JMIR Publications

ABSTRACT

Background:

Teenage pregnancy and early marriage remain persistent public health and human rights concerns in rural Uganda, which has one of the highest teenage pregnancy rates in the world, at approximately 25 percent among women aged 15 to 19. These concerns are particularly pronounced in the Bunyoro sub-region (Kikuube, Kagadi, Kibaale, and Kakumiro Districts), where the neighbouring Hoima district has recorded prevalence of 27 to 30.6 percent, with early marriage identified as one of the strongest independent predictors. These districts combine agrarian and lake-shore fishing economies, active oil and gas development, and refugee hosting, notably the Kyangwali settlement in Kikuube, where poverty, sexual exploitation, early pregnancy, and school dropout among adolescent girls are well documented. Identification and referral of affected adolescents remain largely informal, relying on verbal communication among Village Health Teams (VHTs), Local Council (LC) leaders, and formal service providers, with no standardised or trackable reporting mechanism. A further barrier is the risk of case suppression through local-level collusion, bribery, or undue influence, which community-based reporting systems relying solely on the same local actors risk reproducing rather than addressing. A substantial proportion of cases are believed to go entirely unreported to any formal authority. This protocol treats underreporting itself as a primary problem, while recognising that any observed increase in formally recorded cases reflects improved case ascertainment rather than direct proof of a change in true underlying incidence. Digital, offline-first data-collection tools have been recommended by the World Health Organization to strengthen health-system reporting in settings with inconsistent connectivity, offering a mechanism to formalise and structurally protect a reporting pathway that currently depends entirely on informal, verbal communication.

Objective:

Objectives The general objective is to develop, pilot, and evaluate a community-based digital reporting and referral system for teenage pregnancy and early marriage in the Bunyoro sub-region, Uganda, with structural safeguards against case suppression and undue local influence. The specific objectives are to: 1. Co-design, with VHTs, LC leaders, and district-level referral actors, a structured digital reporting tool and escalation protocol appropriate to the study context. 2. Pilot the system across a defined set of parishes in Kikuube, Kagadi, Kibaale, and Kakumiro Districts. 3. Assess whether the system increases the total number of teenage pregnancy and early marriage cases formally identified and recorded, as an indicator of improved case ascertainment. 4. Assess the effect of the system on referral timeliness, antenatal care linkage, and completeness of follow-up, relative to pre-implementation baseline practice. 5. Evaluate the functioning and measurable effectiveness of the system's structural safeguards against case suppression and collusion. 6. Assess the feasibility, acceptability, and usability of the system among VHTs, LC leaders, and district officers, and generate recommendations for wider-scale, sustainable deployment.

Methods:

This is a mixed-methods implementation research study combining a pre-post quantitative comparison of case ascertainment, referral timeliness, and antenatal care linkage with a Consolidated Framework for Implementation Research (CFIR)-structured qualitative process evaluation. The system will be piloted through a staged rollout, beginning with 8 to 10 parishes in Kikuube and Kagadi Districts (Phase A) before expanding to Kibaale and Kakumiro Districts (Phase B). Monthly parish-level case counts and referral outcomes will be analysed using clustered regression approaches, while implementation processes and safeguard functioning will be evaluated through a CFIR-guided qualitative assessment.

Results:

This protocol has been developed and is being prepared for ethical and regulatory review. No participants have yet been enrolled, no baseline data collection has commenced, and no case or outcome data have been generated. Implementation is anticipated to occur over 24 months across four phases.

Conclusions:

If demonstrated to be feasible and acceptable, this system is expected to generate structured, real-time data on formally identified teenage pregnancy and early marriage cases in the Bunyoro sub-region, and to provide an evidence base and costed pathway for a subsequent, adequately powered comparative effectiveness trial and wider-scale, government-owned deployment Clinical Trial: This is an implementation pilot rather than a randomised controlled trial; it will nonetheless be prospectively registered on a suitable public registry prior to participant enrolment. Not yet registered.