Positive epidemiology, revisited: the case for centering human rights and economic justice.

In recent years, a growing body of research in positive epidemiology has sought to expand the traditional focus of epidemiologic research beyond risk factors for disease and towards a more holistic understanding of health that includes the study of positive assets that shape well-being more broadly. While this paradigm shift holds great promise for transforming people's lives for the better, it is also critiqued for showcasing decontextualized perspectives that could cause great harm to the public's health if translated uncritically into population-based interventions. In this commentary, we argue for orienting positive epidemiology within a human rights and economic justice framework to mitigate this threat, and we discuss two examples of previously proposed health assets (religious involvement and marriage) that demonstrate the urgent need for positive epidemiologic research to center health equity. Finally, to advance the field, we provide recommendations for how future research can address shortcomings of the extant literature by moving from individual-level to societal-level applications. In doing so, we believe that positive epidemiology can be transformed into a powerful force for health equity. This article is part of a Special Collection on Mental Health.

An Examination of Sleep as a Protective Factor for Depression and Anxiety in the Perinatal Period: Novel Causal Analyses in a Prospective Pregnancy Cohort.

Sleep problems are common in the perinatal period. But the effects of sleep health on long-term postpartum depression and anxiety are underexamined. Using marginal structural models, we estimated the effect of sustained restful sleep quality, or adequate sleep quantity, or both, on clinically significant depression and anxiety at 23- and 32-weeks gestation, and 8-weeks, 8-, and 21-months postpartum. Women (n = 9,211) in the Avon Longitudinal Study of Parents and Children cohort reported on sleep quality (difficulty falling asleep, and early morning awakening), sleep quantity (< or > 5 hours and perceived sleep adequacy), depression (Edinburgh Postnatal Depression Scale), and anxiety (Crown-Crisp Experiential Index). Analyses adjusted for fixed (maternal education, age, body mass index, parity, marital status, smoking) and time varying (alcohol use, psychosocial adversities, depression, anxiety or sleep problems at prior time periods) covariates. Descriptive analyses suggest that sleep alterations persist beyond the immediate postpartum period. Estimates of counterfactual prevalences of outcomes under restful sleep quality and adequate sleep suggest a reduction of the population burden of clinically significant depression between 2.4% - 5.9%, and anxiety by 3.4% - 8.0% for the time points assessed. Interventions for perinatal sleep problems may reduce clinically significant depression and anxiety.

Childhood maltreatment and health in the UK Biobank: triangulation of outcome-wide and polygenic risk score analyses.

BACKGROUND: Childhood maltreatment is common globally and impacts morbidity, mortality, and well-being. Our understanding of its impact is constrained by key substantive and methodological limitations of extant research, including understudied physical health outcomes and bias due to unmeasured confounding. We address these limitations through a large-scale outcome-wide triangulation study. METHODS: We performed two outcome-wide analyses (OWAs) in the UK Biobank. First, we examined the relationship between self-reported maltreatment exposure (number of maltreatment types, via Childhood Trauma Screener) and 414 outcomes in a sub-sample of 157,316 individuals using generalized linear models ("observational OWA"). Outcomes covered a broad range of health themes including health behaviors, cardiovascular disease, digestive health, socioeconomic status, and pain. Second, we examined the relationship between a polygenic risk score for maltreatment and 298 outcomes in a non-overlapping sample of 243,006 individuals ("genetic OWA"). We triangulated results across OWAs based on differing sources of bias. RESULTS: Overall, 23.8% of the analytic sample for the observational OWA reported at least one maltreatment type. Of 298 outcomes examined in both OWAs, 25% were significant in both OWAs and concordant in the direction of association. Most of these were considered robust in the observational OWA according to sensitivity analyses and included outcomes such as marital separation (OR from observational OWA, ORo = 1.25 (95% CI: 1.21, 1.29); OR from genetic OWA, ORg = 1.06 (1.03, 1.08)), major diet changes due to illness (ORo = 1.27 (1.24, 1.29); ORg = 1.01 (1.00, 1.03)), certain intestinal diseases (ORo = 1.14 (1.10, 1.18); ORg = 1.03 (1.01, 1.06)), hearing difficulty with background noise (ORo = 1.11 (1.11, 1.12); ORg = 1.01 (1.00, 1.01)), knee arthrosis (ORo = 1.13 (1.09, 1.18); ORg = 1.03 (1.01, 1.05)), frequent sleeplessness (ORo = 1.21 (1.20, 1.23); ORg = 1.02 (1.01, 1.03)), and low household income (ORo = 1.28 (1.26, 1.31); ORg = 1.02 (1.01, 1.03)). Approximately 62% of results were significant in the observational OWA but not the genetic OWA, including numerous cardiovascular outcomes. Only 6 outcomes were significant in the genetic OWA and null in the observational OWA; these included diastolic blood pressure and glaucoma. No outcomes were statistically significant in opposite directions in the two analyses, and 11% were not significant in either OWA. CONCLUSIONS: Our findings underscore the far-reaching negative effects of childhood maltreatment in later life and the utility of an outcome-wide triangulation design with sensitivity analyses for improving causal inference.

Coping and emotion regulation: A conceptual and measurement scoping review.

The fields of coping and emotion regulation have mostly evolved separately over decades, although considerable overlap exists. Despite increasing efforts to unite them from a conceptual standpoint, it remains unclear whether conceptual similarities translate into their measurement. The main objective of this review was to summarize and compare self-reported measures of coping and emotion regulation strategies. The secondary objective was to examine whether other psychological measures (e.g., resilience) indirectly reflect regulatory strategies' effectiveness, thus representing additionally informative approaches. Results indicated substantial overlap between coping and emotion regulation measures. In both frameworks, two to eight individual strategies were usually captured, but only a third included ≤20 items. Most commonly evaluated strategies were reappraisal/reinterpretation, active coping/problem-solving, acceptance, avoidance, and suppression. Evidence also suggested psychological distress and well-being measures, especially in certain contexts like natural stress experiments, and resilience measures are possible indirect assessments of these regulatory strategies' effectiveness. These results are interpreted in the light of a broader, integrative affect regulation framework and a conceptual model connecting coping, emotion regulation, resilience, psychological well-being and psychological distress is introduced. We further discussed the importance of alignment between individuals, contexts, and strategies used, and provide directions for future research. Altogether, coping and emotion regulation measures meaningfully overlap. Joint consideration of both frameworks in future research would widen the repertoire of available measures and orient their selection based on other aspects like length or strategies covered, rather than the framework only.

Bereavement, Memorial Attendance, and Mental Health During the COVID-19 Pandemic: Longitudinal Results from the Nurses' Health Study.

BACKGROUND: Mortality increased during the COVID-19 pandemic. Many bereaved individuals were not able to gather to memorialize their loved ones, yet it is unknown if this contributed to worsening mental health. OBJECTIVE: Examine the association of bereavement in the early part of the COVID-19 pandemic with subsequent psychological distress and the role of memorial attendance in reducing psychological distress among the bereaved. DESIGN, SETTINGS, SUBJECTS: In May 2020, 39,564 older females from the Nurses' Health Study II enrolled in a longitudinal COVID-19 substudy (meanage = 65.2 years, SD = 4.5). METHODS: Linear regression analyses estimated associations of bereavement reported between March and October, 2020 with subsequent psychological distress between January and October 2021, adjusting for sociodemographic and prepandemic depression symptoms. Secondary models examined associations between memorial attendance and psychological distress. RESULTS: Bereavement during the early part of the COVID-19 pandemic was associated with higher psychological distress (adjusted ß = 0.21, 95% CI: 0.15, 0.26) assessed over the next year. Among the bereaved, memorial attendance was associated with lower psychological distress (in-person: adjusted ß = -0.41, 95% CI: -0.53, -0.29; online: adjusted ß = -0.24, 95% CI: -0.46, --0.02). CONCLUSION: Attending memorials was associated with lower subsequent psychological distress among bereaved older females.

Mental health among bereaved youth in the ALSPAC birth cohort: Consideration of early sociodemographic precursors, cognitive ability, and type of loss.

BACKGROUND: Bereaved youth are at greater risk for adverse mental health outcomes, yet less is known about how social context shapes health for bereaved children. Ecosocial theory is employed to conceptualize bereavement in the context of sociodemographic factors. METHOD: This longitudinal study used data from the Avon Longitudinal Study of Parents and Children. Of the 15,454 pregnancies enrolled, 5050 youth were still enrolled at age 16.5 and completed self-report questionnaires on life events and emotional/behavioral symptoms. RESULTS: Sociodemographic precursors associated with parent, sibling, or close friend bereavement included maternal smoking, parental education levels, and financial difficulties. The significant yet small main effect of higher cognitive ability, assessed at age 8, on reduced emotional/behavioral symptoms at age 16.5 (ß = -0.01, SE = 0.00, p < 0.001) did not interact with bereavement. Bereavement of a parent, sibling, or close friend was associated with a 0.19 point higher emotional/behavioral symptom log score compared to non-bereaved youth (95% CI: 0.10-0.28), across emotional, conduct, and hyperactivity subscales. CONCLUSIONS: Descriptive findings suggest sociodemographic precursors are associated with bereavement. While there was an association between the bereavement of a parent, sibling, or close friend and elevated emotional/behavioral symptoms, cognitive ability did not moderate that effect.

Situational Analysis on the Impact of Perinatal Deaths Among Bereaved Families in Ghana.

Background: Annually, about 5.9 million perinatal deaths occur worldwide, leaving millions bereaved due to stillbirths or early neonatal deaths. The highest burden of stillbirths (97%) and newborn deaths (98%) occurs in lower- and middle-income countries, with the majority occurring in Sub-Saharan African countries. Method: This cross-sectional qualitative study was conducted to identify existing policies and protocols to support bereaved families, explore the needs of bereaved families, and to also assess the impact of perinatal death on families in Ghana. All in-depth interviews were audio-recorded, transcribed verbatim and analyzed thematically. The results were presented in narratives and supported with illustrative quotes from respondents. Results: In all, 42 in-depth interviews were conducted with 10 (23.8%) from the Northern belt (Upper East), 11 (26.2%) from the middle belt (Ashanti) and 21 (50.0%) from the Southern belt (Greater Accra). The study revealed that practicing health professionals and other stakeholders within the health service delivery chain were not aware of protocols, written guidelines or written documents to initiate counseling at the facility in the event of a mother losing a child. Most of the respondents did not know what to do in the event that a mother loses a baby during delivery or immediately after. Respondents were in favor of having a policy or guidelines which will help them to counsel families who go through perinatal bereavement. Respondents were of the view that it is important for families who experience perinatal grief to be supported. Conclusion: All staff who meet the pregnant mother during her pre-and-post-delivery stages should be trained on the use of guidelines or policies. There is the need to have a policy, train and equip health staff to ensure that families experiencing perinatal grief are provided with effective counseling. Ghana Health Service should consider training and recruiting professional counselors who will support the health staff in dealing with perinatal grief.

Influence of Maternal Childhood Trauma on Perinatal Depression, Observed Mother-Infant Interactions, and Child Growth.

INTRODUCTION: Mothers who have experienced childhood trauma may be at increased risk for disruptions in caregiving behavior, with potential consequences for early child development. However, assessments of caregiving behavior tend to be self-reported, which may bias results, and have been limited in lower-resource settings. METHODS: In an overall sample of 256 South African mothers followed across the perinatal period, this longitudinal study used structural equation modeling to test pathways of association between maternal childhood trauma and depressive symptoms on observed mother-infant interactions at 3.5 months and subsequent child growth outcomes at 1 year. RESULTS: On average, mothers with childhood trauma histories tended to show lower rated overall interactions with their infants (B = - 0.16, p = .013), which in turn was associated with reduced child growth at 1 year (B = 0.17, p = .046). When this model was adjusted for maternal age and relative socioeconomic status (SES), maternal SES strongly explained child growth (B = 0.31, p < .001) such that the direct effect of mother-infant interactions was no longer significant. DISCUSSION: For child growth in a lower-resource setting, quality of mother-infant interactions could be a relevant predictor but more strongly explained by maternal SES factors, suggesting a need for broader approaches that not only improve dyadic relationships but also address maternal ecological resources.

Extending the Use of the SCORS-G Composite Ratings in Assessing Level of Personality Organization.

The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011 ; Westen, 1995b ) reliably measures the quality of object relations in narrative material. It assesses 8 dimensions (on a continuum from maladaptive to adaptive) that mediate interpersonal functioning. The 8 dimensions can be averaged to create a global or composite score to represent a person's overall object relational functioning. This study aimed to create levels of personality organization using the SCORS-G global score ratings of Thematic Apperception Test (TAT) narratives and to explore the construct validity of these levels using a multimethod approach (i.e., psychopathology, normal personality, and life-event data). Meaningful relationships were found between the SCORS-G level of personality organization and aspects of psychopathology (Personality Assessment Inventory; Morey, 1991 ), regulation and control (NEO Five-Factor Inventory; Costa & McCrae, 1989, 1992b ), and number of psychiatric hospitalizations, suicide attempts, and educational level. Overall, this study demonstrates the potential value of creating levels of personality organization (LPO) using the SCORS-G composite or global ratings as a supplement to the psychological assessment process and further highlights the utility of this measure in the field of personality assessment. Clinical and research-related implications as well as limitations are discussed.

Psychometric properties of the Ndetei-Othieno-Kathuku (NOK) Scale: A mental health assessment tool for an African setting.

BACKGROUND: Research suggests that psychiatric conditions in children and adolescents are highly debilitating, with sparse resources for assessment and treatment in low- and middle-income countries (LMICs). OBJECTIVES: The primary aim of this study was to evaluate the reliability, validity, and latent factor structure of an ethnographically-grounded assessment instrument for detecting common mental health complaints among rural Kenyan children and adolescents. METHODS: The Ndetei-Othieno-Kathuku Scale (NOK) was delivered to 2 282 children aged 10 to 18 years old. Exploratory factor analysis identified four latent factors. This structure was confirmed in subsequent confirmatory factor analyses. External validity was explored by investigating associations among NOK factors and Youth Self-Report DSM-oriented scales. RESULTS: Findings suggest the NOK possesses good internal reliability and a four-factor latent structure corresponding to depression, anxiety, somatic complaints, and a mixed factor. Significant associations ranging from small to medium effect sizes were noted between NOK factors and YSR DSM-oriented scales. CONCLUSIONS: Exploratory findings suggest that the NOK possesses adequate psychometric properties among this population. This ethnographically-grounded instrument may be uniquely suited to screening for mental health complaints among Kenyan children and adolescents.

Toward a more nuanced conceptualization of interpersonal distancing: Differential relationships of adaptive and dysfunctional detachment to stress-based anxiety in college students.

This study investigates the utility of a model for disambiguating the risk vs. protective features associated with detachment in moderating stress-based anxiety. The model distinguishes adaptive detachment (the ability to engage in flexible, goal-directed cognitive distancing accompanied by the capacity to moderate affective arousal and maintain functional levels of interpersonal connectedness) from dysfunctional detachment (a more generalized detached interpersonal style characterized by pervasive social isolation and negative emotionality). College students (N = 104, 71.4% female, mean age = 19.20 (SD = 3.54)) completed measures of detachment, mental health symptoms, and daily hassles; moderator hypotheses were tested by conducting a series of regression analyses. Findings indicate that individuals who report higher levels of adaptive detachment-but not dysfunctional detachment-experienced reduced anxiety in the context of elevated daily stressors. Results suggest that certain aspects of detachment may serve protective functions by reducing anxiety in the context of stressful events.

Development of the Crying Proneness Scale: associations among crying proneness, empathy, attachment, and age.

Crying is a unique form of human emotional expression that is associated with both positive and negative evocative antecedents. This article investigates the psychometric properties of a newly developed Crying Proneness Scale by examining the factor structure, test-retest reliability, and theoretically hypothesized relationships with empathy, attachment, age, and gender. Based on an analysis of data provided by a Dutch panel (Time 1: N = 4,916, Time 2: N = 4,874), exploratory and confirmatory factor analyses suggest that crying proneness is a multidimensional construct best characterized by four factors called attachment tears, societal tears, sentimental/moral tears, and compassionate tears. Test-retest reliability of the scale was adequate and associations with age, gender, empathy, and attachment demonstrated expected relations. Results suggest that this scale can be used to measure crying proneness, and that it will be useful in future studies that aim to gain a better understanding of normal and pathological socioemotional development.

Longitudinal relationships between early-life homelessness and school-aged asthma and wheezing.

BACKGROUND: Homelessness is a disruptive life event with profound impacts on children's health. It remains unclear, however, whether homelessness in early life has an enduring association with asthma and wheezing among school-aged children. OBJECTIVE: To test whether early-life homelessness is prospectively associated with asthma and wheezing during school-aged years. METHODS: We draw on data from 9242 children from the Avon Longitudinal Study of Parents and Children. Children were categorised as 'ever' or 'never' homeless based on maternal reports from the prenatal period through age 5 years. Children were assigned a binary indicator of asthma/wheezing based on maternal reports of asthma and wheezing at ages 6.8, 7.6 and 8.6 years. We used multilevel logistic regression models to test the association of interest in both bivariate analyses and models adjusted for a broad set of potential confounders. We conducted sensitivity analyses using generalised estimating equations and considering asthma and wheezing separately to test the robustness of the results. RESULTS: Between 12.1% and 14.3% of children had asthma or wheezing at ages 6.8, 7.6 and 8.6 years, and these conditions were more common among ever homeless participants. Ever-homeless children displayed higher odds of asthma or wheezing than never-homeless children (OR: 1.59, 95% CI 1.02 to 2.48) after adjustment for child, maternal and household risk factors. Sensitivity analyses yielded similar results. CONCLUSION: Early-life homelessness is prospectively associated with asthma and wheezing among school-aged children and should be prioritised by interventions promoting healthy child development.

Cross-cultural equivalence of the Kessler Psychological Distress Scale (K10) across four African countries in a multi-national study of adults.

The Kessler Psychological Distress Scale (K10) has been widely used to screen psychological distress across many countries. However, its performance has not been extensively studied in Africa. The present study sought to evaluate and compare measurement properties of the K10 across four African countries: Ethiopia, Kenya, Uganda, and South Africa. Our hypothesis is that the measure will show equivalence across all. Data are drawn from a neuropsychiatric genetic study among adult participants (N = 9179) from general medical settings in Ethiopia (n = 1928), Kenya (n = 2556), Uganda (n = 2104), and South Africa (n = 2591). A unidimensional model with correlated errors was tested for equivalence across study countries using confirmatory factor analyses and the alignment optimization method. Results displayed 30 % noninvariance (i.e., variation) for both intercepts and factor loadings across all countries. Monte Carlo simulations showed a correlation of 0.998, a good replication of population values, indicating minimal noninvariance, or variation. Items "so nervous," "lack of energy/effortful tasks," and "tired" were consistently equivalent for intercepts and factor loadings, respectively. However, items "depressed" and "so depressed" consistently differed across study countries (R2 = 0) for intercepts and factor loadings for both items. The K10 scale likely functions equivalently across the four countries for most items, except "depressed" and "so depressed." Differences in K10 items were more common in Kenya and Ethiopia, suggesting cultural context may influence the interpretation of some items and the potential need for cultural adaptations in these countries.

Post-traumatic stress and future substance use outcomes: leveraging antecedent factors to stratify risk.

Background: Post-traumatic stress disorder (PTSD) and substance use (tobacco, alcohol, and cannabis) are highly comorbid. Many factors affect this relationship, including sociodemographic and psychosocial characteristics, other prior traumas, and physical health. However, few prior studies have investigated this prospectively, examining new substance use and the extent to which a wide range of factors may modify the relationship to PTSD. Methods: The Advancing Understanding of RecOvery afteR traumA (AURORA) study is a prospective cohort of adults presenting at emergency departments (N = 2,943). Participants self-reported PTSD symptoms and the frequency and quantity of tobacco, alcohol, and cannabis use at six total timepoints. We assessed the associations of PTSD and future substance use, lagged by one timepoint, using the Poisson generalized estimating equations. We also stratified by incident and prevalent substance use and generated causal forests to identify the most important effect modifiers of this relationship out of 128 potential variables. Results: At baseline, 37.3% (N = 1,099) of participants reported likely PTSD. PTSD was associated with tobacco frequency (incidence rate ratio (IRR): 1.003, 95% CI: 1.00, 1.01, p = 0.02) and quantity (IRR: 1.01, 95% CI: 1.001, 1.01, p = 0.01), and alcohol frequency (IRR: 1.002, 95% CI: 1.00, 1.004, p = 0.03) and quantity (IRR: 1.003, 95% CI: 1.001, 1.01, p = 0.001), but not with cannabis use. There were slight differences in incident compared to prevalent tobacco frequency and quantity of use; prevalent tobacco frequency and quantity were associated with PTSD symptoms, while incident tobacco frequency and quantity were not. Using causal forests, lifetime worst use of cigarettes, overall self-rated physical health, and prior childhood trauma were major moderators of the relationship between PTSD symptoms and the three substances investigated. Conclusion: PTSD symptoms were highly associated with tobacco and alcohol use, while the association with prospective cannabis use is not clear. Findings suggest that understanding the different risk stratification that occurs can aid in tailoring interventions to populations at greatest risk to best mitigate the comorbidity between PTSD symptoms and future substance use outcomes. We demonstrate that this is particularly salient for tobacco use and, to some extent, alcohol use, while cannabis is less likely to be impacted by PTSD symptoms across the strata.

Longitudinal patterns of childhood homelessness and early adolescent trajectories of internalising and externalising behaviour.

BACKGROUND: Child homelessness has been associated with elevated mental health problems during early adolescence, a period of onset for psychiatric problems. Prior literature has relied on cross-sectional studies, limiting the understanding of temporality and trajectories of psychopathology. We extend prior literature by examining associations between child homelessness and internalising and externalising symptom trajectories in early adolescence, with consideration of timing and persistence of homelessness. METHODS: Using population-based longitudinal data from the Avon Longitudinal Study of Parents and Children, we used multilevel models to examine the effects of homelessness prior to age 9, the timing of homelessness (eg, early vs middle childhood) and cumulative exposure to homelessness on internalising and externalising trajectories across ages <0-9 years. We also tested for sex differences in these associations. RESULTS: Of the 8391 participants, 5.5% reported exposure to homelessness at least once before age 9. Children who experienced homelessness had elevated internalising and externalising symptoms compared with their consistently housed peers, with excess risk evident among children who first experienced homelessness in middle childhood (relative to early childhood) and children who experienced recurrent homelessness. We did not observe changes in symptom trajectories over the course of 4 years. Men who experienced homelessness displayed a more pronounced risk of internalising symptoms relative to women and men who did not experience homelessness. CONCLUSION: Childhood homelessness is associated with persistently elevated internalising and externalising symptoms across early adolescence compared with their consistently housed peers. Interventions and policies to address family homelessness may lead to better mental health among adolescents.

Resilient phenotypes among bereaved youth: a comparison of trajectory, relative, and cross-domain approaches.

BACKGROUND: Bereavement is a common traumatic event associated with adverse health outcomes across the life course. Despite these risks, not all bereaved individuals experience these negative effects. Limited scientific consensus exists on how to define resilience in individuals who have experienced the death of a loved one. METHODS: Using a sample of N = 3766 youth from the Avon Longitudinal Study of Parents and Children birth cohort, we identified bereavement of a family member between ages 7 and 8.5. We derived and compared three different approaches to assess resilience among bereaved youth. Trajectory-based psychological resilience identified sub-groups with similar psychological symptom profiles between ages 6 and 16 using latent growth mixture models. Relative psychological resilience at age 16 leveraged standardized residuals from a model regressing psychological symptoms on bereavement to determine better-than-expected psychological functioning relative to bereavement status. Relative cross-domain resilience around age 16 was a sum score of the residuals approach applied to eight unique domains of health. Predictive validity of each approach was assessed using depressive symptoms at age 17.5 RESULTS: Overall, N = 877 (23%) youth were bereaved of a family member between ages 7 and 8.5. Using latent growth mixture models, a three-class solution described 84% of bereaved youth with low and stable psychological symptoms over time, 8% with worsening symptoms, and 8% with improving yet elevated symptoms. Each relative resilience score was largely concordant with the trajectory-based approach in identifying individuals as resilient or not, though relative psychological resilience demonstrated a stronger degree of concordance than the cross-domain score. Relative psychological and cross-domain resilience exhibited moderate to low correlation, depending on the domains included (r = 0.14-0.43). For each approach, resilience significantly predicted lower depressive symptoms at age 17.5, highlighting predictive validity of these measures. CONCLUSIONS: Psychological symptom trajectories among bereaved youth aligned with those previously identified among bereaved adults. The residual-based approach to defining resilience exhibited limited utility in the context of bereavement. When identifying risk and resilience after bereavement, researchers and clinicians must address the interplay across psychosocial and physical health domains, as bereaved youth considered resilient from a mental health perspective may benefit from intervention in other domains.

Prevalence of Substance Use and Its Association with Sociodemographic and Behavioral Factors among Women Who Conduct Sex Work in Kenya.

Female sex workers (FSWs) in sub-Saharan Africa are a marginalized group with an increased morbidity risk. Psychoactive substance use among this group is common and increases the risk of adverse health consequences. The type of substance used, extent, and nature of use varies with different settings and regions. We examine the use of specific psychoactive substances among FSWs residing in an urban informal settlement in Nairobi. This cross-sectional study was conducted between April and August 2017. Structured questionnaires were administered in face-to-face interviews. Descriptive statistics and logistic regression were undertaken to examine prevalence, patterns, and factors associated with use of specific substances. Out of 301 FSWs, 98% reported current psychoactive substance use. The most used substance was alcohol with 95.6% of the study population reporting use in the past year. Of these, 151 (50.2%) met criteria for very high-risk drinkers. Reported current use was 61.5% for cannabis, 47.2% for khat, and 30.9% for tobacco. Factors independently associated with hazardous and harmful alcohol use included earning a higher monthly income (>USD50) and disclosure of sex work to close family and friends. There is an urgent need for preventive and curative interventions to address the high prevalence of substance use among FSW residing in high-risk urban informal settlements in Kenya.

A Longitudinal Investigation of Resilience as a Protective Factor During the COVID-19 Pandemic.

COVID-19 is a global stressor that has been shown to impact mental health outcomes. Given that COVID-19 is a unique stressor that has been shown to have mental health consequences, identifying protective factors is imperative. The protective influences of resilience are demonstrated through the extant literature, though less is known about resilience and COVID-19 impact. The current study seeks to expand the existing literature on resilience, and on mental health outcomes influenced by COVID-19, by longitudinally investigating relative resilience as a buffer against posttraumatic stress disorder (PTSD) symptoms and alcohol consumption, in the wake of a global pandemic. Participants included 549 undergraduates with a history of lifetime trauma exposure. Using a longitudinal path model, we tested the interaction between relative resilience (i.e., an individual's deviation from distress levels predicted by prior trauma exposure relative to other individuals in the same cohort) and COVID-19 impact domains (i.e., social media use, worry, exposure, change in substance use, and housing/food insecurity) on PTSD symptoms and alcohol consumption. Findings demonstrate a significant interaction between the COVID-19 worry impact domain and baseline resilience on later PTSD symptoms, whereby COVID-19 worry impacts PTSD symptoms at low levels of resilience (ß = .26, p < .001), marginally impacts PTSD symptoms at mean levels of resilience (ß = .09, p = .05), and does not impact PTSD symptoms at high levels of resilience (ß = -.08, p = .16). There were no significant main effects nor interaction effects of resilience on alcohol consumption. This article adds to the literature on resilience and COVID-19 through examining both internalizing (i.e., PTSD) and substance use outcomes, using longitudinal data, and using a quantitative measure of resilience.