Violent Discipline in North Kivu, Democratic Republic of Congo: The Role of Child Gender and Disability Status in Cross-sectional Analysis.

INTRODUCTION: Violence is used to punish or educate children across the world, with detrimental effects on their physical, emotional, and social health that persist into their adulthood. This study aimed to understand the use of violent discipline by caregivers in conflict-affected communities and how it varied by the child's gender and disability level. METHODS: Using cross-sectional data collected from 394 respondents (196 men and 198 women) in North Kivu, Democratic Republic of Congo, logistic generalized estimating equations stratified by gender assessed the association between past-three-month perpetration of violent discipline, caregiver demographics, conflict experiences, and disability attitudes, as well as child demographics of age, gender, disability level, and the interaction of gender and disability. RESULTS: Compared to women with boy children with no disability, odds of perpetration of violent discipline were higher among those with girl children with no disability (aOR: 2.24; 95%CI: 1.11-4.51) and boy children with moderate or severe disability (aOR: 2.91; 95%CI: 1.14-7.33), and the interaction of girl children with a moderate or severe disability showed a 7.80 increase in odds of perpetration; however, association with women's discriminatory disability attitudes was not significant. In contrast, the interaction of child gender and disability level were not significantly associated with perpetration of violent discipline for men, but disability attitudes were significantly associated (aOR: 1.07; 95%CI: 1.00-1.15). DISCUSSION: Results suggest that levels of violence in conflict-affected households in North Kivu, DRC are high, with women reporting higher levels of violent discipline overall, and amplified use of violence against girl children with disabilities. More research and programs with an intersectional lens are needed in conflict settings to better understand and address the use of violent discipline and underlying discriminatory norms around gender and disability.

SIGNIFICANCE: Violence against children in the home varies by gender and disability level. Evidence from predominantly Global North contexts demonstrates that children with disabilities are more likely to experience violence, with heightened risk for girls. Among conflict-affected communities in DRC, women had higher odds of using violence against girls and children with disabilities, and even higher for girl children with disabilities. Violence perpetration was also associated with the caregivers' conflict experiences. This suggests that to strengthen violence prevention in conflict settings, research and programs must be more accessible to and inclusive of people with disabilities and address inequitable gender norms.

Preventing Co-occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Role of Family Functioning and Programmatic Reflections.

Co-occurring intimate partner violence (IPV) and child abuse occur at staggering levels in eastern Democratic Republic of Congo (DRC), yet little is known about the relationship between these forms of violence and a feminst-grounded conceptualization of family functioning nor how best to programmatically address these multiple forms of violence in the home. Analysis of cross-sectional baseline data from 203 adult couple dyads participating in a randomized controlled trial was undertaken to (1) understand the correlation of family functioning and violence in the home in North Kivu, DRC; (2) unpack potential shared correlates of violence in the home and family functioning, such as attitudes and behaviors; and (3) describe programmatic implications for delivering violence prevention programming that seeks to address multiple forms of violence in the home. Findings suggest over half of all families reported experiencing IPV against women or use of child abuse by any caregiver. Moderate levels of family functioning were also reported, although women reported lower levels. In adjusted models, a one-point change in family functioning score was associated with a 0.12 reduction in odds of co-occurring experience of IPV and use of child abuse for women, and a 0.03 reduction in odds of co-occurring perpetration for men. A focus on improving family functioning as a primary outcome, alongside explicit targeting of harmful gender norms and skills-based approaches, may be a promising avenue to integrate approaches from different violence prevention fields while maintaining a strong dedication to intersectional feminist-grounded approaches that allows for separate, but at times combined, approaches to reducing IPV and child abuse in the home.

Co-Occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Influence of Early Life Experiences of Abuse.

Little is known about co-occurring intimate partner violence (IPV) against women and child abuse within families in humanitarian settings. Baseline data from 203 couples in eastern Democratic Republic of Congo were analyzed to assess associations between childhood experiences of abuse with present co-occurring violence. Over half of women (56.1%) and men (50.5%) reported co-occurring violence. Adjusted models demonstrate experiencing physical abuse as a child was associated with greatest odds of recent co-occurring violence while witnessing parental IPV had mixed influence. Programmatic approaches focused on reducing early childhood violence may be promising to prevent both IPV and child abuse.

Developing an Inclusive Conceptual Model for Preventing Violence in the Home in Humanitarian Settings: Qualitative Findings From Myanmar and the Democratic Republic of Congo.

This qualitative study sought to explore the shared risk factors and social norms that may underpin the co-occurrence of intimate partner violence, child maltreatment, and violence against other marginalized household members in the home. Data are drawn from participants who completed either in-depth interviews (N = 51 men, N = 52 women participants) or focus groups (N = 22 men, N = 23 women participants) and were living in two distinct humanitarian settings: North Kivu, Democratic Republic of the Congo, and Northern Shan State and Southern Kachin State, Myanmar. Within this overarching objective, attention to these shared drivers for violence in the home, which may arise from people having multiple and interacting social identities, such as disability status, gender, and age, was explored through an inclusion lens and inductive coding approaches. Findings point to risk factors of violence in the home at all levels of the ecological model, which are underpinned at the macro level by gender inequality, armed conflict, and political instability, among other factors. With the community and family levels, gender inequality manifested in norms related to the acceptability of violence, family reputation, and aged and gendered power hierarchies within the home. Shared risk factors of violence at these levels also included displacement/migration-related stressors, inconsistent income, and lack of community resources to support families, especially for those with disabilities. At the most time-proximal level, interactions between role (non)fulfillment, inability of families to meet their basic needs, alcohol and substance abuse, and abusive expressions of anger were found to catalyze instances of violence in the home. The conceptual model also illuminates potential levers and inclusive entry points that prevent violence in the home for diverse women, children, persons with disabilities, and older persons. Key attention to addressing gender inequality and acceptance of violence must be a cornerstone of sustainable programming, alongside complementary approaches that address other shared risk factors.

Learner Levels of Supervision Across the Continuum of Pediatrics Training.

PURPOSE: To describe trajectories in level of supervision ratings for linked entrustable professional activities (EPAs) among pediatric learners in medical school, residency, fellowship. METHOD: The authors performed secondary analyses of 3 linked datasets of level of supervision ratings for the Core EPAs for Entering Residency, the General Pediatrics EPAs, and the Subspecialty Pediatrics EPAs. After identifying 9 activities in common across training stages and aligning the level of entrustment-supervision scales across the datasets, piecewise ordinal and linear mixed effects models were fitted to characterize trajectories of supervision ratings. RESULTS: Within each training period, learners were rated as needing less supervision over time in each activity. When transitioning from medical school to residency or during the first year of residency, learners were rated as needing greater supervision in activities related to patient management, teamwork, emergent care, and public health/QI than in earlier periods. When transitioning from residency to fellowship, learners were always rated as needing greater supervision than they had been accorded at the end of residency and sometimes even more than they had been accorded at the start of residency. CONCLUSIONS: Although development over training is often imagined as continuous and monotonically increasing competence, this study provides empirical evidence supporting the idea that entrustment is a set of discrete decisions. The relaxation of supervision in training is not a linear process. Even with a seamless curriculum, supervision is tightly bound to the training setting. Several explanations for these findings are discussed.

Narrative Performance Level Assignments at Initial Entrustment and Graduation: Integrating EPAs and Milestones to Improve Learner Assessment.

PURPOSE: To determine which narrative performance level for each general pediatrics entrustable professional activity (EPA) reflects the minimum level clinical competency committees (CCCs) felt should be associated with graduation as well as initial entrustment and compare expected narrative performance levels (ENPLs) for each EPA with actual narrative performance levels (ANPLs) assigned to residents at initial entrustment. METHOD: A series of 5 narratives, corresponding to the 5 milestone performance levels, were developed for each of the 17 general pediatrics EPAs. In academic year (AY) 2015-2016, the CCCs at 22 Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network member sites reported ENPLs for initial entrustment and at time of graduation. From AYs 2015-2016 to 2017-2018, programs reported ANPLs for initial entrustment decisions. ENPLs and ANPLs were compared using a logistic mixed effects model. RESULTS: ENPLs for graduation and entrustment were most often level 3 (competent) followed by level 4 (proficient). For 8 EPAs, the ENPLs for graduation and entrustment were the same. For the remaining 9, some programs would entrust residents before graduation or graduate them before entrusting them. There were 4,266 supervision level reports for initial entrustment for which an ANPL was provided. ANPLs that were lower than the ENPLs were significantly more likely to be assigned to the medical home-well child (OR = 0.39; 95% CI: 0.26-0.57), transition to adult care (OR = 0.43; 95% CI: 0.19-0.95), behavioral or mental health (OR = 0.36; 95% CI: 0.18-0.71), make referrals (OR = 0.31; 95% CI: 0.17-0.55), lead a team (OR = 0.34; 95% CI: 0.22-0.52), and handovers (OR = 0.18; 95% CI: 0.09-0.36) EPAs. CONCLUSIONS: CCCs reported lower ENPLs for graduation than for entrustment for 5 EPAs, possibly indicating curricular gaps that milestones and EPAs could help identify.

Discovering the Benefits of Group Peer Review of Submitted Manuscripts.

Problem: Traditionally, journal editors expect individuals to complete peer reviews of submitted manuscripts on their own. Recently, a number of editors of health sciences journals have begun to support, and even espouse, the practice of group peer review (GPR). With GPR, multiple individuals work together to complete the review with permission from the journal editor. Motivated by the idea that GPR could provide a meaningful service learning experience for participants in an interprofessional educational scholarship course, we conducted three such reviews and subsequently reflected on our experience and the lessons we learned. We frame our reflections using guiding principles from the domains of peer review, professional development, and educational scholarship. Intervention: The course director arranged for manuscripts to review with the editors of three health sciences journals. Each GPR occurred during a separate weekly session of the course. Each GPR was completed using a similar set of steps, which included (a) gaining familiarity with review criteria, (b) reading aloud and discussing the manuscript's abstract as a class, (c) reading and critiquing assigned sections as individuals and then small groups, (d) building consensus and sharing notes, (e) having the course director synthesize notes into a single review for submission to the journal. Context: The course on educational scholarship involved 15 faculty representing faculty from the University of Utah's School of Medicine, College of Nursing, College of Pharmacy, College of Health, and School of Dentistry. The course director led three GPR sessions mid-way through the yearlong course. Impact: Participants' reflections indicate that GPR (a) conformed to principles of effective peer review; (b) resulted in a meaningful service learning experience within a formal professional development program, deepening understanding of core concepts of educational scholarship; and (c) represented an authentic example of engaging in educational scholarship (i.e., designing and evaluating an intervention while drawing upon and contributing to a body of shared understanding within a community of practice). Lessons Learned: Our principles-based approach to completing GPR within a professional development course on educational scholarship can serve as a model for others to follow. A rigorous, meaningful group review can occur in 1 hour using a combination of group and individual activities focused on matching review criteria to the submitted manuscript. As a result, we continue to include GPR in future offerings of this interprofessional course on educational scholarship, and we continue to study ways to optimize its value as a service learning experience.

Quantifying photo-production of triplet excited states and singlet oxygen from effluent organic matter.

The organic matter present in wastewater effluents (EfOM), is likely to have different properties than the organic matter present in the receiving water. The properties of EfOM will affect the fate of contaminants of emerging concern because EfOM is a source of photochemically produced reactive intermediates (PPRIs) capable of transforming contaminants. Effluent water samples were taken seasonally from sixteen wastewater treatment plants in Minnesota and two effluent dominated rivers in California and Arizona. Samples (n = 94) were tested for water chemistry, light absorption characteristics, and excited state triplet organic matter (3EfOM∗) and singlet oxygen (1O2) production. Based on analysis of spectral parameters, EfOM had higher molecular weight and lower aromatic content than organic matter present in stormwaters from Minnesota, which are representative of human-impacted natural organic matter (NOM) containing waters. The second order rate constant for the reaction of the 3EfOM∗ probe 2,4,6-trimethylephenol (kT,TMP) for the effluents was 7.79 (±3.03) × 108 M-1s-1, and this value was used to calculate apparent quantum yields for 3EfOM∗ production, which ranged from 0.006 to 0.114. The quantum yield for the production of singlet oxygen ranged from 0.007 to 0.064. Processes in the wastewater treatment train, season, and water chemistry parameters did not serve as predictors of 3EfOM∗ or 1O2 production. Among the parameters measured, Spearman rank correlations were strongest between quantum yields of 1O2 and 3EfOM∗ and E2/E3 (absorption at 250 nm/absorption at 365 nm). This relationship, however, is weaker than that previously observed for NOM. The efficiency of 1O2 production from 3EfOM∗ was 54%. Results indicate that 2,4,6-trimethylphenol samples nearly all of the triplets in EfOM that have sufficient energy to produce 1O2, which may not be the case for NOM.

Crossing the Gap: Using Competency-Based Assessment to Determine Whether Learners Are Ready for the Undergraduate-to-Graduate Transition.

In 2011, the Education in Pediatrics Across the Continuum (EPAC) Study Group recruited four medical schools (University of California, San Francisco; University of Colorado; University of Minnesota; and University of Utah) and their associated pediatrics clerkship and residency program directors to be part of a consortium to pilot a model designed to advance learners from undergraduate medical education (UME) to graduate medical education (GME) and then to fellowship or practice based on competence rather than time spent in training. The central design features of this pilot included predetermined expectations of performance and transition criteria to ensure readiness to progress from UME to GME, using the Core Entrustable Professional Activities for Entering Residency (Core EPAs) as a common assessment framework. Using this framework, each site team (which included, but was not limited to, the EPAC course, pediatric clerkship, and pediatric residency program directors) monitored learners' progress, with the site's clinical competency committee marking the point of readiness to transition from UME to GME (i.e., the attainment of supervision level 3a). Two of the sites implemented time-variable transition from UME to GME, based on when a learner met the performance expectations and transition criteria. In this Article, the authors describe each of the four sites' implementation of Core EPA assessment and their approach to gathering the data necessary to determine readiness for transition. They conclude by offering recommendations and lessons learned from the pilot's first seven years of development, adaptation, and implementation of assessment strategies across the sites, and discussing next steps.

Retrospective evaluation of Project Envision: A community mobilization pilot program to prevent sexual violence in New York City.

Sexual violence is a public health problem associated with short- and long-term physical and mental health consequences. Most interventions that aim to prevent sexual violence before it occurs target individual-level change or promote bystander training. Community-level interventions, while increasingly recommended in the sexual violence prevention field, are rarely documented in peer-reviewed literature. This paper is a targeted process evaluation of Project Envision, a 6-year pilot initiative to address social norms at the root of sexual violence through coalition building and community mobilization in three New York City neighborhoods, and reflects the perspectives of those charged with designing and implementing the program. Evaluation methods included a systematic literature review, archival source document review, and key informant interviews. Three themes emerged from the results: community identity and implications for engagement; capacity and readiness for community mobilization and consequences for implementation; and impacts on participants. Lessons learned include the limitations of using geographic boundaries to structure community interventions in urban settings; carefully considering whether communities should be mobilized around an externally-identified issue; translating theoretical frameworks into concrete tasks; assessing all coalition partners and organizations for readiness; critically evaluating available resources; and recognizing that community organizing is a skill that requires investment from funders. We conclude that Project Envision showed promise for shifting institutional norms towards addressing root causes of sexual violence in addition to providing victim services.

Environmental photochemistry of dienogest: phototransformation to estrogenic products and increased environmental persistence via reversible photohydration.

Potent trienone and dienone steroid hormones undergo a coupled photohydration (in light)-thermal dehydration (in dark) cycle that ultimately increases their environmental persistence. Here, we studied the photolysis of dienogest, a dienone progestin prescribed as a next-generation oral contraceptive, and used high resolution mass spectrometry and both 1D and 2D nuclear magnetic resonance spectroscopy to identify its phototransformation products. Dienogest undergoes rapid direct photolysis (t1/2 ∼ 1-10 min), forming complex photoproduct mixtures across the pH range examined (pH 2 to 7). Identified products include three photohydrates that account for ∼80% of the converted mass at pH 7 and revert back to parent dienogest in the absence of light. Notably, we also identified two estrogenic compounds produced via the A-ring aromatization of dienogest, evidence for a photochemically-induced increase in estrogenic activity in product mixtures. These results imply that dienogest will undergo complete and facile photolytic transformation in sunlit surface water, yet exhibit greater environmental persistence than might be anticipated by inspection of kinetic rates. Photoproduct mixtures also include transformation products with different nuclear receptor binding capabilities than the parent compound dienogest. These outcomes reveal a dynamic fate and biological risk profile for dienogest that must also take into account the composition and endocrine activity of its transformation products. Collectively, this study further illustrates the need for more holistic regulatory, risk assessment, and monitoring approaches for high potency synthetic pharmaceuticals and their bioactive transformation products.

QSARs for phenols and phenolates: oxidation potential as a predictor of reaction rate constants with photochemically produced oxidants.

Quantitative structure-activity relationships (QSARs) for prediction of the reaction rate constants of phenols and phenolates with three photochemically produced oxidants, singlet oxygen, carbonate radical, and triplet excited state sensitizers/organic matter, are developed. The predictive variable is the one-electron oxidation potential (E1), which is calculated for each species using density functional theory. The reaction rate constants are obtained from the literature, and for singlet oxygen, are augmented with new experimental data. Calculated E1 values have a mean unsigned error compared to literature values of 0.04-0.06 V. For singlet oxygen, a single linear QSAR that includes both phenols and phenolates is developed that predicts experimental rate constants, on average, to within a factor of three. Predictions for only 6 out of 87 compounds are off by more than a factor of 10. A more limited data set for carbonate radical reactions with phenols and phenolates also gives a single linear QSAR with prediction of rate constant being accurate to within a factor of three. The data for the reactions of phenols with triplet state sensitizers demonstrate that two sensitizers, 2-acetonaphthone and methylene blue, most closely predict the reactivity trend of triplet excited state organic matter with phenols. Using sensitizers with stronger reduction potentials could lead to overestimation of rate constants and thus underestimation of phenolic pollutant persistence.

Reversible Photohydration of Trenbolone Acetate Metabolites: Mechanistic Understanding of Product-to-Parent Reversion through Complementary Experimental and Theoretical Approaches.

Photolysis experiments (in H2O and D2O) and quantum chemical calculations were performed to explore the pH-dependent, reversible photohydration of trenbolone acetate (TBA) metabolites. Photohydration of 17α-trenbolone (17α-TBOH) and 17ß-trenbolone (17ß-TBOH) occurred readily in simulated sunlight to yield hydrated products with incorporated H(+) at C4 and OH(-) at either C5 (5-OH-TBOH) or C12 (12-OH-TBOH) in the tetracyclic steroid backbone. Although unable to be elucidated analytically, theory suggests preferred orientations of cis-12-OH-TBOH (relative to C13 methyl) and trans-5-OH-TBOH, with the former most thermodynamically stable overall. Both experiment and theory indicate limited stability of trans-5-OH-TBOH at acidic pH where it undergoes concurrent, carbocation-mediated thermal rearrangement to cis-12-OH-TBOH and dehydration to regenerate its parent structure. Experiments revealed cis-12-OH-TBOH to be more stable at acidic pH, which is the only condition where its reversion to parent TBA metabolite occurred. At basic pH cis-12-OH-TBOH decayed quickly via hydroxide/water addition, behavior that theory attributes to the formation of a stable enolate resistant to dehydration but prone to thermal hydration. In a noteworthy deviation from predicted theoretical stability, 17α-TBOH photohydration yields major trans-5-OH-TBOH and minor cis-12-OH-TBOH, a distribution also opposite that observed for 17ß-TBOH. Because H(+) and OH(-) loss from adjacent carbon centers allows trans-5-OH-TBOH to dehydrate at all pH values, the presumed kinetically controlled yield of 17α-TBOH photohydrates results in a greater propensity for 17α-TBOH reversion than 17ß-TBOH. Additional calculations explored minor, but potentially bioactive, trenbolone analogs that could be generated via alternative rearrangement of the acidic carbocation intermediate.

Adolescent relationship violence: help-seeking and help-giving behaviors among peers.

Young people tend to disclose relationship violence experiences to their peers, if they disclose at all, yet little is known about the nature and frequency of adolescent help-seeking and help-giving behaviors. Conducted within a sample of 1,312 young people from four New York City high schools, this is the first paper to ask adolescent help-givers about the various forms of help they provide and among the first to examine how ethnicity and nativity impact help-seeking behaviors. Relationship violence victims who had ever disclosed (61%) were more likely to choose their friends for informal support. Ethnicity was predictive of adolescent disclosure outlets, whereas gender and nativity were not. Latinos were significantly less likely than non-Latinos to ever disclose to only friends, as compared to disclosing to at least one adult. The likelihood of a young person giving help to their friend in a violent relationship is associated with gender, ethnicity, and nativity, with males being significantly less likely than females to give all forms of help to their friends (talking to their friends about the violence, suggesting options, and taking action). Foreign-born adolescents are less likely to talk or suggest options to friends in violent relationships. This study also found that Latinos were significantly more likely than non-Latinos to report taking action with or on behalf of a friend in a violent relationship. This research shows that adolescents often rely on each other to address relationship violence, underlining the importance of adolescents' receipt of training and education on how to support their friends, including when to seek help from more formal services. To further understand the valuable role played by adolescent peers of victims, future research should explore both which forms of help are perceived by the victim to be most helpful and which are associated with more positive outcomes.

Visual diagnosis: 2-month-old girl with left eye swelling, profuse tearing.

Nasolacrimal duct (NLD) obstruction is the most common cause of persistent tearing in a child younger than 1 year. Other possible causes include congenital eyelid abnormalities, chemical irritation, trauma, occult foreign body, congenital or early-onset glaucoma, and conjunctivitis. • In addition to NLD obstruction signs, dacryocystoceles also present with swelling over the nasolacrimal sac. The swelling often has a bluish discoloration. • Management of NLD obstruction requires a conservative approach with observation and nasolacrimal massage because spontaneous resolution occurs in approximately 90% by age 6 months and in more than 99% by age 12 months. Referral to an ophthalmologist for children with persistent symptoms should be deferred until at least ages 6 to 9 months. • Because of the high risk of complications with dacryocystoceles, especially infection, these patients require urgent ophthalmology referral. • Acute dacryocystitis presents with erythema, swelling, warmth, and tenderness of the lacrimal sac. The infection must be identified and treated early to prevent complications, such as periorbital and orbital cellulitis, meningitis, brain abscess, and sepsis.

Traditional male ideology and service system involvement among drug-involved men who perpetrate intimate partner violence: a longitudinal study.

The purpose of this study is to examine the extent to which drug-involved men who perpetrate male-to-female intimate partner violence (IPV) are engaged with various formal service systems as well as whether adherence to traditional male ideologies-thought to drive perpetration of male-to-female IPV-affects help-seeking behavior. This study also seeks to redress a gap in the research literature stemming from the general reliance on batterers intervention programs to acquire samples of IPV perpetrators. A sample of 126 men receiving methadone maintenance treatment who reported perpetrating IPV against a female partner participated in this longitudinal study. A large majority (88%) of participants reported use of additional services beyond methadone treatment (e.g., medical, employment/ vocational, etc.). Using generalized linear modeling, we found that greater endorsement of traditional male ideologies significantly predicted lower subsequent service utilization overall, except for legal services, for which there was a significant positive association. These findings suggest targeted assessment and engagement strategies may be required to involve a greater number of drug-involved men who perpetrate IPV with a wider spectrum of health and social services.

Phonological awareness and language intervention in preschoolers from low socio-economic backgrounds: a longitudinal investigation.

This study examines the literacy outcomes for children from socially disadvantaged backgrounds who had received specific whole-class phonological awareness (PA) and language intervention in preschool. The participants were 57 children who had been involved in the original intervention study. Their PA skills, letter-sound knowledge, real word and non-word spelling and reading comprehension were assessed in Grade 2. The results indicated that children who had received intervention in preschool performed similarly to the children who had not received intervention. The gains made in PA and language skills post intervention had failed to augment further literacy development. A post hoc examination of individual student profiles, however, revealed that a subgroup of children who had received intervention had maintained their enhanced performance and that the intervention cohort had similar scores on tests of PA ability to their age-matched peers in the population. It was concluded that whole-class, teacher-delivered, PA and language intervention, while effective in the short term, does not lead to a generalized improvement in literacy skills in Grade 2. Possible reasons for the failure of the program to produce medium term gains are discussed.