Global assessment of existing HIV and key population stigma indicators: A data mapping exercise to inform country-level stigma measurement.

BACKGROUND: Stigma is an established barrier to the provision and uptake of HIV prevention, diagnostic, and treatment services. Despite consensus on the importance of addressing stigma, there are currently no country-level summary measures to characterize stigma and track progress in reducing stigma around the globe. This data mapping exercise aimed to assess the potential for existing data to be used to summarize and track stigma, including discrimination, related to HIV status, or key population membership at the country level. METHODS AND FINDINGS: This study assessed existing indicators of stigma related to living with HIV or belonging to 1 of 4 key populations including gay men and other men who have sex with men, sex workers, people who use drugs, and transgender persons. UNAIDS Strategic Information Department led an initial drafting of possible domains, subdomains, and indicators, and a 3-week e-consultation was held to provide feedback. From the e-consultation, 44 indicators were proposed for HIV stigma; 14 for sexual minority stigma (including sexual behavior or orientation) related to men who have sex with men; 12 for sex work stigma; 10 for drug use stigma; and 17 for gender identity stigma related to transgender persons. We conducted a global data mapping exercise to identify and describe the availability and quality of stigma data across countries with the following sources: UNAIDS National Commitments and Policies Instrument (NCPI) database; Multiple Indicator Cluster Surveys (MICS); Demographic and Health Surveys (DHS); People Living with HIV Stigma Index surveys; HIV Key Populations Data Repository; Integrated Biological and Behavioral Surveys (IBBS); and network databases. Data extraction was conducted between August and November 2020. Indicators were evaluated based on the following: if an existing data source could be identified; the number of countries for which data were available for the indicator at present and in the future; variation in the indicator across countries; and considerations of data quality or accuracy. This mapping exercise resulted in the identification of 24 HIV stigma indicators and 10 key population indicators as having potential to be used at present in the creation of valid summary measures of stigma at the country level. These indicators may allow assessment of legal, societal, and behavioral manifestations of stigma across population groups and settings. Study limitations include potential selection bias due to available data sources to the research team and other biases due to the exploratory nature of this data mapping process. CONCLUSIONS: Based on the current state of data available, several indicators have the potential to characterize the level and nature of stigma affecting people living with HIV and key populations across countries and across time. This exercise revealed challenges for an empirical process reliant on existing data to determine how to weight and best combine indicators into indices. However, results for this study can be combined with participatory processes to inform summary measure development and set data collection priorities going forward.

Syndemic Vulnerability and Condomless Sex Among Incarcerated Men in Mexico City: A Latent Class Analysis.

In order to address common statistical and population-based limitations in epidemiological literature applying syndemic theory, this study uses latent class analysis (LCA) to explore how health and social problems coalesce and shape sexual risk behaviors linked to HIV transmission in three Mexico City prisons. Among the studied male inmates, LCA identified four classes, defined by low syndemic risk (61.4%); marijuana (14.3%); depression, substances, and trauma (19.7%); and depression, substances, and marijuana (4.7%). In multinomial regression models, classes with a greater number of syndemic exposures were associated with increased odds of condomless anal sex during incarceration. In analyses stratified by pre-incarceration sexual risk behaviors, however, high syndemic burden classes were associated with condomless anal sex during incarceration differently. Overall, the study findings suggest that LCA has potential utility for syndemic analyses and highlight the need to attend to health and social adversities when addressing sexual risk behaviors and HIV transmission during incarceration.

Culture and Comorbidity: Intimate Partner Violence as a Common Risk Factor for Maternal Mental Illness and Reproductive Health Problems among Former Child Soldiers in Nepal.

Our objective was to elucidate how culture influences internal (psychological), external (social), institutional (structural), and health care (medical) processes, which, taken together, create differential risk of comorbidity across contexts. To develop a conceptual model, we conducted qualitative research with 13 female child soldiers in Nepal. Participants gave open-ended responses to intimate partner violence (IPV) vignettes (marital rape, emotional abuse, violence during pregnancy). Twelve participants (92%) endorsed personal responses (remaining silent, enduring violence, forgiving the husband). Twelve participants endorsed communication with one's husband. Only four participants (31%) sought family support, and three contacted police. Ultimately, 12 participants left the relationship, but the majority (nine) only left after the final IPV experience, which was preceded by prolonged psychological suffering and pregnancy endangerment. In conclusion, comorbidity risks are increased in cultural context that rely on individual or couples-only behavior, lack external social engagement, have weak law and justice institutions, and have limited health services.

Systematic review of structural interventions for intimate partner violence in low- and middle-income countries: organizing evidence for prevention.

BACKGROUND: Despite growing attention to intimate partner violence (IPV) globally, systematic evaluation of evidence for IPV prevention remains limited. This particularly is true in relation to low- and middle-income countries (LMIC), where researchers often organize evidence by current interventions strategies rather than comprehensive models of IPV. Applying the concept of structural interventions to IPV, we systematically reviewed the quantitative impact of such interventions for prevention of male-to-female IPV in LMIC in order to (a) highlight current opportunities for IPV research and programming and (b) demonstrate how structural interventions may provide an organizing framework through which to build an evidence base for IPV prevention. METHODS: We identified articles by systematically searching PubMed and Web of Science, reviewing references of selected studies, and contacting 23 experts. Inclusion criteria included original research, written in English, published between January 2000 and May 2015 in the peer-reviewed literature. Studies evaluated the quantitative impact of structural interventions for the prevention of male-to-female IPV in LMIC through (a) IPV incidence or prevalence or (b) secondary outcomes theoretically linked to IPV by study authors. After initial screening, we evaluated full text articles for inclusion and extracted data on study characteristics, outcomes, and risk of bias, using forms developed for the review. RESULTS: Twenty articles (16 studies) from nine countries met inclusion criteria, representing 13 randomized control trials and seven additional studies, all of which reported results from economic, social, or combined economic and social interventions. Standardized at p < 0.05 or 95 % confidence intervals not including unity, 13 studies demonstrated statistically significant effects for at least one primary or secondary outcome, including decreased IPV and controlling behaviors; improved economic wellbeing; enhanced relationship quality, empowerment, or social capital; reduced acceptability of IPV; new help seeking behaviors; and more equitable gender norms. Risk of bias, however, varied in meaningful ways. CONCLUSIONS: Our findings support the potential effectiveness of structural interventions for IPV prevention. Structural interventions, as an organizing framework, may advance IPV prevention by consolidating available evidence; highlighting opportunities to assess a broader range of interventions, including politico-legal and physical approaches; and emphasizing opportunities to improve evaluation of such interventions.

Effectiveness of a family violence prevention program on mental health outcomes for adult men and women in North Kivu, Democratic Republic of Congo: Insights from a pilot trial.

The eastern Democratic Republic of Congo (DRC) has faced dual burdens of poor mental health and heightened levels of violence against women and children within the home. Interventions addressing family violence prevention may offer a path to mitigate mental distress within the eastern DRC. This exploratory analysis uses data from a pilot cluster randomized controlled trial conducted in North Kivu, DRC, assessing the impact of Safe at Home, a violence prevention intervention. Mental health was assessed at endline using the Patient Health Questionnaire-4. Statistical analyses employed multilevel linear regression. Assuming successful randomization, impact of the Safe at Home intervention on mental health differed by participant gender. Women enrolled in the Safe at Home intervention reported statistically significant decreases in mental distress symptoms [ß (95%CI) = -1.01 (-1.85, -0.17)], whereas men enrolled in Safe at Home had similar scores in mental distress to the control group [ß (95%CI) = -0.12 (-1.32, 1.06)]. Ultimately, this exploratory analysis provides evidence of the potential for a family violence prevention model to improve women's mental health in a low-resource, conflict-affected setting, although further research is needed to understand the impact on men's mental health.

Drivers of men's use of intimate partner violence in conflict-affected settings: learnings from the Democratic Republic of Congo.

BACKGROUND: Intimate partner violence against women (IPVAW) is prevalent in conflict-affected settings. Yet, there is limited knowledge about the risk factors that influence men's use of IPVAW in conflict-affected settings. This paper adopts a transdisciplinary perspective to understand how experiences hypothesized to increase men's use of IPVAW relate to each other and to men's use of IPVAW. The findings may help researchers and interventionists to better select and target interventions for IPVAW in conflict-affected settings. METHODS: We used baseline data from the Tushinde Ujeuri project in the Democratic Republic of Congo. Men with at least partial data for the variables of interest were included in the analysis (n = 2080). We estimated a structural equation model that explored how five constructs - interpersonal violence, mental health, socioeconomic adversity, gender inequitable attitudes, and conflict violence - influenced men's self-reported past-year use of physical and/or sexual IPVAW. RESULTS: The model had acceptable fit (χ2 = 1576.574, p = 0.000; RMSEA = 0.041; CLI = 0.882; SRMR = 0.055). There was a statistically significant path from interpersonal violence to IPVAW (ß = 0.875; OR = 2.40). Interpersonal violence also was linked to gender inequitable attitudes (ß = 0.364), which were linked to increased use of IPVAW (ß = 0.180; OR = 1.20). Moreover, interpersonal violence was linked to trauma symptoms (ß = 0.331), which were linked to increased use of IPVAW (ß = 0.238; OR = 1.27). Use of IPVAW decreased as conflict exposures increased (ß=-0.036; OR = 0.96), and there was no path from socioeconomic adversity to IPVAW. CONCLUSIONS: Our findings suggest interpersonal violence exposures, trauma symptoms, and gender inequitable attitudes are all risk factors for the use of IPVAW in a conflict-affected setting. While continuing to focus on gender inequitable attitudes and norms, interventionists should also consider addressing men's experiences of victimization and mental wellbeing. Doing so can help to improve trauma symptoms and may hold promise to reduce IPVAW in conflict-affected settings.

Exploring transdiagnostic stress and trauma-related symptoms across the world: a latent class analysis.

Background: Although trauma exposure is universally prevalent, the ways in which individuals respond to potentially traumatic events vary. Between-country differences have been identified as affecting the development and manifestation of transdiagnostic psychological symptoms, but it remains unclear how stress and trauma-related transdiagnostic symptoms and risk patterns differ based on geographic region.Objective: To explore whether there are distinct classes of stress and trauma-related transdiagnostic symptoms and to determine predictors of class membership in a global sample.Method: Participants (N = 8675) from 115 different countries were recruited online between 2020-2022 and completed the Global Psychotrauma Screen, which assesses stress and trauma exposure, related symptoms, and risk factors. A latent class analysis (LCA) was used to identify classes of stress and trauma-related symptoms per world region (African States, Asia-Pacific States, Eastern European States, Latin American and Caribbean States, Western European and Other States, and North America) and the total sample. Likelihood of class membership was assessed based on demographics, characteristics of the potentially traumatic event, and potential risk factors across the world regions.Results: Similar class compositions were observed across regions. A joint latent class analysis identified three classes that differed by symptom severity (i.e. high, moderate, low). Multinomial logistic regression analyses revealed several factors that conferred greater risk for experiencing higher levels of symptoms, including geographic region, gender, and lack of social support, among others.Conclusions: Stress and trauma-related symptoms seem to be similarly transdiagnostic across the world, supporting the value of a transdiagnostic assessment.

A latent class analysis of transdiagnostic stress and trauma-related symptoms in a global sample showed high, medium, and low symptom classes.Class compositions were similar across global geographic regions.Several factors were associated with high symptom class membership globally, including gender, geographic region, and lack of social support.

Women's Employment and Intimate Partner Violence: Understanding the Role of Individual and Community Structural Drivers in Low- and Middle-Income Countries.

Empirical findings on the relationship between women's employment and intimate partner violence (IPV) in low- and middle-income countries (LMICs) are mixed. These varied findings may arise because research thus far has given insufficient attention to how individual attributes and community context shape the pathways between women's employment and IPV. Using publicly available Demographic and Health Survey (DHS) data from 20 LMIC settings (n = 168,995), we investigate (1) how women's employment is associated with past-year IPV and (2) if associations differ by household- or community-level structural drivers of IPV: women's attitudes toward IPV, women's participation in household decision-making, and relative wealth. We fit mixed-effects logistic regression models exploring the total, individual, community, and contextual effects of women's employment on past-year IPV; effect measure modification by structural drivers; and cross-level interactions between community-level structural drivers and individual employment. Our analyses reveal positive associations between total (odds ratio [OR] = 1.31; 95% CI [1.27, 1.35]), individual (OR = 1.23; 95% CI [1.19, 1.27]), community (OR = 1.06; 95% CI [1.06, 1.07]), and contextual effects (OR = 1.04; 95% CI [1.03, 1.05]) of women's employment for IPV. Only individual wealth demonstrated statistically significant effect measure modification for the relationship between individual employment and past-year IPV (ratio of OR = 0.95; 95% CI [0.92, 0.99]). These findings suggest interventions that focus only on increasing women's employment may be associated with harmful increases in the occurrence of IPV, even when these interventions enable a large proportion of women in a community to be employed. Structural interventions that change norms of women's autonomy or attitudes toward IPV at the household or community levels may be insufficient to ameliorate these negative effects, whereas interventions that increase household wealth partly may buffer these effects.

Partner Alcohol Use and Attitudes Toward Intimate Partner Violence: Independent and Synergistic Effects on Intimate Partner Violence Across 19 Low- and Middle-Income Countries.

Although partner alcohol use and acceptance of intimate partner violence against women (IPVAW) are critical determinants of IPVAW, little is known about their interaction. We explored how partner alcohol use and attitudes toward IPVAW act independently and jointly at the individual and community levels to influence women's reports of experiencing IPVAW across low- and middle-income countries. We conducted secondary analyses using a pooled sample of reproductive-aged women (n = 166,621) from 19 Demographic and Health Survey datasets. We fit a series of a priori-defined mixed-effects logistic regression models of the total effects, within- and between-community effects, and contextual effects of past-year IPVAW on partner alcohol use, acceptance of IPVAW, and their multiplicative interaction. We then fit a series of models stratified by community alcohol use and acceptance of IPVAW. Partner alcohol use (odds ratio [OR] = 3.20; 95% confidence interval [CI]: [3.07, 3.33]) and women's acceptance of IPVAW (OR = 1.83; 95% CI: [1.76, 1.89]) were consistently associated with increased odds of experiencing IPVAW. Sub-multiplicative interactions were present for within-community effects (ratio of OR = 0.86; 95% CI: [0.79, 0.94]), whereas supra-multiplicative interactions were present for between-community effects (ratio of OR = 1.002; 95% CI: [1.0002, 1.005]) and contextual effects (ratio of OR = 1.003; 95% CI: [1.0007, 1.005]). The odds of IPVAW associated with partner alcohol use was greatet in communities with lower partner alcohol prevalence and lower acceptance of IPVAW. It is important to consider norms and attitudes toward IPVAW alongside alcohol use when understanding epidemiological patterns of IPVAW and potential opportunities for preventive programs and policymaking. Future studies should focus on the complex interactions, at multiple social levels, between interacting risk factors for IPVAW.

School-based MHPSS interventions in humanitarian contexts: a realist review.

OBJECTIVE: The aim of this review is to elucidate the characteristics of school-based mental health and psychosocial support (MHPSS) interventions in humanitarian contexts and the hypothesised mechanisms by which they influence well-being or learning outcomes. METHODS: We conducted a realist review and searched PubMed, Embase, Global Health, CINAHL, PsychInfo, PILOTS and grey literature through January 2022. Eligible studies included children age 6-12 years, were conducted in humanitarian contexts in low-income or middle-income countries, and focused on universal MPHSS prevention in an educational setting, using any study design. Data were extracted and analysed using narrative synthesis and realist analysis techniques to create 'context-mechanism-outcome' configurations that were iteratively developed to modify, refine and substantiate programme theories. RESULTS: Twenty-seven articles, representing 19 studies, were included in the review. We analysed data from 26 articles. Eleven evidenced-informed programme theories were developed at the levels of the child (n=4), teacher (n=3), caregiver (n=2), school environment (n=1) and school managers/administrators (n=1). At the child level, mechanisms related to strengthening coping skills, emotion regulation, interpersonal relationships led to improved psychosocial well-being or learning outcomes. At the teacher level, coping skills and the provision of support to students were linked to psychosocial well-being and learning outcomes. At the caregiver level, strengthening interpersonal bonds trigger improved psychosocial well-being, and at the school environment level, fostering feelings of security was linked to psychosocial well-being and learning outcomes. We did not find any evidence supporting the programme theory at the school managers/administrators level. We found limited evidence of positive impacts of the included interventions to support these programme theories. CONCLUSIONS: These programme theories are a promising start towards ensuring school-based MHPSS interventions in humanitarian contexts better address the well-being and learning needs of children. Future research is needed to support these programme theories and enhance the evidence base.

SH+ 360: novel model for scaling up a mental health and psychosocial support programme in humanitarian settings.

We explore multi-sectoral integration as a model for scaling up evidence-based mental health and psychosocial support interventions in humanitarian settings. We introduce Self Help Plus 360, designed to support humanitarian partners across different sectors to integrate a psychosocial intervention into their programming and more holistically address population needs.

Interpersonal violence and suicidality among former child soldiers and war-exposed civilian children in Nepal.

BACKGROUND: Suicide risk reduction is crucial for 15-29-year-old youth, who account for 46% of suicide deaths in low- and middle-income countries. Suicide predictors in high-resource settings, specifically depression, do not adequately predict suicidality in these settings. We explored if interpersonal violence (IPV) was associated with suicidality, independent of depression, in Nepal. METHODS: A longitudinal cohort of child soldiers and matched civilian children, enrolled in 2007 after the People's War in Nepal, were re-interviewed in 2012. The Depression Self-Rating Scale and Composite International Diagnostic Interview assessed depression and suicidality, respectively. Non-verbal response cards were used to capture experiences of sexual and physical IPV. RESULTS: One of five participants (19%) reported any lifetime suicidal ideation, which was associated with sexual IPV, female gender, former child soldier status and lack of support from teachers. Among young men, the relationship between sexual IPV and suicidality was explained by depression, and teacher support reduced suicidality. Among young women, sexual IPV was associated with suicidality, independent of depression; child soldier status increased suicidality, and teacher support decreased suicidality. Suicide plans were associated with sexual IPV but not with depression. One of 11 female former child soldiers (9%) had attempted suicide. CONCLUSION: Sexual IPV is associated with suicidal ideation and plans among conflict-affected young women, independent of depression. Reducing suicide risk among women should include screening, care, and prevention programs for sexual IPV. Programs involving teachers may be particularly impactful for reducing suicidality among IPV survivors.

Connectivity, prison environment and mental health among first-time male inmates in Mexico City.

Research from high-income countries suggests that prison populations are affected disproportionately by mental illness. However, little research has examined mental health among prisoners in low- and middle-income countries or associations between mental health and contextual factors surrounding the prison experience among susceptible first-time inmates in these settings. The current study examines associations between connectivity, prison environment and mental health (major depression and substance use) among novice male inmates (n = 593) in three Mexico City prisons. Severe depression (46.2%), any substance use (53.8%) and heavy substance use (45.7%) were prevalent. Among key co-variates, recent visitors were protective for severe depression, conjugal visits for any substance use and prison employment for heavy substance use. Physical attacks were associated with increased prevalence of depression, sentence time served with both any and heavy substance use and overcrowding with any substance use. These findings suggest the need for routine health assessments to improve identification and treatment programmes to minimise mental health burden. Addressing demographic risk factors as well as contextual determinants, by decreasing physical violence and overcrowding and supporting outside connections for prisoners, may help improve inmate mental health.

Reproduction, functional autonomy and changing experiences of intimate partner violence within marriage in rural India.

CONTEXT: The literature on intimate partner violence in resource-poor contexts relies primarily on cross-sectional studies. Because changes in women's status and empowerment are hypothesized to influence violence vulnerability, longitudinal studies are needed to determine the potential benefits and harms associated with such changes. METHODS: Data were collected prospectively from a representative cohort of 4,749 married women in rural areas of four socially and demographically diverse states in India in 1998-1999 and 2002-2003. A multinomial regression model including social and demographic characteristics and intersurvey changes and events related to functional autonomy and reproduction was fitted to a categorical outcome measuring the absence (reference), initiation, cessation and continuation of intimate partner violence. RESULTS: Continued freedom of movement, increased freedom of movement and continued financial autonomy between baseline and follow-up were associated with a lower risk of violence initiation rather than no violence (relative risk ratio, 0.7 for each). Having a first child was associated with lower risk of violence initiation and continuation rather than no violence (0.6 and 0.2, respectively). Women who reported that their relative economic contribution to the household decreased or increased and women who experienced an unwanted pregnancy had a higher risk of violence continuation rather than no violence (1.8, 1.8 and 1.5, respectively). The death of a child was associated with higher risk of violence initiation rather than no violence (1.4). CONCLUSION: Future research to inform interventions to reduce intimate partner violence should consider how changes in women's reproductive experiences and functional autonomy may be linked to changes in intimate partner violence.

Pile sorting innovations: exploring gender norms, power and equity in sub-Saharan Africa.

Understanding gender norms, power and equity is important for developing successful sexual and reproductive health interventions. However, little attention has been given to how to capture the gender ideals and imbalances that inform these relationships in low resource settings. Pile sorting exercises were conducted in four gender-segregated focus groups in Ethiopia and Kenya. Each group received cards illustrated with a man, woman and man and woman together and cards labelled with duties and decisions. Participants discussed and decided together whether men, women or both performed each duty and decision and assigned the cards accordingly. Participants then reflected on and physically manipulated the piles to challenge gender norms, investigate role flexibility and identify agents of social change. Data collected included photographs of the pile sorts and recordings of the discussions. Conducting pile sorting within focus group discussions enabled comparative analyses of gender norms, while enriching data by focusing discussions and encouraging consensus building. Innovative applications facilitated participants' abilities to engage abstract concepts, reflecting on issues of gender norms, power and equity.