlation analysis. Statistical significance was considered at p\u0026lt;0.05 and 95% confidence intervals are reported. Data were analyzed using StataNow/SEv14 (StataCorp LLC College Station Texas 77845).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants socio-demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 1, there were slightly more females (53.31%) than males (46.69%) with average age of 15.45 years (SD \u0026plusmn; 1.88), and the majority were aged 15-18 years (71.57%). Overall, 17.61% of students were orphans; among those most had lost only their father (48.08%) or mother (40.38%) \u0026nbsp;with only 6 students (11.5%) having lost both the mother and father. Most participants (92.54%) had attained the ordinary level of secondary education, while 42.6% of the parents had attained advanced/high school education. The majority (74.50%) were from the Central region, and 53.97% lived in urban areas. Most participants (78.23%) lived in permanent houses and 33.57% reported presence of domestic violence in the home. The mean monthly family income was 171.82 USD (SD\u0026plusmn;343.4), with 58.82% earning \u0026le;100 USD monthly and majority of parents or guardians (57.29%) were small business owners. Nearly half (49.82%) reported a family history of mental illness and 25.83% of participants had at least one behavioral disorder or at least one emotional disorder (21.19%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Participants socio-demographic characteristics\u0026nbsp;(N=302)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 477px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e141 (46.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e161 (53.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eAge category, years (M=15.45, SD=1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003e19-22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e15 (5.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003e15-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e214 (71.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003e10-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e70 (23.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eLevel of education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eAdvanced level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e22 (7.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eOrdinary level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e273 (92.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eEastern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e77 (25.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eCentral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e225 (74.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eUrbanity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e139 (46.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e163 (53.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eNature of housing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003ePermanent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e230 (78.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eSemi-permanent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e64 (21.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eDomestic violence in the home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e96 (33.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e190 (66.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOrphan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e53 (17.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e248 (82.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOrphan type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eLost both mother and father\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e6 (11.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eOnly mother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e21 (40.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eOnly father\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e25 (48.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eParent\u0026apos;s education level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e37 (13.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eElementary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e29 (10.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e118 (42.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eCollege/ university\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e93 (33.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eFamily history of mental illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e138 (49.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e139(59.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eFamily\u0026apos;s total monthly income (USD)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e171.82 (\u0026plusmn;343.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e83.3 (2.8 - 2,639)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eFamily\u0026apos;s total monthly income (USD)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003e\u0026le; 100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e39 (58.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003e\u0026gt;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e27 (40.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eParent or guardian\u0026rsquo;s employment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eProfessional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e33 (11.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eCasual laborer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e22 (7.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eTeacher\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e23 (7.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eSmall business owner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e165 (57.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e45 (15.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eHaving \u0026ge;1 behavioral disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e224 (74.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e78 (25.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eHaving \u0026ge;1 emotional disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e238 (78.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 231px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e64 (21.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Uganda shillings (UGX) to United States Dollar (USD) rate of 1USD=3,600UGX was used. M=Mean. SD=Standard Deviation, Mdn=Median\u003c/p\u003e\n\u003cp\u003eAs shown in Table 2, almost half (48.6%) of the participants had utilized traditional medicine. After statistical adjustment, only the location of the school in terms of being urban or rural and parent or guardian\u0026rsquo;s education level were independently associated with traditional medicine utilization. The prevalence of traditional medicine utilization among those who went to rural schools was 1.3 times that among those who went to urban schools [aPR:1.30(95%CI 1.01-1.68), p=0.04]. The prevalence of traditional medicine utilization among those whose parents or guardians completed college/ university was 38% lower compared to those whose parents or guardians had no formal education [aPR:0.62(95% CI 0.41-0.94), p=0.025].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Bivariate and multivariable analysis of correlates of traditional medicine utilization (N=286)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTraditional medicine utilization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ecPR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eaPR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u0026nbsp;\u003c/strong\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u0026nbsp;\u003c/strong\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eAge category, years (M=15.45, SD=1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e10-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e40(28.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e26(18.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e15-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e94(67.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e110(76.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.20(0.59-2.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e19-22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e5(3.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e8(5.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.60(0.77-3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eCentral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e105(75.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e105(71.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eEastern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e34(24.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e42(28.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.89(0.67-1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNature of housing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ePermanent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e104(76.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e116(81.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eSemi-permanent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e32(23.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e27(18.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.15(0.87-1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eDomestic violence in the home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e47(36.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e43(30.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e83(63.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e98(69.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.88(0.68-1.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eOrphan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e118(84.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e117(80.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e21(15.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e29(19.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.84(0.59-1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eOrphan type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eBoth parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3(14.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3(10.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eOnly mother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e9(42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12 (41.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.86(0.33-2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eOnly father\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e9(42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14(48.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.78(0.30- 2.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eFamily history of mental illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e66(51.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e67(48.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e61(48.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e70(51.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.94(0.73-1.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eFamily\u0026apos;s total monthly income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026le; 100USD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e15(60.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e23(58.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026gt;100USD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e10(40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e16(41.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.97(0.52-1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eHaving \u0026ge;1 behavioral disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e106(76.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e106(72.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e33(23.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e41(27.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.89(0.67-1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eHaving \u0026ge;1 emotional disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e113(81.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e113(76.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e26(18.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e34(23.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.87(0.63- 1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e59(42.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e74(50.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e80(57.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e73(49.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.18(0.92-1.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.17(0.91-1.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eLevel of education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAdvanced level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e6(4.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14 (9.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eOrdinary level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e129(95.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e130(90.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.66(0.84-3.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.40(0.70-2.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eUrbanity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e65(46.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e90(61.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e74(53.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e57(38.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.34(1.06-1.71)**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.30(1.01-1.68)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eParent or guardian\u0026rsquo;s education level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e22(17.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e13(9.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eElementary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e11(8.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e18(13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.60(0.35-1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.69(0.41-1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e57(44.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e52(38.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.83(0.60-1.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.89(0.64-1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eCollege/ University\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e38(29.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e52(38.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.67(0.47-0.95)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.62(0.41-0.94)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eParent or guardian\u0026rsquo;s employment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eProfessional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14(10.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e16(11.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eCasual laborer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e6(4.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e16(11.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.58(0.27-1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.57(0.26-1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eTeacher\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e11(8.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e11(7.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.07(0.61-1.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.11(0.63-1.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eSmall business owner\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e78(58.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e79(56.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.06(0.70-1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.88(0.58-1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e24(18.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e19(13.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.19(0.75-1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.95(0.60-1.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ecPR\u003c/strong\u003e: crude prevalence ratio; \u003cstrong\u003eaPR\u003c/strong\u003e: adjusted prevalence ratio *p\u0026le;0.04; **p\u0026le;0.025\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study revealed that nearly half (48.6%) of school-going adolescents and young people with self-reported mental health conditions utilized traditional medicine. Though we did not assess decision making in this study, it is most likely that for adolescents who are considered minors, their parents and guardians influence their healthcare utilization choices. Therefore, this discussion is based on that assumption. This high prevalence is not a surprise since studies in other African countries indicate that traditional medicine is often seen as more culturally appropriate and accessible than biomedical care(\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Therefore, our findings are particularly of concern given that adolescence is a growth phase where untreated mental health conditions can have long-term consequences on academic achievement, social functioning, and overall development(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Though we did not explore dual utilization of TM and biomedical care, findings from systematic reviews also indicate that traditional medicine is often used alongside biomedical treatments(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite this, the high prevalence of TM utilization underscores the need to promote use of biomedical medicine since there are many effective mental health treatments and therapies especially when healthcare is timely sought. Dependance on TM may lead to delayed healthcare seeking, and thus exacerbate mental health related challenges among adolescents and young people. Most traditional practices applied in traditional mental health care lack scientific evidence(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In addition, some of the TM practices have been linked to human rights and physical abuses including chaining patients and starving of patients(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) through food restriction and forced fasting(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Alternatively, the known TM preference could be leveraged to engage providers to offer basic psychosocial support to patients and as a channel to formal health care referral. This may help prevent late healthcare seeking behavior among adolescents and young people with mental conditions. Improved health care utilization has been reported where such engagements have been leverage, for example referral of expectant mothers by traditional birth attendants is reported to improve skilled birth attendance(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe prevalence of TM utilization among those who went to rural schools was 1.3 times that among those who went to urban schools. This is in line with findings from Ethiopia and Nigeria which also reported higher TM utilization in rural areas compared to urban areas(\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). One reason for this could be the possible traditional beliefs among people in rural areas, and limited access to biomedical care. Other researchers have also reported that traditional healers are a very much used source of mental healthcare, especially in areas with limited and unaffordable biomedical mental health services like in sub-Saharan Africa (SSA)(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). It has also been reported that rural areas in Africa possess strong beliefs in TM with even a perception that most traditional medicines are better and more effective for some conditions (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Such beliefs may facilitate more trust in TM than biomedical care just as other scholars have reported(\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Health facilities may need to consider integrating mental health services into outreaches to serve rural areas. Targeted health education with emphasis on the dangers of TM since some traditional medicines have been found to have harmful side effects(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) resulting from herbal constituents, contamination, or adulteration(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) may also be important for the population.\u003c/p\u003e \u003cp\u003eThe prevalence of TM utilization among those whose parents or guardians completed college/university was 38% lower compared to those whose parents or guardians had no formal education. Though there have been mixed findings about the relationship between parent\u0026rsquo;s education level and TM utilization(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), most studies align with our findings(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) while others are contrary(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Higher TM use among those with low or no formal education could be attributed to possible higher health literacy among more educated parents which may counter possible beliefs in TM. Initiatives focused on promoting biomedical healthcare for mental health conditions should target such populations with lower formal levels of education. Contextualized approaches including use of translated education media that is culturally responsive as well as alternative health promotion approaches would be important.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study may have been affected by social desirability bias. Some studies have indicated that non-disclosure of TM use is very common(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and this could have affected our results. This analysis was based on secondary data analysis, and we did not assess decision making in this study which may have helped us to interpret our findings more authoritatively. We also did not explore dual utilization of TM and biomedical care, and social-cultural factors yet these could have been important to our discussion and conclusion. In addition, the age category of 19\u0026ndash;22 years was underrepresented meaning that these results may only be interpreted in the context of adolescents. Nevertheless, this is one of the few studies focused on TM utilization for mental health among school going adolescents in Uganda.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA large proportion of adolescents in secondary schools with a self-reported mental condition utilized traditional medicine, influenced by rural residence, and parents\u0026rsquo; education status. The high prevalence of traditional medicine use emphasizes the need for promoting biomedical healthcare to ensure timely and effective treatment for mental health conditions. Addressing traditional medicine use, particularly among rural populations and those with lower education levels may require increased access to quality mental healthcare, and education about biomedical treatments. Education focused on mindset change may also facilitate transition from utilization of TM to biomedical healthcare. More research among adolescents should focus on assessment of the effect of social-cultural factors on traditional medicine utilization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Makerere University School of Medicine Research Ethics Committee (SOMREC). Permission to conduct the study was also obtained from the Uganda National Council for Science and Technology (UNCST). All respondents provided informed consent to participate in the study. Confidentiality and privacy were maintained throughout the research process.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe acknowledge the District Education Officers (DEOs), schools\u0026rsquo; management, and research assistants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was funded in part by the Swedish International Development Cooperation Agency (Sida) and Makerere University under Sida contribution No: 51180060.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConceptualization: CA, AK, RA; Methodology: CA, AK, RA; Writing \u0026ndash; original draft: AK; Writing \u0026ndash; review \u0026amp; editing: AK, CA, RA, MB, JD-G, LDC, RK. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eInstitute for Health and Humanity, Medical College of Wisconsin, Milwaukee, WI 53226, USA.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eMakerere University College of Health Sciences, Uganda.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eUganda Martyrs University, Uganda.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eMinistry of Health, Uganda.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors consented to publish this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLiu L, Villavicencio F, Yeung D, Perin J, Lopez G, Strong KL, et al. 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Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review. BMJ global health. 2018;3(5):e000895.\u003c/li\u003e\n \u003cli\u003eAe-Ngibise K, Cooper S, Adiibokah E, Akpalu B, Lund C, Doku V, et al. \u0026lsquo;Whether you like it or not people with mental problems are going to go to them\u0026rsquo;: A qualitative exploration into the widespread use of traditional and faith healers in the provision of mental health care in Ghana. International Review of Psychiatry. 2010;22(6):558-67.\u003c/li\u003e\n \u003cli\u003eByrne A, Morgan A. How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance. International Journal of Gynecology \u0026amp; Obstetrics. 2011;115(2):127-34.\u003c/li\u003e\n \u003cli\u003eFlatie T, Gedif T, Asres K, Gebre-Mariam T. Ethnomedical survey of Berta ethnic group Assosa Zone, Benishangul-Gumuz regional state, mid-west Ethiopia. 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Impact of Traditional Medicine Integration with Modern Healthcare in Africa. 2024.\u003c/li\u003e\n \u003cli\u003eErnst E. Serious psychiatric and neurological adverse effects of herbal medicines -- a systematic review. Acta psychiatrica Scandinavica. 2003;108(2):83-91.\u003c/li\u003e\n \u003cli\u003eNxumalo N, Alaba O, Harris B, Chersich M, Goudge J. Utilization of traditional healers in South Africa and costs to patients: Findings from a national household survey. Journal of Public Health Policy. 2011;32(1):S124-S36.\u003c/li\u003e\n \u003cli\u003eChintamunnee V, Mahomoodally MF. Herbal medicine commonly used against non-communicable diseases in the tropical island of Mauritius. Journal of Herbal Medicine. 2012;2(4):113-25.\u003c/li\u003e\n \u003cli\u003eLadele A, Bisi-Amosun O. Level of utilization of traditional and orthodox medicines by rural dwellers in Ile-Ogbo Community of Osun State, Nigeria. Journal of Agricultural Extension. 2014;18(1):155-68.\u003c/li\u003e\n \u003cli\u003eME B. Alternative medicine use among workers in an urban setting in North-Central Nigeria. Prevalence.31:0.319.\u003c/li\u003e\n \u003cli\u003eUsifoh S, Udezi A. Social and economic factors influencing the patronage and use of complementary and alternative medicine in Enugu. Journal of Pharmacy \u0026amp; Bioresources. 2013;10(1):17-24.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prevalence, traditional medicine, mental health, adolescents, behavioral health","lastPublishedDoi":"10.21203/rs.3.rs-6559755/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6559755/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Mental health disorders among adolescents and young people are a big public health concern, particularly in low- and middle-income countries. Despite the growing burden, access to conventional mental healthcare remains limited. We investigated the correlates of traditional medicine (TM) utilization among students with self-reported mental health disorders in Uganda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eIn this cross-sectional study, we analyzed secondary data from a subsample of 302 students with self-reported history of a mental health disorder out of a sample of 1970 who completed the survey. In the primary study, stratified random sampling was used to select schools, and participants were selected proportionally. We used modified Poisson regression to examine the factors independently associated with TM use including demographic characteristics and the presence of emotional or behavioral disorders. Statistical significance was set at a p-value of less than 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eMost participants were female (53.31%) and aged between 15 and18 years (71.57%). The majority of were in ordinary level of secondary education (92.54%), came from the Central region (74.50%) and attended schools in urban areas (53.97%). The median monthly family income was $83.3, with over half earning ≤$100 monthly (58.82%). Nearly half of the participants reported a family history of mental illness (49.82%), and a notable percentage had at least one behavioral disorder (25.83%) or emotional disorder (21.19%). The adjusted model suggested that rural school attendees had a 1.3 times higher prevalence of TM utilization [aPR:1.30(1.01-1.68), p=0.04] compared to urban ones, and those with parents or guardians who completed college/university had a 38% lower prevalence [aPR:0.62(0.41-0.94), p=0.025] of TM utilization compared to those with parents or guardians without formal education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eA large proportion of the students utilized TM, largely influenced by rural residence, and parents’ education status. The high prevalence of TM use emphasizes the need for promoting biomedical healthcare to ensure timely and effective treatment for mental health conditions with a focus on socio-economic disparities.\u003c/p\u003e","manuscriptTitle":"Correlates of traditional medicine utilization among school-going adolescents and young people with mental health disorders in central and eastern Uganda: a cross-sectional survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 11:18:00","doi":"10.21203/rs.3.rs-6559755/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-12T03:24:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T09:24:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32610908779859369498361404572543240964","date":"2025-11-12T06:59:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-16T02:36:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129296168662248469071660973370438309651","date":"2025-08-04T05:03:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-05T03:16:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-21T11:08:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-13T12:38:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-13T12:33:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2025-04-29T23:10:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d8aa5cd-336b-4a06-b179-15720af7f6aa","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T02:25:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 11:18:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6559755","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6559755","identity":"rs-6559755","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}